Patient education center

Low back pain is considered to be chronic if it has been present for greater than three months. Chronic low back pain may originate from an injury, disease or stresses on different structures of the body. The type of pain may vary greatly and may be felt as bone pain, nerve pain or muscle pain. The sensation of pain may also vary. For instance, pain may be achey, burning, stabbing or tingling, sharp or dull, and well-defined or vague. The intensity may range from mild to severe.

Many times, the source of the pain is not known or cannot be specifically identified. In fact, in many instances, the condition or injury that triggered the pain may be completely healed and undetectable, but the pain may still continue to bother the patient. Nevertheless, even if the original cause of the pain is healed or unclear, the pain felt by the patient is real and the treating physician knows this.

Chronic low back pain may be the result by many different conditions. It may start from diseases, injuries or stresses to a number of different anatomic structures including bones, muscles, ligaments, joints, nerves or the spinal cord. The affected structure sends a signal through nerve endings, up the spinal cord and into the brain where it registers as pain.

A number of different theories have developed to try to explain chronic pain but the exact mechanism is not completely understood. In general, it is believed that the nerve pathways that carry the pain signals from the nerve endings through the spinal cord and to the brain may become sensitized. Sensitization of these pathways may increase the frequency or intensity with which pain is perceived. A stimulus that is usually not painful, such as light touch, can be amplified or changed by these sensitized pathways and experienced as pain. Sometimes, even after the original injury or disease process has healed, sensitized pathways continue to send signals to the brain. These signals feel just as real and sometimes worse than the pain caused by the original injury or disease process.

Imagine an old television set or computer screen in which the same image is projected continuously. This image is eventually “burned” into the screen. Even when the screen is turned off, the image can still be seen on the screen. In the same manner, after the original source of pain is healed or no longer present, chronic pain patients may continue to feel pain. Although this is an oversimplification of what may happen in chronic pain, it helps to illustrate the current understanding of this condition.

How is chronic low back pain diagnosed?

As mentioned earlier, chronic low back pain is defined as back pain that lasts greater than three months. During the evaluation of chronic back pain, the goal is to rule out any injuries or disease processes that place the patient at risk of further injury if not treated or addressed. In addition, a specialist will consider diagnoses that can be treated in order to reduce the pain. A good patient history and a thorough physical examination by a well-trained physician are the most important aspects of the evaluation. Serious injuries and illnesses can often be diagnosed or ruled out based on the history and physical exam alone. Lack of a definite diagnosis does not necessarily mean more testing is needed. Needless tests do not add anything to what the physician has already discovered in his or her physical examination and review of previously performed studies and treatments. In fact, unnecessary testing is not only expensive to the patient, but can expose the patient to unnecessary risks or radiation.

If the treating physician feels that more testing is needed based on the patient’s history and physical exam findings, he or she will discuss this with the patient. Testing may include blood tests, radiography (X-ray imaging), bone scans, computed tomography (CT) scans, magnetic resonance imaging (MRI), diagnostic injections, electromyography (EMG) and many other specialized tests.

Often, the exact cause of the pain is still not well defined at the end of the evaluation. Nevertheless an evaluation is successful if it has ruled out those processes that place the patient at risk if they are not treated.

What treatments are available?

Treatments for chronic back pain can vary greatly depending on the type and source of the pain. If a treatable source of the pain is found, then the underlying process can be addressed. When the underlying cause is either not specifically identifiable or not amenable to treatment, then the symptoms are treated. The goals of the treatment are to reduce pain, improve quality of life and increase function.

There are several different general categories of treatment that are usually recommended for chronic back pain. These categories include physical therapy, medications, coping skills, procedures and alternative medicine treatments. The treating physician will tailor a program involving a combination of these options to address the patient’s needs. Involvement of a physician with special training in chronic pain management may be advisable in some cases.

Physical therapy includes patient education, and patient training in a variety of stretching and strengthening exercises, manual therapies and modalities (ice, heat, transcutaneous electrical nerve stimulation [TENS], ultrasound, etc.). Active therapies which the patient can continue on his or her own (such as exercise and strengthening) usually have the most permanent and long lasting effects. A home exercise program (HEP) is usually in place before the patient is discharged from therapy. Exercise and strengthening are designed to increase stability and strength around the structures in the back that are being stressed. These techniques also work to avoid deconditioning that results from decreased activity. Exercises are tailored specifically to the patient and the type of back pain being addressed.The goal of educating the patient is to prevent progressive loss of activity because of fear of movement.

Medications used for treatment of pain are multiple and varied. They fall into several different categories. Both non-narcotic and, rarely, narcotic pain medications may be used in the treatment of chronic back pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful with pain control and may help reduce inflammation. Muscle relaxants can also help with chronic pain and may enhance the effects of other pain medications. Nerve stabilizing drugs (antidepressants and antiseizure medications) are used to treat nerve-mediated pain. All these medications have different side effect profiles and interactions, and should be carefully monitored by a physician.

Coping skills are extremely important in the management of chronic back pain. Chronic pain directly affects all areas of a patient’s life. Pain affects mood, and a patient’s mood affects his or her ability to cope with pain. Pain also affects how patients interact with other people. For this reason, teaching patients appropriate coping skills for dealing with anxiety, depression, irritability and frustration can be invaluable. Involvement of a trained pain specialist, psychologist or psychiatrist greatly enhances the treatment of chronic back pain.

Procedures ranging from minimally invasive injections to surgery may be used to manage chronic pain. Sometimes, implantable devices, such as a spinal cord stimulator, are beneficial in managing chronic pain. The patient, with the help of his or her physician, should discuss the potential risks and benefits of any procedures considered. A second opinion may provide additional information or alternative approaches to managing your condition.

Complementary medicine also offers a variety of treatments, often helpful in the treatment of chronic pain. These treatments include acupuncture, dry needling, nutritional therapy, use of magnets and many others. It is important for a patient to discuss these treatments with his or her treating physician, to ensure that there are no harmful effects and that they do not interfere with other treatments being prescribed.

