Tag Archives: neck and back pain

Spine-Related Musculoskeletal Conditions – Part 5 – Disc Bulge, Disc Herniation, and Disc Protrusion

Our posts in this series have been reviewing spine-related musculoskeletal conditions that are frequently seen in dentists and surgeons.  In this post, we will be looking at disc bulge, disc herniation, and disc protrusion.

Disc Bulge, Disc Herniation, and Disc Protrusion

Definitions:

  • Disc Bulge: Protrusion of a spinal disc outside the vertebral body that has not fully ruptured through the disc membrane, known as the annulus.
  • Disc Herniation: Protrusion of a spinal disc outside the vertebral body that has ruptured through the annulus, exposing a portion of the nucleus – the gel-like center of the disc.
  • Disc Protrusion: A general term to describe any type of disc bulge or herniation, in which a portion of the disc protrudes beyond the vertebral body.

Overview: A number of terms are used to describe spinal disc pathology and the associated symptoms.  To complicate matters further, there is not a clear consensus among medical professionals about the precise meaning of each term.

There are thirty-three vertebrae in the vertebral column of the human spine, twenty-four of which articulate and move.  Between each of the vertebrae in the three articulating sections of the spine – the cervical, thoracic, and lumbar spine – there is an intervertebral disc.  Each disc, composed of soft jelly-like center (nucleus) surrounded by a capsule of connective tissue (annulus), provides shock absorption and flexibility within the spine. When the protrusion puts pressure on the spinal cord or a nerve root, it can lead to a wide range of symptoms.

Symptoms: Symptoms will vary based on the location of the disc:

  • Lumbar: Pain radiating down the leg (sciatica) is the most common symptom associated with a lumbar disc herniation. Weakness in the foot and difficulty when raising the big toe (foot drop) and numbness/pain on the top of the foot are also prevalent.
  • Cervical: Pain, weakness, numbness, and tingling in the shoulder, arm, or hand depending on the location of the herniated disc.

Causes: Disc bulges are often the result of the normal process of aging, and by themselves may not cause any recognizable symptoms. Bad posture associated with frequent sitting or standing and occupational hazards such as repetitive bending or standing can accelerate the formation of disc bulges.

Disc herniation is often a progression in severity from a disc bulge.  As discs wear down over time, they may degenerate and lose some of their water content.  This condition, known as Degenerative Disc Disease, is discussed in greater detail below.  As discs degenerate and degrade, they become more flexible and the annulus may be more susceptible to tearing or rupturing.  Disc herniation can also be caused by traumatic, acute injuries such as a hard fall or blow to the back.

Diagnosis:  Diagnosis of a herniated or bulging disc typically begins with a physical exam that tests the patient’s reflexes, muscle strength, walking ability, and sensory perception (light touches, pin pricks, etc.).  If a protrusion is indicated by the physical test, imaging may be ordered in the form of X-rays, MRIs, CT scans, and/or Myelograms.

Treatment:  Non-invasive treatment may include heat therapy, exercise, physical therapy, chiropractic treatment, therapeutic ultrasound, and medication.  Epidural steroid injections may be considered as an intermediate treatment.  For more severe cases, a microdiscectomy may be performed, typically in an outpatient setting.  In this procedure, a small portion of bone and/or disc material is removed to relieve pressure on the affected nerve root.

Our next post will discuss degenerative disc disease.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

References:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Spine-Related Musculoskeletal Conditions – Part 4 – Spondylolisthesis

In this series of blog posts, we have been reviewing spine-related musculoskeletal conditions.  The next condition we will be looking at is spondylolisthesis.

Spondylolisthesis

Definition: Occurs when a vertebra (typically in the lumbar spine) slides forward over the vertebra beneath it.

Overview:  The vertebrae in the spinal column are linked together by small joints (facets) that permit the spine to bend forward (flexion) and backward (extension) while limiting rotational movement.  Spondylolisthesis occurs when a joint defect in the vertebrae (resulting from either a stress fracture or degeneration) permits one vertebra to slip forward on the one beneath it.

Spondylolisthesis is most common in the lower back, though in rare cases it can occur in the cervical spine.  It most frequently occurs at the L4-L5 and L3-L4 levels of the lumbar spine.

