Basic information regarding the spine will be presented in this issue. Knowing how your spine was designed to work will make it easier for you to understand the disorders that can affect the spine and how it functions.

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For ages childhood to about 30, the discs are very flexible and maintain their height and stability very well. In the 30's, changes begin to occur in the discs as they first begin to lose liquid. This liquid is replaced by calcified tissue that is hard and not flexible. As the disc ages and loses liquid, it also gets smaller and shorter in height. Spine stability and flexibility start to decrease causing older people to say, "I used to be able to do that without a problem but now it is harder!" These people will find it more difficult to bend, climb, and reach as the flexibility of the spine is reduced.

As the disc continues to wear out (degenerate) it becomes thinner, which allows the bone edges to come closer together. The bones can rub against each other and cause irritation and inflammation, which are very uncomfortable. Bones react to stress and irritation by producing more bone. This abnormal extra bone growth results in arthritis of the spine that also reduces spine flexibility.

What is your mental image picture of a little old man? At some point in the description you will undoubtedly comment on his inability to stand up straight. Now he didn't just wake up one morning all of a sudden unable to stand up straight. If you were to look at pictures of this person that were taken at 5 year intervals (25, 20, 15, 10, and 5 years ago) you would see a gradual but steady progression from being upright to his present slumped over posture. It is a slow but unrelenting process that can do a great deal of harm if not handled correctly at an early age.

On the other hand, what is your mental image picture of a woman that is 'young for her age'? I bet her most telling characteristic would be her upright posture!

The spine healthy person can distribute their weight across the entire surface of the bones so no single point is overly stressed. Unfortunately, our little old man is bearing all of his weight on the front edge of his bones. He has lost the ability to spread out the weight across the entire surface of his bones.

The front areas are constantly feeling more weight than they should have to handle. Extra abnormal bone growth will develop in the areas with increased pressure. As stated earlier, these arthritic changes limit the motion between the spine bones and result in decreased flexibility. Our little old man will be more rigid and will have pain when he attempts to be more active.

At present, there is no method known that will stop the aging process with degeneration of the spinal discs. However, with proper spine mechanics, the aging process will take a much slower course that will preserve spine flexibility and stability beyond the average life expectancy. So it is possible to be pain free, with a very flexible spine well into old age if proper body mechanics are instilled early in the teen years and maintained through middle and adult life.

Now that we have a clearer understanding of the aging process, we can address the problem of herniation (protrusion) of the spinal discs. The discs are held in place by very dense and strong ligaments. Ligaments are formed from fibers that hold bones to other bones. The ligaments are like very strong rubber bands that permit for some motion of the spine bones. After allowing movement, they always pull the bones back to where they belong. Since the discs are between the spine bones, the ligaments enclose the disc and hold it in place.

The disc can not move unless the ligaments tear or become weak. As we get older, the strength of these ligaments decreases much like an old rubber band that doesn't quite have the strength to shorten back down to its original shape after being stretched. Without the support from the ligaments, the disc can protrude out of its position when the spine absorbs force. Jumping, prolonged standing, twisting, an abrupt stop or even a fall can produce enough force to move the disc when the support from the ligaments is lacking.

Discs seldom herniate (protrude, stick out) in the very young or very old! A young person's ligament is much like a brand new rubber band. It can be stretched for spine motion but will always return to the original shape to pull the bones back where they belong. Young ligaments can tolerate an enormous amount stress without weakening.

In the very old person, the disc would have already become calcified (like the bone itself) and the disc is not able to move on its own. The spine is now rigid and not able to absorb much shock without fracturing (breaking). This rigidity is the reason that the spine bones break in the elderly when the spine is exposed to a strong force.

As you may have already realized, the ligaments need to be weakened and the disc needs to remain flexible for a disc to herniate, which is the exact situation found in the middle aged adult. The ligaments are now stretched out so they are not tightly pressed against the disc. These ligaments have forgotten their original shape and tension. They do not provide stability for the discs to remain in place.

Middle-aged adults are active and can be exposed to abnormal spine forces. Work injuries, sports injuries and injuries from motor vehicles transmit very strong forces to the spine elements. If the force is great enough, the disc may move out of place. When a disc moves out of place it is called a herniation or protrusion. If the protruding disc touches a nerve or the spinal cord, the person will feel pain, numbness and weakness.