What is acute low back pain?

Acute low back pain is defined as low back pain present for up to six weeks. It may be experienced as aching, burning, stabbing, sharp or dull, well-defined, or vague. The intensity may range from mild to severe and may fluctuate. The pain may radiate into one or both buttocks or even into the thigh/hip area.

Low back pain may begin following a strenuous activity or jarring trauma, but often is seemingly unrelated to a specific activity. The pain may begin suddenly or develop gradually.

Who experiences acute low back pain?

At least 80% of individuals experience a significant episode of low back pain at some point in their lives. At any given point in time, at least 15% of individuals report that they are experiencing low back pain. Some consider the symptom of low back pain to be a part of the human experience.

What causes low back pain?

The exact source of acute low back pain is often difficult to identify. In fact, there are numerous possible pain producers including muscles, soft connective tissue, ligaments, joint capsules and cartilage, and blood vessels. These tissues may be pulled, strained, stretched or sprained. Additionally, annular tears (small tears that occur in the outer layer of the intervertebral disc) can initiate severe pain. Even if the actual tissue damage is minor, and likely to repair quickly, the pain experienced may be quite severe.

No matter which tissue is initially irritated, a cascade of events occurs which contributes to the pain experience. Numerous chemical substances are released in response to tissue irritation. These substances “stimulate” the surrounding pain sensitive nerve fibers, resulting in the sensation of pain. Some of these chemicals trigger the process of inflammation, or swelling, which also contributes to pain. The chemicals associated with this inflammatory process feed back more signals which perpetuate the process of swelling. The inflammation attributable to this cycle of events may persist for days to weeks.

Muscular tension (spasm) in the surrounding tissues may occur resulting in a “ trunk shift” (the body tilts to one side more than the other) due to muscular imbalance. Additionally, a relative inhibition or lack of the usual blood supply to the affected area may occur so that nutrients and oxygen are not optimally delivered and removal of irritating byproducts of inflammation is impaired.

How long will an episode of low back pain last?

The good news is that even if the exact source of pain is not determined, usually the acute pain subsides spontaneously over time. The originally irritated tissue heals. Fifty percent of episodes nearly completely resolve within two weeks, and 80% by six weeks. Unfortunately, the duration and severity of an a single episode cannot be predicted based on the onset, location of pain, or even the initial severity. Excruciating initial pain may resolve within several days, while moderate or mild symptoms may persist for weeks. However, up to 30% of individuals will experience recurrent pain or develop persistent pain in the future.

Is this pain dangerous?

The seriousness of low back pain is relative. The symptoms of acute low back pain are usually benign and self limited. Even a ruptured disc has a chance of improving without surgery. Rarely, however, low back pain is caused by a more serious process such as a fracture, infection or cancer. This is more common in individuals over age 50, those with a history of cancer, those with severe pain at rest, with associated fever, with underlying medical problems such as diabetes, heavy alcohol or drug use, long time corticosteroid use, or osteoporosis. Pain in the legs, weakness, or difficulty with bowel or bladder control warrant prompt medical evaluation. For all cases of pain lasting longer than six weeks, medical evaluation is advised.

How should acute low back pain be managed?

Some of the best advice for treatment for acute low back pain is to continue to remain active “as tolerated”. Continuing to perform everyday activities may seem counterintuitive, and the natural inclination may be to stay in bed or “freeze”, to guard and avoid activity. Yet, activity keeps blood and nutrients flowing to the affected area, inhibiting inflammation and reducing muscular tension. Many individuals with low back pain find that they can perform their usual, but more controlled cardiovascular activities, such as walking, in spite of the pain and often feel better after the activity. More vigorous or uncontrolled activities such as weight lifting or competitive or contact sports are inadvisable while pain is severe.

There is no reason not to completely avoid stretching muscles and tissues in the legs and back during an acute episode, but stretching should not cause more severe pain.

Local application of heat or ice can temporarily reduce pain and heat may facilitate stretching, but does not necessarily speed long term recovery.

Medication: Both acetominophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are analgesics (pain relievers) which are known to provide effective reduction in of acute low back pain. NSAIDs also inhibit the above described inflammatory process described earlier. These medications should be used only as prescribed by a physician. NSAIDs are associated with possible side effects in certain individuals and risk for such effects increases when used for prolonged periods. The more common side side effects include excessive bruising and bleeding, and stomach upset irritation, with kidney and liver problems possible with sustained use.etc.

“Muscle relaxants” are medications that do not actually relax skeletal muscle. However, they do calm or sedate the central nervous system and can be useful to facilitate sleep and secondarily reduce contributing emotional or muscular tension in the setting of severe pain. These medications must be used under the direction of a prescribing physician.

Narcotics (also called opioids) are strong pain relievers and do reduce the symptoms of acute low back pain. Because narcotics are sedating, they can be useful to facilitate sleep during the first few nights of symptoms. Long term use of narcotics is associated with undesirable side effects including physical dependency, sedation, depression, constipation, increased sensitivity of pain sensitive fibers, and interruption of restorative sleep cycle. Narcotics should only be used as prescribed by and under the direction of a physician.

Other treatments: Physical therapy modalities such as ultrasound, electrical stimulation, traction, mobilization and chiropractic manipulation can provide temporary relief, but are not proven to improve long term recovery. Acute low back pain usually resolves spontaneously and in most cases, as long as activity can be maintained, formal therapy is may not be required.

If the pain is severe, participation in activities is impaired, or if motion is significantly restricted, a physical therapist can provide additional education and advice regarding strategies for restoring motion, resuming activities, preventing deconditioning and achieving a position of comfort during sleep.

For those with persistent or recurrent low back pain, a medical evaluation is indicated and a physical therapist-supervised exercise program is likely advisable. The goal should always be towards developing and transitioning to a fully independent home or health club exercise regimen. Emphasis will likely be placed on optimizing trunk or “core” strength and improving general flexibility and cardiovascular endurance.