There are two types of spondylolisthesis: isthmic spondylolisthesis (IS) and degenerative spondylolisthesis (DS). IS occurs when a stress fracture of a small bone called the pars interarticularis permits a vertebra to slip forward over the vertebra below it.  IS is rare, and is most common in young children who participate in sports that put repeated stress on the lower back.

DS is far more common and most regularly occurs among people over the age of 50.  DS is a result of the gradual breakdown of the intervertebral discs and the facet joints in the spine.  As the discs lose volume, more stress and pressure is placed on the facet joints.  As the facet joints begin to degrade under the increased wear and pressure, they may allow too much flexion and cause a vertebra to slip forward over the vertebral body below it.

The slippage can place direct pressure on the spinal cord (spinal stenosis) and on the nerve roots exiting the spinal column (foraminal stenosis).

Symptoms: Lower back pain, leg pain (especially “running down” the leg), and sciatic pain are common.  Numbness or weakness often occurs in one or both legs.  Leg/back pain that is worse when bending over or twisting is common, as is pain that is worse standing than sitting.

Causes: Degenerative disc disease is a common cause of spondylolisthesis.  As we discussed above, when the intervertebral discs lose volume the spinal column becomes more compressed.  Without the shock absorption of the discs, more pressure is exerted on the facet joints.  This pressure and wear accelerates the degradation of the facets and allows for the increased flexion in the spine that can lead to vertebral slippage.  As clinical dentistry has moved from a standing profession to a seated one, dentists are at a higher risk for lower back conditions like spondylolisthesis.  Axial loading (the weight of the body compressing the spine vertically) on the lumbar spine is significantly higher in a seated position than it is standing.

Diagnosis: X-rays are used to determine whether or not a vertebra is out of place.  If the displaced vertebra is putting pressure on the spinal cord or nerve roots, a CT scan may be ordered to identify the severity of the problem.

Treatment: As with many other conditions discussed in this series, conservative treatment may include some combination of physical therapy, exercise, strength training, manual manipulation, and medication.  Epidural steroid injections are sometimes prescribed for those in severe pain.  Spinal fusion surgery is sometimes used for severe pain that has not been successfully treated with less invasive treatment.  Typically, a posterior fusion with a pedicle screw implementation is used, but a surgeon may also recommend a spinal fusion done from the font of the spine simultaneously.

Our next post in the series will examine disc bulge, disc herniation, and disc protrusion.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

References:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Spine-Related Musculoskeletal Conditions – Part 3 – Stenosis

In this series, we have been looking at spine-related musculoskeletal conditions that many dentists and surgeons suffer from.  In this post, we will be looking at spinal and foraminal stenosis.

Cervical Spinal Stenosis:

Definition: The narrowing of the spinal canal in the cervical vertebrae, often due to inflammation of the surrounding cartilage and tissue.

Overview: The spinal canal is formed by the hollow spaces in the middle of the vertebrae, which form a protective tunnel for the spinal cord to pass through the spinal column. Cervical spinal stenosis is a progressive and potentially dangerous condition that occurs when inflammation narrows the cervical spinal canal. The narrowing of this already tight space can result in direct pressure on the spinal cord, leading to a number of neurological complications.  Cervical spinal stenosis can be crippling if the spinal cord becomes damaged.

Symptoms: Symptoms usually develop gradually over time and can include numbness, weakness, tingling in neck, shoulders, arms, hands, or legs, as well as intermittent, sharp pain in the arms and legs, especially when bending forward.  Deterioration of fine motor skills and issues with gait and balance can also occur.  In more severe cases, bladder and bowel issues may develop.

Causes: Though in rare cases cervical spinal stenosis is a congenital condition, it often results from inflammation due to other spinal conditions, such as spinal osteoarthritis, degenerative disc disease, and disc bulging.

Diagnosis: A combination of X-ray, MRI, and computed tomography (CT) scans may be used to diagnose spinal stenosis.  Blood tests may be used to eliminate other diseases such as multiple sclerosis and vitamin B12 deficiency.