Don't worry, there is some hope! There are muscles that run up and down and all around the spinal column. Muscles do not lose their ability to contract and stretch. Muscles are much different than ligaments since ligaments eventually become stretched and ineffective. If properly maintained, muscles can provide great flexibility as well as the necessary support for the spine bones and discs. The spine musculature is our last line of defense against spine instability, ligament damage and disc movement.

The middle-aged person needs desperately to maintain the strength of the spine muscles for protection against major damage to the spine. Unfortunately, most middle-aged people exercise less and allow their spine muscles to weaken. With stretched ligaments, weak muscles and strong forces, middle-aged people are most prone to disc herniation.

In this issue on spine basics, the importance of proper posture and correct use of the spine was discussed. The term body mechanics refers to the way the body is used to perform certain tasks. The spine provides strength and flexibility and these are greatest when the spine bones remain in their correct structural alignment from the neck into the chest and through the low back.

If these shapes and relationships are maintained, the spine is better able to absorb the forces placed on it during sitting, standing, walking, running and at the time of injury. Using the spine the way it was designed, always to the best mechanical advantage, will decrease stress on the bones, discs and ligaments. Maintaining the correct shape in all activities will promote a healthier neck and back.

Maintaining proper posture and body mechanics throughout all activities over the course of a lifetime will slow down changes associated with aging and allow flexibility and strength of the spine. Continue to monitor how you are standing and sitting during all activities to be sure to maintain an upright spine position.

The simple yet effective LifeBack exercise program was designed to strengthen the spinal support musculature. If performed diligently, the program can help prevent spinal instability and promote proper body mechanics for everyone. These methods have decreased the pain and disability of many back pain sufferers. There are no magic pills or magic cures. Proper maintenance of the spine takes effort and personal responsibility. The LifeBack exercise program will be reviewed in an upcoming issue of the Newsletter.

Now to a question from one of our readers.

"My husband is 35 years old and he injured his low back while unloading a trailer at work 5 months ago. He has not worked since the time of the injury and he is still in pain when he tries to become more active. Should my husband have surgery for his back pain?"  

This is a very common question and there is no simple answer. Here are some guidelines to follow when trying to make sense of situations like these. 

Issues such as the health of the patient, how the injury occurred, the occupation, working status, limitation of activity, pain level, exact diagnosis and response to treatment are all important.  Each must be added to the equation and the patient himself needs to make an informed decision.  

The remainder of our discussion applies to no single patient in particular but will assist everyone faced with a surgical decision gather the necessary facts to make the best possible decision for themselves.  No decision should be made without consulting with the family physician and surgeon who are aware of the particular needs and problems with each patient.   That being said, consider these points.  

Age and health of the patient: 

Younger patients tolerate surgery better than do the elderly.  Recovery times are faster for younger and healthier people.  Younger people usually do not have significant medical problems (high blood pressure, heart disease, lung disease, etc.) that would complicate the surgery and recovery period.  

Mechanism of injury: 

Back pain that develops over many years with increasing pain that did not have an abrupt cause (car accident, fall, work injury, etc.) usually is associated with changes in the anatomy of the spine.  These changes could significantly impact the surgical procedure and recovery time.  For example, arthritis of the spine is very common and develops much faster in patients with back pain over many months and years.  If surgery is performed, the arthritis is usually present at many different locations in the spine.  While there may be a successful surgery and recovery, widespread arthritis of the spine may limit the improvement that was expected when the patient decided to have surgery.  

On the other hand, an abrupt injury that causes a change in the disc (herniation or protrusion) that puts pressure on a nerve usually responds well to surgical correction if treated rapidly before arthritic changes can develop.  During the surgery in this case, there are fewer chances of complications since the injury caused a specific problem usually at only one location without widespread disease of the spine already present.   

Patient's Occupation: 

This is a very important consideration.  A patient with a sedentary type of job (deskwork, supervisor, light lifting, etc.) would still be able to work and earn a living even with some discomfort.  Treatment can be ongoing as the patient still remains employed.  Therapy and exercises could be tried for a longer period of time before considering the surgery.    There would be a very different situation if the patient had a physical job (driver, packer, baggage handler, bricklayer, carpenter, laborer, etc.) where he or she is unable to work because of the pain.  Now a whole different set of family dynamics comes into play.  Not many families can absorb a long period of no income!  Bills for food, children's clothing, tuition, rent and other expenses do not stop because of a back injury! 