Spinal injections: Spinal injections are generally not considered an appropriate treatment for acute, self-limited low back pain. There are several injection options for persistent or recurrent pain, including epidural steroid, facet joint and trigger point injections, which can be determined following a comprehensive medical evaluation.

Do I need an X-ray or an MRI?

In most cases of acute low back pain, diagnostic testing is not required. X-ray imaging or other diagnostic tests may be advised in cases of pain associated with severe trauma, history of cancer, fever, diabetes, other medical problems, illicit IV drug use, age over 50, bowel or bladder dysfunction, nocturnal pain or osteoporosis. Various types of imaging tests can be obtained. These include regular X-ray studies, bone scan, computed tomography (CT) scan and magnetic resonance imaging (MRI). The choice of test depends on what medical condition your physician is suspecting. It is important to realize that the “final” diagnosis is based on a combination of history, physical examination and diagnostic testing, not imaging tests alone.

Acute low back pain can be a very painful experience, but fortunately often resolves fairly quickly. There are situations when the pain does not improve satisfactorily which should then prompt comprehensive medical attention. A variety of diagnostic tests and treatment options are available. The primary goal is to resolve the acute episode as quickly as possible and secondarily to prevent future episodes through proper education, exercise and conditioning.

General Information

The cervical spine refers to that portion of the spinal column that is within our neck. This portion of the spine needs to be flexible enough to allow us to turn our head from side to side and up and down, but at the same time needs be strong enough to protect the delicate spinal cord and spinal nerves that travel through it.

The cervical spinal column is made up of seven vertebrae and the discs and ligamentous bands between these bones. Each of these seven vertebrae has a channel within it through which the spinal cord travels. As part of the normal aging process, the discs lose some of their water content and start bulging out as we get older. In some patients, however, the bulging of the disc and other arthritic changes between the vertebrae results in narrowing of the space for the spinal cord and its branches, known as nerve roots. ‘Stenosis’ means narrowing and cervical stenosis refers to narrowing of the space for the spinal cord or nerve branches in the cervical spine.

The spinal cord is like the main cable that brings television signals to the house. The spinal nerve roots are branches of the main cable that carry signals to each room within a house. The spinal cord carries signals from the brain into our arms, legs and body and, at the same time, carries signals back to the brain from our arms, legs and body. The spinal nerve roots control individual muscles or are responsible for feeling in certain parts of the arm or leg.

Cervical myelopathy refers to a loss of function in the upper and lower extremities secondary to compression of the spinal cord within the neck. Cervical radiculopathy refers to a loss of function in a specific region within the upper extremity secondary to irritation and / or compression of a spinal nerve root in the neck.

What are the symptoms?

Cervical myelopathy tends to creep up on patients in most cases. It can result in subtle changes in the way their hands work. Patients feel their hands are clumsier; they may drop objects more often, they may not be able to button their shirts as easily as they could, or their handwriting may become worse. Patients may develop unsteadiness, requiring holding onto objects more frequently while walking. Their gait may become noticeably wobbly. At times, they feel their brain doesn’t know exactly where their legs are in time and space. In extreme cases, patients may develop more profound weakness and numbness in their arms and legs and rarely changes in bowel or bladder control.

Cervical radiculopathy will manifest itself as pain traveling from the neck into a specific region of either arm, forearm or hand. In many instances, this will be accompanied by numbness in a similar distribution or weakness in specific muscles in either the arm, forearm or hand.

What is the natural history of these conditions
(What could I expect if I do nothing?)

The “natural history” of cervical radiculopathy depends in large part on how long the patient has had symptoms for. In patients who present with very early symptoms, the prognosis is generally very good. Most of these patients will have complete resolution of their pain, numbness and weakness over a 6-12 week period.

In patients who have had symptoms for a slightly longer period of time, the prognosis is less clear. Some patients will go onto complete resolution of pain with (and, in some cases, without) limited treatment such as modification of activities, heat, ice, physical therapy or over-the-counter medications. Approximately one third of these patients will have some lingering degree of symptoms that they may be able to cope with. A small percentage will have symptoms that are unbearable and may need further treatment.

The “natural history” of clinically obvious cervical myelopathy is somewhat more guarded. The consensus is that patients with myelopathy will have progression of symptoms. What is not known is when the symptoms will progress, how much they will progress or how rapidly they will progress. Approximately 75% of patients will have stepwise deterioration in their function with stable periods in between the episodes of deterioration. Twenty percent will have slow steady deterioration and another 5% will have rapid deterioration.

How is it diagnosed?

You should see your doctor if you have worsening function in your arms and/or legs and if your primary care physician feels that this is related to your cervical spine. If you have persistent pain, numbness or weakness in one of your arms that is not relieved following a short period of observation, you should certainly see your doctor.

Your doctor will begin by letting you relate the history of how your symptoms began and how they progressed. You will be asked a series of questions and a physical examination then carried out that is directed primarily at your neck, and nerve function in your arms and legs. Your doctor will check your balance, test your gait.

X-rays may be requested and will in some patients show signs of degenerative changes in the disc spaces or facet joints. Bending x-rays of the neck may show a small degree of “slip slide” between the neck vertebrae.

Magnetic resolution imaging [MRI] of the neck may be ordered. MRI pictures allow your doctor to visualize structures that may be impinging on the spinal cord or the nerve branches. In some patients, injection of dye into the spinal cord [myelogram] may be required and this is followed by CT scans [computerized tomography].

Electrical testing of the nerves and spinal cord is requested in some patients. Electromyogram [EMG] and nerve conduction studies help distinguish cervical radiculopathy from other nerve problems in the arm and forearm such as carpal tunnel syndrome. Somatic sensory evoke potentials [SSEP] are electrical tests that study signal conduction through the spinal cord and may be ordered in some patients with cervical myelopathy.

What treatments are available?