Treatment: Conservative, non-invasive treatments may include exercise, physical therapy, and activity modification.  Medications may include anti-inflammatory drugs, narcotic pain medication, muscle relaxers, and epidural steroid injections.  In more severe cases, several surgical options exist, dependent upon the particular characteristics of the patient’s condition:

  1. Anterior cervical discectomy/corpectomy with fusion (ADCF): The spine is accessed through the front of the patient’s neck, the disc is removed from between the two vertebrae, and the vertebrae are then fused together to stabilize the spine.
  2. Laminectomy: This is a “decompression” surgical procedure performed to relieve pressure on the spinal cord. In this surgery, the lamina (the rear portion of the vertebra covering the spinal canal) is removed from the affected vertebra to enlarge the spinal canal and decrease pressure on the spinal cord.
  3. Interspinous Process Spacers: In this procedure, small metal spacers are surgically placed between the vertebrae to restore the spacing typically created by a healthy disc. This procedure is typically reserved for individuals with foraminal stenosis, however, and has only had limited effectiveness with patients suffering from spinal stenosis.

Foraminal Stenosis

Definition: Compression of the nerve roots connected to the spinal cord, caused by the narrowing of the passageway through which the nerves exit the spinal column.

Overview: The nerve roots branching off the spinal cord to other parts of the body exit the spinal column through small openings on the sides of the vertebrae called a foramen. This space can become clogged or narrowed due to a number of spine-related conditions. The narrowing or partial obstruction of the foraminal canal caused by one of these conditions can put pressure on the nerve roots emerging from the spinal column, and may lead to an array of neurological symptoms that get progressively worse over time.

Symptoms: Tingling, numbness, or weakness in the feet or hands.  Local pain in the extremities.  “Pins and needles” or burning sensation. Intermittent neck or back pain.

Causes: Bulging or herniated discs may obstruct the foraminal canal, putting pressure on the nerve roots.  It can also be caused by spinal osteoarthritis, osteophytes, and spondylolisthesis.  Dentists are susceptible to foraminal stenosis, as they often hold their necks in extended positions.

Diagnosis: A CT scan and a Myelogram are used to diagnose foraminal stenosis. A Myelogram is an X-ray in which an opaque dye (which shows up on the X-ray) is injected into the sac around the nerve roots. The dye moves through the foramina, allowing the doctor to see the degree to which the foramen is narrowed or obstructed.

Treatments: Conservative treatments may include physical therapy, stretching and strength training, and oral pain-relieving medication. Corticosteroid injections are an option for more severe cases to reduce inflammation and pain.  In extreme cases, a surgical procedure known as a foraminotomy may be used to remove the bone spur or disc material that is putting pressure on the nerve root as it exits the spinal column through the foramen.

Our next post in this series will discuss spondylolisthesis.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

References:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Spine-Related Musculoskeletal Conditions – Part 2 – Spinal Osteoarthritis

In the first part of this series, we discussed the fact that dentists and surgeons often suffer from musculoskeletal conditions.  In the remaining posts in this series, we will be looking at particular musculoskeletal conditions, starting with spinal osteoarthritis.

Spinal Osteoarthritis

Definition: Spinal osteoarthritis is also known as degenerative joint disease. It is a breakdown of the cartilage in the facet joints, which link together the spine’s vertebrae.

Overview: At the top and bottom of each vertebra is a small pair of joints called facets. Facets connect the vertebrae in order to restrict movement in certain directions and to allow the spine to move as one fluid unit.  The surfaces of the facets, like any other joint in the human body, are covered by a lubricating cartilage which allows them to operate smoothly and with little friction.

When the cartilage protecting the facets degrades or wears down, the bony surfaces of the facets rub against each other.  This can cause inflammation, severe pain, and the formation of osteophytes (bone spurs) on or around the joint surfaces.  It may also cause numbness and/or weakness in the legs and arms as a result of contact between the vertebrae and the nerves leaving the spinal cord.

Symptoms: Neck pain and stiffness. Severe pain may radiate down into shoulders and up the neck.  Weakness, numbness, or tingling in the fingers, hands, and/or arms are also often present.  Usually back discomfort is relieved when a person is lying down.  Studies have also linked anxiety and depression to osteoarthritis.[1]

Causes: Spinal osteoarthritis frequently occurs in conjunction with degenerative disc disease.  As the discs between the vertebrae in the spinal column degrade and decrease in volume, the increased pressure and contact between the facet joints can cause an accelerated degradation of the joint cartilage.

Repetitive strain or stress on the spine, often due to poor posture, to is a common cause of spinal osteoarthritis.  People with jobs requiring repetitive movements and strained positions are considered to be at greater risk for conditions like spinal osteoarthritis; however, injury or trauma to a joint or a genetic defect involving cartilage are also causes.  Dentists are at a higher risk than many other professions to develop this condition due to the awkward, static postures they must maintain.