Sometimes employers will offer a light duty position that will be less strenuous. Inquiring of the employer about taking a light duty position on a temporary basis is worthwhile and should be investigated. Income from the light duty position, even if less than the normal salary, will offset some of the financial burden associated with inability to work. Light duty gives the injured person a more normal set of daily activities. He or she carries the responsibility of getting up every day, getting to work, earning a living and dealing with normal living tasks. Very frequently, injured people fall rapidly into a very dangerous state of malaise. The longer a person is away from work of some sort, the lower the chance of ever returning to work at all.

Even with a back or neck pain, performing normal daily activities including some type of work is essential. When the pain limits these normal daily tasks with no significant improvement after 6 months, surgery may be an option. 

Interpretation of Test Results: 

It is very important to have the necessary diagnostic tests.  Initially, a qualified physician familiar with spine anatomy and nerve injury performs a history and physical examination.   These examinations should be performed frequently to assess progress and response to treatment.  Changes in the treatment program can be made with these periodic assessments.   

Many diagnostic tests are available.  These would include XRay, CT Scan, MRI, EMG, NCV, SSEP and others which all have their place in specific situations.  (Each of these will be discussed in future newsletters.) 

The patient presents to the doctor with symptoms that are usually explained as stiffness, weakness, pain or numbness.  These symptoms are what are referred to as subjective complaints.  The abnormalities that the doctor finds on physical examination are referred to as objective findings. It is very common to find abnormalities on diagnostic tests that have nothing to do with the patient's problem! This is especially true of the MRI and CT imaging studies.

SURGERY PERFORMED FOR THESE UNRELATED ABNORMALITIES WILL NOT HELP THE PATIENT. THIS TYPE OF SURGERY WILL DO MORE HARM THAN GOOD AND IT SHOULD BE AVOIDED AT ALL COST!

Matching the results of diagnostic tests to the subjective complaints of the patient and the objective findings of the doctor is critical when trying to determine if surgery would be of benefit to the patient.  Most physicians treat patients, not their MRI's or XRays!

Response to Treatment:

This seems quite obvious and is usually misleading. Needless to say, if a treatment program is working and there is no progression of damage to the nerves, it probably should continue.  How long is long enough? 

Therapy performed over a period of months, in most cases, is no longer improving the patient's condition. This therapy is actually being used for maintenance. Most of the time, a good home exercise program is equally effective in maintaining the level of improvement reached with treatment. Since it is far better for the patient to be independent of the therapist as soon as possible, most reputable therapists start teaching the home program very early in the program. A major goal of any treatment plan should be to make the patient confidently independent of the therapist.

Obviously, there are different levels of improvement. If therapy is successful in easing some of the pain during sitting and standing that does not mean that a patient is able to return to work unloading trailers! Improvement must be viewed in the proper context.

A worker's response to treatment in a controlled environment with limited physical activity does not demonstrate his or her ability to return to a physically demanding job.  Most back pain will improve if the patient limits their activity.  If the patient needs to go back to work in a more rigorous atmosphere, the improvement in therapy may not be sufficient to avoid surgery.  The point here is that improvement must be judged in the proper setting!  Surgery may be necessary even if the patient shows some improvement on treatment.   

Summary: 

Our injured worker described in the question has a lot to consider. If there is a surgically treatable cause for his continued pain (disc herniation for example) that corresponds to his subjective symptoms and the doctor's objective findings, if he has had only limited improvement after 6 months of treatment, if he can not work in his present condition, and if he has no other significant medical problems that might complicate his recovery, he may consider the surgical option.

These decisions must be made with the guidance of the treating physician and surgeon considering all of the specifics that pertain to the individual. As a general rule, I always promote personal responsibility and independence from medication and therapy as soon as possible. There are times when surgery is the option that allows for a more rapid and complete resolution to these complex problems.

As always, this discussion was not meant to be a substitute for consultation with qualified physicians and surgeons.  Surgery is a major decision and needs to be considered carefully.  No decision for or against surgery should be based on this discussion alone!   This newsletter exists to educate our readers in the causes, diagnosis and treatment of neck and back pain.  Questions from our subscribers provide the topics for discussion.