Most patients with cervical radiculopathy will be treated initially with non-operative measures. These measures typically include a short period of modification of activities. Modification of activities may include simple techniques such as changing the height of your computer monitor or the height of your chair at work. Your doctor may recommend applying ice or head to the painful area, or using over-the-counter anti-inflammatory medications judiciously, keeping in mind that overuse of any medication can be accompanied by unwanted side effects. Prolonged bed rest can lead to deconditioning and is generally not recommended.

In patients whose pain is not controlled with these measures, stronger medications such as prescription anti-inflammatory agents, muscle relaxants or narcotic analgesics may be required for a short period of time. Physical therapy is an important part of the rehabilitation process. Your physical therapist will carry out an evaluation of your function, and then instruct you on proper ergonomics and a gentle program of stretching and flexibility. As the pain resolves, mild strengthening exercises will be instituted. A primary benefit of physical therapy conditioning is avoidance of secondary stiffness or inflammation at your shoulder, elbow or elsewhere in the neck and upper extremities, commonly seen in patients who have pain and weakness.

In some patients with cervical radiculopathy, your doctor may recommend injection treatments for your problem. Most commonly, these will be epidural steroid injections. These are targeted injections of corticosteroid into the area around the nerve that is inflamed in your neck. The purpose of the injection is to reduce the inflammation and relieve the pain associated with the irritated nerve.

In patients with mild cervical stenosis and without clinically obvious myelopathy, cautious nonoperative care is an option. This generally begins with a thorough education regarding their condition. Patients need to understand that narrowed dimensions of their spinal cord can predispose them to myelopathy at some point in the future.

Patients should be cautious to avoid situations or injury that might place their spinal cord at more risk. A short period of immobilization in a soft cervical collar may be helpful in some patients. Physical therapists can help with instructions on proper gait mechanics and the use of canes or walkers that can prevent falls. Occupational therapists can provide suggestions that help with everyday tasks such as bathing, dressing, opening jars or turning keys.

In patients who have narrowing of the space for the spinal cord, progressive myelopathy may be precipitated by the development of degenerative changes with age, injury to the already compressed spinal cord from a fall or motor vehicle collision, spinal instability or a combination of all of the above. If symptoms of cervical myelopathy are evident or progressing, you ought to be assessed by your doctor.

Surgery for Cervical Stenosis, Myelopathy and Radiculopathy

In those patients where nonoperative measures are unsuccessful, surgical measures provide a good option. Your NASS doctor may recommend surgical intervention for cervical radiculopathy either through the front [anterior] or the back [posterior] of the neck, or both the front and back of your neck. Several factors will be considered by your NASS doctor in choosing the type of surgery you undergo. These will include the exact location of any compression on your spinal cord or nerve branches, the number of levels at which there is compression, the overall alignment of your cervical spine and your overall medical condition.

When surgery is carried out through the front of the neck, a small incision is made in the front of your neck. The tissues are gently moved to the side and the cervical vertebrae easily accessed. The structures impinging on the nerve root are removed. Frequently a block of bone obtained from a bone bank or your pelvis will be inserted in the disc space and a metal plate and screws will be used to stabilize two vertebra. Anterior surgery may be required at more than one level and may require removal of the discs and the vertebrae. Following surgery you may be in a neck brace for a short period of time depending on the surgical procedure.

When surgery is carried out through the back [posterior] of the neck, a small incision is made directly over the area where the nerve branches off of the spinal cord. A high speed burr may be used to remove some of the bone spurs impinging on the nerve branch. Small disc fragments can be removed through this hole. Following surgery, a period of immobilization may be used.

Posterior surgery can also involve a wider decompression of the entire cervical spinal cord through two operations: laminectomy and laminoplasty. In both of these operations, the pressure on the spinal cord is relieved by removing portions of the back of the vertebra. In laminectomy, the back of the vertebra is completely removed. In laminoplasty, a hinge is created on one side of the back of the vertebra and the lamina lifted up on this hinge to make room for the spinal cord. Occasionally metal screws and plates are used following either of these operations to stabilize the cervical spinal column.

What is it? How is it treated?
What is a herniated disc?

The spine is made up of a series of connected bones called "vertebrae." The disc is a combination of strong connective tissues which hold one vertebra to the next and acts as a cushion between the vertebrae. The disc is made of a tough outer layer called the "annulus fibrosus" and a gel-like center called the "nucleus pulposus." As you get older, the center of the disc may start to lose water content, making the disc less effective as a cushion. This may cause a displacement of the disc’s center (called a herniated or ruptured disc) through a crack in the outer layer. Most disc herniations occur in the bottom two discs of the lumbar spine, at and just below the waist.

A herniated lumbar disc can press on the nerves in the spine and may cause pain, numbness, tingling or weakness of the leg called "sciatica." Sciatica affects about 1-2% of all people, usually between the ages of 30 and 50.

A herniated lumbar disc may also cause back pain, although back pain alone (without leg pain) can have many causes other than a herniated disc.

What treatments are available?

Most (80-90%) patients with a new or recent acute disc herniation will improve without surgery. The doctor will usually try using nonsurgical treatments for the first few weeks. If the pain still keeps you from your normal lifestyle after completing treatment, your doctor might recommend surgery. Although surgery may not return leg strength to normal, it can stop your leg from getting weaker, and relieve leg pain. Surgery is usually recommended for relief of leg pain (>90% success); surgery is less effective in relieving back pain.

Nonsurgical treatment

Your doctor may prescribe nonsurgical treatments including a short period of rest, anti-inflammatory medications to reduce the swelling, analgesic drugs to control the pain, physical therapy, exercise or epidural steroid injection therapy. If you are told to rest, follow your doctor's directions on how long to stay in bed. Too much bed rest may give you stiff joints and weak muscles, which will make it harder to do activities that could help reduce the pain. Ask your doctor whether you should continue to work while you are being treated.

Your doctor may start treatment and, with the help of a nurse or physical therapist, begin education and training about performing the activities of daily living without placing added stress on your lower back.