Diagnosis: X-rays may be used to identify loss of cartilage, bone spurs, and bone damage. Magnetic resonance imaging (MRI) may be used to analyze the intervertebral discs and the nerves exiting the spinal column.

Treatment: Conservative, non-invasive treatment plans may include some combination of heat/cold therapy, medication, physical therapy, strength training, and stretching. In more severe cases, a surgical treatment such as spinal fusion is utilized.

Our next post in this series will examine spinal stenosis, another common cause of neck and back pain.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

[1] Sharma, A., et. al, Anxiety and depression in patients with osteoarthritis: impact and management challenges, Open Access Rheumatology: Research and Reviews 2016:8 (2016).

References:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Spine-Related Musculoskeletal Conditions – Part 1 – Spondylosis

Living with a spine-related condition can be scary and overwhelming. Unfortunately, the complex nature of the spine and the nervous system can often make the search for answers a frustrating and demoralizing endeavor.  In this series of posts we are going to talk about several spine-related musculoskeletal conditions, many of which are frequently diagnosed in dentists, surgeons, and other physicians.

If you are suffering from a spine-related condition, you have likely visited not only your primary care physician, but also a physical therapist, a chiropractor, a neurologist, an orthopedic surgeon, and/or a pain management doctor.  It’s common for those suffering from a musculoskeletal condition to hear several different terms to describe a set of symptoms, be given multiple explanations for what is causing their pain, and be given a variety of (often conflicting) treatment recommendations.

Dentists and physicians in certain surgical specialties are particularly susceptible to spine-related musculoskeletal conditions, which are among the top reasons insureds file disability claims.  The forward-flexed, static posture that dentists and surgeons must maintain to perform procedures can lead to the overuse and repetitive strain of the neck and back, and contribute to the development of a litany of musculoskeletal conditions.  One study showed that 62% of the general population present musculoskeletal work-related pain, and this increased to 93% when the sample population was made up entirely of dentists.[1]  Unfortunately, although one often thinks of spinal and back injuries occurring later in life after years of strain, chronic musculoskeletal pain is experienced by many dentists by their third year of dental school.[2]

We’ve created this series of blog posts as a resource to help clear up some of the confusion surrounding the common terms used to refer to spine-related musculoskeletal conditions.  For each term we’ll provide a definition, overview, list of common symptoms, causes, methods of diagnosis, and common treatments. In this post, we’re going to briefly look at spondylosis, and then in later posts we will take a more in depth look at some other spine-related conditions.

Spondylosis

Definition: This is an umbrella term used to broadly describe degeneration in the spine.  Some doctors may use it interchangeably with spinal osteoarthritis.  Spondylosis is a descriptive term rather than a clinical diagnosis – it is used to describe anyone suffering from both pain and spinal degeneration.  If your doctor uses this term to describe your condition, you may want to your physician for a more specific diagnosis.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

[1] Dias, Ana Giselle Aguiar, et. al, Prevalence of repetitive strain injuries/work related musculoskeletal disorders in different specialties of dentists, RGO, Rev. Gauch. Odontol. Vol. 62 no. 2, Campinas Apr./June 2014,  http://dx.doi.org/10.1590/1981-8637201400020000042714  (citing Regis Filho GI, Michels G, Sell I. Lesões por esforços repetitivos/distúrbios osteomusculares relacionados ao trabalho em cirurgiões-dentistas. Rev Bras Epidemiol. 2006;9(3):346-59, http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1415-790X2006000300009&lng=en).

[2] Kristina Lynch, My back is hurting my practice, Part I, AGD Impact, Feb. 2006.

References:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Alternative Treatments for Chronic Pain

Often, when an insured begins to suffer chronic pain, the insured’s first thought is to contact his or her doctor to seek out a prescription for pain medication.  At the same time, many insureds do not want to take pain medication because such medication can often have harmful side effects.  In this post, we will be looking at some alternative methods of treating chronic pain that insureds who are hesitant about taking pain medication may want to consider.

Acupuncture[1]

This is a technique where practitioners stimulate specific points on the body by inserting thin needles into the skin.