The goals of nonsurgical treatment are to reduce the irritation of the nerve and disc and to improve the physical condition of the patient to protect the spine and increase overall function. This can be accomplished in the majority of herniated disc patients with an organized care program that combines a number of treatment methods.

Some of the first treatments your doctor may prescribe include therapies such as ultrasound, electric stimulation, hot packs, cold packs and manual ("hands on") therapy to reduce your pain and muscle spasm, which will make it easier to start an exercise program. Traction may also provide limited pain relief for some patients. Occasionally, your doctor may ask you to wear a lumbar corset (soft, flexible back brace) at the start of treatment to relieve your back pain, although it doesn’t help heal the herniated disc. Manipulation may provide short-term relief from nonspecific low back pain, but should be avoided in most cases of herniated disc.

At first, the exercises you learn may be gentle stretches or posture changes to reduce the back pain or leg symptoms. When you have less pain, more vigorous exercises will likely be used to improve flexibility, strength, endurance and the ability to return to a more normal lifestyle. Exercise instruction should start right away and be modified as recovery progresses. Learning and continuing a home exercise and stretching program are important parts of treatment.

Medication and pain management

Medications used to control pain are called analgesics. Most pain can be treated with nonprescription medications such as aspirin, ibuprofen, naproxen or acetaminophen. If you have severe persistent pain, your doctor might prescribe narcotics for a short time. Sometimes, but not often, a doctor will prescribe muscle relaxants. However, you want to take only the medication you need because taking more doesn't help you recover faster, might cause unwanted side effects (such as constipation and drowsiness) and can result in dependency. All medication should be taken only as directed. Make sure you tell your doctor about any kind of medication you are taking, even over-the-counter drugs and supplements, and if he/she prescribes pain medication, let him/her know how it is working for you.

Nonsteroidal anti-inflammatory medications (NSAIDs) are analgesics and are also used to reduce swelling and inflammation that occur as a result of disc herniation. These include asprin, ibuprofen, naproxen and a variety of prescription drugs. If your doctor gives you anti-inflammatory medications, you should watch for side effects like stomach upset or bleeding. Chronic use of prescription or over-the-counter NSAIDs should be monitored by your physician for the development of any potential problems.

Other medications are available that also have an anti-inflammatory effect. Corticosteroid medications --- either orally or by injection --- are sometimes prescribed for more severe back and leg pain because of their very powerful anti-inflammatory effect. Corticosteroids, like NSAIDs, can have side effects. Risks and benefits of this medication should be discussed with your physician. Epidural injections or "blocks" may be recommended if you have severe leg pain. These are injections of corticosteroid into the epidural space (the area around the spinal nerves), performed by a doctor with special training in this technique. The initial injection may be followed by one or two more injections at a later date, and should be done as part of a comprehensive rehabilitation and treatment program.

Trigger point injections are injections of local anesthetics (sometimes combined with corticosteroids) directly into painful soft tissue or muscles along the spine or over the back of the pelvis. While occasionally useful for pain control, trigger point injections do not help heal a herniated lumbar disc.

Surgery

The goal of surgery is to make the herniated disc stop pressing on and irritating the nerves, causing symptoms of pain and weakness. The most common procedure is called a "discectomy" or "partial discectomy," in which part of the herniated disc is removed. In order to see the disc clearly, sometimes it is necessary to remove a small portion of the lamina, the bone behind the disc. Bone removal may be minimal (hemi-laminotomy) or more extensive (hemi-laminectomy). Some surgeons use an endoscope or microscope in some cases.

Discectomy can be done under either local, spinal or general anesthesia. The patient lies face down on the operating table, generally in a kneeling position. A small incision is made in the skin over the herniated disc and the muscles over the spine are pulled back from the bone. A small amount of bone may be removed so the surgeon can see the compressed nerve. The herniated disc and any loose pieces are removed until they are no longer pressing on the nerve. Any bone spurs (osteophytes) are also taken out to make sure that the nerve is free of pressure. Usually, there is very little bleeding.

What can I expect after surgery?

If your main symptom is leg pain (rather than low back pain), you can expect good results from surgery. Before surgery, your doctor will do an examination and tests to make sure that the herniated disc is pressing on a nerve and causing your pain. Physical examination should show a positive straight leg raise test demonstrating sciatica and possibly muscle weakness numbness or reflex changes. Additional tests can include an imaging test (magnetic resonance image [MRI], computed tomography [CT] or myelography) that clearly shows nerve compression. If these tests are all positive for you, and your doctor is sure that you have nerve compression, your chance of significant relief from leg pain after surgery is approximately 90%. Although you should not expect to be pain-free every day, you should be able to keep the pain under control and resume a fairly normal lifestyle.

Most patients will not have complications after discectomy, but it is possible you may have some bleeding, infection, tears of the protective lining of the spinal nerve roots (dura mater) or injury to the nerve. It is also possible that the disc will rupture again and cause symptoms. This occurs in about 5% of patients.

Ask your doctor for recommendations on postsurgical activity restrictions. It is usually a good idea to get out of bed and walk around immediately after recovering from anesthesia. Most patients go home within 24 hours after surgery, often later the same day. Once home, you should avoid driving, prolonged sitting, excessive lifting and bending forward for the first four weeks. Some patients will benefit from a supervised rehabilitation program after surgery. You should ask your doctor if you can use exercise to strengthen your back to prevent recurrence.

How do I know if I need emergency surgery?

Very rarely, a large disc herniation may press on the nerves which control the bladder and bowel, causing loss of bladder or bowel control. This is usually accompanied by numbness and tingling in the groin or genital area and is one of the few indications that you need surgery immediately for a herniated lumbar disc. Call your doctor at once if this happens.

What is it? What treatments are available?
What is a herniated cervical disc?

The backbone, or spine, is composed of a series of connected bones called "vertebrae." The vertebrae surround the spinal cord and protect it from damage. Nerves branch off the spinal cord and travel to the rest of the body, allowing for communication between the brain and the body. The brain can send a message down the spinal cord and out through the nerves to make the muscles move. The nerves also send information such as pain and temperature from the body back to the brain.

The vertebrae are connected by a disc and two small joints called "facet" joints. The disc, which is made up of strong connective tissues which hold one vertebra to the next, acts as a cushion or shock absorber between the vertebrae. The disc and facet joints allow for movements of the vertebrae and therefore let you bend and rotate your neck and back.

The disc is made of a tough outer layer called the "annulus fibrosus" and a gel-like center called the "nucleus pulposus." As you get older, the center of the disc may start to lose water content, making the disc less effective as a cushion. As a disc deteriorates, the outer layer can also tear. This can allow displacement of the disc's center (called a herniated or ruptured disc) through a crack in the outer layer, into the space occupied by the nerves and spinal cord. The herniated disc can then press on the nerves and cause pain, numbness, tingling or weakness in the shoulders or arms. Your doctor may test for changes in the reflexes, sensation and strength in your arms caused by the herniated cervical disc. Rarely, the herniated disc may put pressure on the spinal cord, causing problems in the legs as well.

How is it diagnosed?

A thorough clinical evaluation to determine the character and location of the pain plus an examination of the neck and careful assessment of any weakness, loss of sensation or abnormal reflexes can often diagnose and locate a disc herniation.

The doctor's diagnosis can be confirmed by using X-ray imaging, computed tomography (CT) scans or magnetic resonance imaging (MRI). The X-ray image can show bone spurs and narrowing of the disc space as the spine ages and deteriorates, but cannot show a disc herniation or nerves in the spine. The CT and MRI scans provide more detailed pictures of all the spinal elements (vertebrae, discs, spinal cord and nerves) and can identify most disc herniations.

Additionally, electrical (nerve conduction) studies may be performed to look for signs or evidence of nerve damage that can result from a disc hernation.

What treatments are available?

Many patients with symptoms of a herniated cervical disc will improve without any treatment. For patients who continue to have pain, there are a number of other options such as:
Many patients will improve with nonsurgical treatment. Your doctor may prescribe nonsurgical treatments including a short period of rest, a neck collar, anti-inflammatory medications to reduce the swelling, analgesic drugs to control the pain, physical therapy, exercise or epidural steroid injection therapy. The goals of nonsurgical treatment are to reduce the irritation of the nerve from the herniated disc material, relieve pain and improve the physical condition of the patient. This can be accomplished in the majority of herniated disc patients with an organized care program that often combines a number of treatment methods. Ask your doctor whether you should continue to work while you are being treated.

After the onset of pain from a herniated cervical disc, a short (one to two days) period of rest may be beneficial. After this short period of rest, it is important to begin moving again to prevent stiff joints or weak muscles. Your doctor, with the help of a nurse or physical therapist, may also begin education and training on specific exercises to strengthen your neck. These exercises may be performed at home or you may visit a physical therapist for a more specific program to meet your needs and abilities. It is important to perform the exercises as described by the doctor or physical therapist.

Your doctor or physical therapist may also use traction, electrical stimulation, hot packs, cold packs and manual ("hands on") therapy to reduce your pain,
inflammation and muscle spasm.

Medication and pain management Medications used to control pain are called analgesics. Most pain can be treated with nonprescription medications such as aspirin, ibuprofen (Motrin, Nuprin, Advil), naproxen (Aleve) or acetaminophen (Tylenol). If you have severe persistent pain, your doctor might prescribe narcotics for a short time. Sometimes your doctor will prescribe muscle relaxants. However, you want to take only the medication you need because taking more doesn't help you recover faster, might cause unwanted side effects (such as constipation and drowsiness) and can result in dependency. All medication should be taken only as directed. Make sure you tell your doctor about any kind of medication you are taking---even over-the-counter drugs or supplements --- and if he/she prescribes pain medication, let him/her know how it is working for you. Also, be sure to notify your doctor of any allergic reactions to medication you have ever experienced.

Nonsteroidal anti-inflammatory medications (NSAIDs) are analgesics and are also used to reduce swelling and inflammation that occur as a result of disc herniation. These include aspirin, ibuprofen, naproxen and a variety of prescription drugs. If your doctor gives you anti-inflammatory medications, you should watch for side effects like stomach upset or bleeding. Chronic use of prescription or over-the-counter NSAIDs should be monitored by your physician for the development of any potential problems.

Corticosteroid medications, either orally or by injection, are sometimes prescribed for more severe arm and neck pain because of their very powerful anti-inflammatory effect. Corticosteroids, like NSAIDs, can have side effects. Risks and benefits of this medication should be discussed with your physician.

Epidural injections or "blocks" may be recommended if you have severe arm pain. These are injections of corticosteroid into the epidural space (the area around the spinal nerves), performed by a doctor with special training in this technique. The initial injection may be followed by one or two more injections at a later date. This should be done as part of a comprehensive rehabilitation and treatment program. The purpose of the injection is to reduce inflammation of the nerve and the disc.

Trigger point injections are injections of local anesthetics (sometimes combined with corticosteroids) directly into painful soft tissue or muscles along the spine. While occasionally useful for pain control, trigger point injections do not help heal a herniated cervical disc.

For patients whose pain does not improve with the previous treatments, surgery may be necessary. The goal of surgery is to remove the portion of the disc that is pushing on the nerve. This is done by a procedure called a discectomy. Depending on the location of the herniated disc, the surgeon may make an incision either in the front or back of your neck to reach the spine. The technical decision of whether to perform the operation from the front of the neck (anterior approach) or the back of the neck (posterior approach) is influenced by many factors including the exact location of the disc herniation and the experience and preference of the surgeon. With either approach, the disc material is removed from the nerve, usually with good results. Because removal of the herniated disc fragment from the front removes most of the disc in addition to the herniated portion, fusion is often recommended and performed at the same time.

What can I expect after surgery?

Many patients are able to go home within a short period of time, sometimes as litle as 24 hours after surgery. After surgery, your doctor will give you instructions on when you can resume your normal daily activities.