The Case For.  Results from several studies suggest that acupuncture is an effective method of treating chronic pain, particularly low-back pain, neck pain, and osteoarthritis/knee pain.

The Case Against.  Studies also suggest that, although acupuncture can help relieve back pain immediately after treatment, it is less effective as a long-term solution.  Additionally, improperly performed acupuncture can cause serious side effects, including infections, punctured organs, collapsed lungs, and injury to the central nervous system.

Hypnosis[2]

Stress often aggravates and increases chronic pain.  Hypnosis seeks to lessen pain levels by alleviating stress levels.

The Case For.  Multiple studies have shown that hypnosis is useful for reducing pain, including an analysis of studies by the Mount Sinai School of Medicine that revealed moderate to large pain-relieving effects from hypnosis.

The Case Against.  Other studies suggest that the positive effects of hypnosis are merely the result of a placebo effect.

Yoga[3]

While exercise is often recommended as a treatment for chronic pain, many insureds fear that rigorous exercise will actually increase, not lessen, their pain.  Yoga offers a gentle way to exercise that doesn’t involve too much stress on joints while still enabling you to strengthen the muscles around your joints.

The Case For.  Duke University Medical Center completed a review of 20 years’ worth of studies and found that yoga is an effective treatment for many forms of chronic pain, including osteoarthritis, carpal tunnel syndrome, and fibromyalgia.

The Case Against.  Yoga can be difficult for people who aren’t very flexible, and classes can sometimes be too strenuous for those just starting out.  Beginners should start with basic poses before attempting advanced poses that could exacerbate their pain if not performed properly.

Food[4]

Many people assert that altering your diet is an effective method of fighting pain-causing illnesses.  More specifically, foods that have been linked to lowering pain levels include:

  • Cherries (arthritis, muscle pain)
  • Ginger (migraines, arthritis, sore muscles)
  • Salmon (aching back, neck, and joints)
  • Turmeric (aching joints)
  • Edamame (arthritis)
  • Hot peppers (arthritis)

The Case For.  All of these foods are easy to find and fairly easy to work into your diet.  They are also present a natural alternative to medicines that may have potentially harmful side effects.

The Case Against.  These treatment options won’t necessarily work unless the rest of your diet is fairly healthy.  The potentially helpful effects of these foods will often be offset by the junk food that many people consume.  Consequently, a major overhaul your diet may be necessary in order to see any meaningful results.

Continue reading Alternative Treatments for Chronic Pain

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Pain Killers and Their Risks

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We have talked extensively about how various disabilities, such as arthritis, carpal tunnel syndrome, and chronic neck and back pain, can affect you and your practice. One of the ways of dealing with all of these disabilities is to take painkillers such as Advil and Aleve, or NSAIDs (non-steroidal anti-inflammatory drugs). Many people will be prescribed these medications, or take them over-the-counter, for issues ranging from a small headache to disabling pain.

However, just because these drugs are common doesn’t mean they’re completely foolproof or safe. Recently, the FDA has announced that there should be changes made to the labels of NSAIDs regarding their risks. Instead of saying that they “may cause” an increased risk of heart attack or stroke, the FDA urges that the wording should state that they do “cause an increased risk”.

In 2013, a study found that high doses of NSAIDs heightened the risk of heart attack by one-third. In a 2014 study, people taking NSAIDs were 19% more likely to die from a stroke. It is also important to understand that while higher risks occur at higher doses, the FDA warns that the increased chance of heart attack and stroke can occur as early as one week into treatment. Also noteworthy is that if you, or your family, have a history of heart disease, you are even more susceptible.

Even more interesting is that taking antidepressants and NSAIDs at the same time has been shown to heighten one’s risk for intracranial hemorrhage, which is bleeding that occurs around the brain. While the occurrence of bleeding was still relatively low (only about 6 per 1000 people studied), the combination of the two drugs increased occurrence by 60%.

This is especially relevant not only due to doctors and dentists having a great chance to develop debilitating pain due simply to their professions, but also because it is shown that doctors and dentists are also at a higher risk for depression and mental illness.

While we certainly don’t encourage you to stop taking your NSAIDs, we simply advise that you stay educated about what these medications mean for your health. We also recommend speaking with a doctor about your options and what would be best for your specific health needs. If your pain is so incapacitating that you you think you may need to file for disability, be sure to contact a disability insurance lawyer so they they can help you with the process.

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