A thorough postoperative rehabilitation program is advisable to help you resume the activities of daily living. Most patients will benefit from a postoperative exercise program or supervised physical therapy after surgery. You should ask your doctor about exercises to help with recovery.
Surgery is very effective in reducing the pain in the arms and shoulders caused by a herniated cervical disc. However, some neck pain may persist.
Most patients respond well to discectomy; however, as with any surgery, there are some risks involved. These include bleeding, infection and injury to the nerves or spinal cord. It is also possible that pain will not improve following surgery or that symptoms may return. In about 3% to 5% of patients, the disc will rupture again and cause symptoms at a later time.

What is it? How is it treated?

The vertebrae are the bones that make up the spine. The spinal canal runs through the vertebrae and, in the lower (or lumbar) spine, contains the nerves supplying sensation and strength to the legs. Between the vertebrae are the intervertebral discs and the spinal facet joints.

The discs become less spongy and less fluid-filled with age. This can result in reduced disc height and bulging of the hardened disc into the spinal canal. The bones and ligaments of the spinal facet joints can thicken and enlarge (because of arthritis) also pushing into the spinal canal. These changes cause narrowing of the lumbar spinal canal which is known as spinal stenosis.

Spinal stenosis is like the lime build-up on the inside of a garden hose. Over time, it narrows the diameter of the hose, just as spinal stenosis narrows the spinal canal.

What are the symptoms?

Spinal stenosis does not necessarily cause symptoms. Many people can have significant stenosis on imaging studies but fail to have symptoms.

When present, symptoms may include pain or numbness in the back and/or legs, or cramping in the legs. Weakness in the legs may occur. Rarely, bowel and/or bladder problems can occur.

Symptoms are often worse with prolonged standing or walking. Symptoms may come and go, and may vary in severity when present. Bending forward or sitting increases the room in the spinal canal and may lead to reduced pain or completed relief from pain.

How is it diagnosed?

Your physician will take a history and perform a physical examination.
X-ray images s may be ordered that may reveal evidence of narrowed discs and/or thickened facet joints. A magnetic resonance imaging (MRI) study may be obtained for a more detailed evaluation of spinal structures. Or, a computed axial tomography (CAT) scan and/or a lumbar myelogram may be advised for similar improved detail.

Each of these studies can provide information about the presence, location and extent of spinal canal narrowing and nerve root pressure.

What treatments are available?

If your doctor determines that lumbar spinal stenosis is causing your pain, he or she will usually try nonsurgical treatments at first.

These treatments may include anti-inflammatory medications (orally or by injection) to reduce associated swelling or analgesic drugs to control pain.
Physical therapy may be prescribed with goals of improving your strength, endurance and flexibility so that you can maintain or resume a more normal lifestyle.

Spinal injections (such as an epidural injection of cortisone) may be prescribed.

Medication and pain management

Your doctor may use one medication or a combination of medications as part of your treatment plan. Medications used to control pain are called analgesics. Most pain can be treated with nonprescription medications like aspirin, ibuprofen, naproxen or acetaminophen. Some analgesics, referred to as nonsteroidal anti-inflammatory drugs, or NSAIDs, are also used to reduce swelling or inflammation that may occur. These include aspirin, ibuprofen, naproxen and a variety of prescription drugs. If your doctor gives you analgesics or anti-inflammatory medications, you should watch for side effects like stomach upset or bleeding. Chronic use of prescription or over-the-counter analgesics or NSAIDs should be monitored by your physician for the development of any potential problems.

If you have severe persistent pain that is not relieved by other analgesics or NSAIDs, your doctor might prescribe narcotic analgesics (such as codeine) for a short time. Take only the medication amount that is prescribed. Taking a larger dosage doesn't help you recover faster. Side effects include nausea, constipation, dizziness and drowsiness and use can result in dependency. All medication should be taken only as directed. Make sure you tell your doctor about any kind of medication you are taking---even over-the-counter drugs and supplements---and inform your doctor whether or not your medication is working for you.

Other medications are available that have an anti-inflammatory effect. Corticosteroid medications, either orally or by injection, are sometimes prescribed for more severe back and leg pain because of their very powerful anti-inflammatory effect. Corticosteroids, like NSAIDs, can have side effects. Risks and benefits of this medication should be discussed with your physician.

Selected spinal injections, or "blocks," may be used to relieve symptoms of pain. These are injections of corticosteroid into the epidural space (the area in the spinal canal surrounding the spinal nerves) or facet joints performed by a doctor with special training in this technique. Depending on response to initial injection, several follow-up procedures may be performed at later dates. Injections are often done as part of a comprehensive rehabilitation and treatment program.

Nonsurgical treatment

Symptoms of spinal stenosis frequently result in activity avoidance. This results in reduced flexibility, strength and cardiovascular endurance. A physical therapy or exercise program usually begins with stretching exercises to restore flexibility to tight muscles. You may be advised to stretch frequently to maintain flexibility gains. Cardiovascular (aerobic) exercise, such as stationary bicycling or walking on a treadmill, may be added to build endurance and improve circulation to the nerves. Improved blood supply to the nerves may alleviate the symptoms of spinal stenosis.

You may also be given specific strengthening exercises for the muscles of the back, abdomen, and legs. Everyday activities can be less challenging if flexibility, strength and endurance are optimized. Your therapist and physician may advise you on how best to incorporate a maintenance exercise program into your life, either at home using simple equipment, or at a fitness facility.

For some individuals with spinal stenosis, home modification and safety will be considered. Perhaps the washer and dryer should be moved to a more convenient location. A bedside commode may be advisable. Bathroom safety devices are prescribed if needed. Strategies for preparing meals, pacing activities and conserving energy may be reviewed. Optimal fitting of assistive walking devices such as canes and walkers may be recommended.

Unless significant or progressive leg weakness develops, or bowel or bladder problems occur, the presence of spinal stenosis by itself usually does not represent a dangerous condition in the adult, Therefore, treatment is aimed at pain reduction and increasing the patient's ability to function.

Nonsurgical treatments do not correct the spinal canal narrowing of spinal stenosis itself but may provide long-lasting pain control and improved life function without requiring more invasive treatment. A comprehensive program may require three or more months of supervised treatment.

What if I need surgery?

Surgery is reserved for that small percentage of patients whose pain cannot be relieved by nonsurgical treatment methods. Surgery will also be advised for those individuals who develop progressive leg weakness, or bowel and bladder problems.
Because spinal stenosis is a narrowing of the bony canal, the goal of the surgery is to open up the bony canal to improve available space for the nerves. This is called lumbar decompression surgery, or laminectomy.

Surgery, when necessary, will relieve the leg pain and less reliably, will relieve the back pain. Patients are allowed to return to most activities within weeks.

Postoperative rehabilitation may be advised to assist in return to normal activities.

Sometimes, in spinal stenosis, the vertebrae shift or slip in relation to each other (spondylolisthesis). Abnormal motion (instability) may then occur between the vertebrae. In such cases, spinal fusion surgery may be required in addition to decompression in order to stabilize the involved vertebrae.

A fusion is performed by placing bone graft, bone substitute, and/or instrumentation between the vertebrae being fused. Fusion can be performed from the front (anterior approach) or from the back (posterior approach), or may require both anterior and posterior approach. The choice of approach is influenced by many technical factors including the need for spur removal, anatomic variation between patients, and degree of instability. The success rate of fusion surgery is over 65%.

After surgery, you will remain in the hospital for at least several days. Most patients are able to return to all activities within six to nine months. A postoperative rehabilitation program is usually prescribed to guide return to activities and normal life.

What is it? How is it treated?

Osteoporosis is the most common bone disease in the United States and developed countries. It is a disease of low bone mass resulting in deterioration of the structure of bones. This deterioration can weaken your bones so much that you can fracture a bone without major trauma. Everyday activities, such as lifting a bag of groceries or rolling over in bed can result in a fracture.

The wrists, hips and spine are at greatest risk of damage from osteoporosis-related fractures. Often these fractures may be your first sign that you have osteoporosis. Unfortunately, by the time a fracture has occurred, you have already lost a substantial amount of bone. It is important to assess your level of risk of low bone mass early in life in order to prevent osteoporosis and bone fractures, pain and disfigurement. In cases of hip fracture, there is an increased risk of death that comes with the fracture.

Who does it affect?

According to the National Osteoporosis Foundation, 10 million Americans currently have osteoporosis and another 18 million have low bone mass. Although 80% of those affected by osteoporosis are women, it does affect men as well.
There are many risk factors associated with osteoporosis. Age, genetics and gender are three important factors.

• Age. As you age, whether you are a man or a woman, there is an average loss of 0.5% bone mass every year after age 50.
• Genetics. You also have a 50-85% increased risk of developing osteoporosis if you have a family member with it. In the past it was not easy to diagnosis osteoporosis so you may not know if some of your relatives had the disease. However, the development of a dowager's hump (stooped posture), significant loss of height or a bone fracture in a direct relative suggests a family history of osteoporosis.
• Gender. If you are a woman you may be at greater risk of developing osteoporosis than a man, in part because of the higher bone mass, or strength, men may develop before the age of 40. One in two women and one in eight men will have an osteoporosis-related fracture in their lifetime.

Women are also at risk of greater bone loss after menopause. You may lose as much as 3% of your bone mass every year in the first five to seven years after menopause. However, postmenopausal bone loss can often be limited with medications including hormone replacement therapy.

Other risk factors that you can control include lifestyle choices such as smoking and excessive alcohol and caffeine intake. A well-balanced, healthy diet is important. Inadequate dietary intake of calcium and vitamin D, which is needed to absorb the calcium, and poor nutrition can also rob you of the needed building blocks for development and maintenance of strong bones. Whether you are younger or older, a lack of physical exercise will also contribute to low bone mass.

The timing of these risk factors has a large impact on bone strength. For example, if you suffered from disordered eating during adolescence and stopped menstruating, you likely never obtained your highest peak bone mass. The risk of developing osteoporosis depends on how much bone mass you obtain by age 30 and how well you maintain it throughout your life. But whatever your age, there are things you can do to minimize your risk.

Many chronic diseases (such as rheumatoid arthritis or hyperthyroidism) as well as some medications (including steroids or blood thinners) can also lead to low bone mass. If you have one of these conditions or require medications that can affect your bones, it is even more important for you to reduce any controllable risk factors and seek medication management when needed.

How is it diagnosed?

Diagnosis can now be made quickly and conveniently with a dual-energy X-ray absorptiometry (DEXA) scan. A plain X-ray examination is not sensitive enough to detect osteoporosis until a substantial amount of bone has been lost. A DEXA scan takes 30 minutes, is painless and only exposes you to 1/10 of the radiation as a chest X-ray. Your results are compared to the average score for a young adult, regardless of your age. This is called a T-score and can be used to predict your fracture risk. A low T-score means your bones are fragile. A T-score of -1.0 to -2.5 in considered an indication of osteopenia (weak bones) and a score lower than -2.5 shows that you have osteoporosis.

What treatments are available?

Treatment of low bone mass and prevention/treatment of osteoporosis should address all your risk factors. This includes making sure you are getting enough calcium and vitamin D (either from your diet or with supplements), as well as doing weightbearing exercise such as walking and light strength training, all of which are needed to build strong bones.

The average American diet provides less than 600 mg per day of calcium. The National Osteoporosis Foundation recommends you get 1,000-1,500 mg every day, depending on your age and gender. You can get your daily recommended intake of calcium and vitamin D by eating more dairy products such as cheese, butter, cream, fortified milk, yogurt and ice cream. Green leafy vegetables such as broccoli, collards, kale, mustard greens, turnip greens and bok choy (Chinese cabbage) are other good sources of calcium. Vitamin D is also found in fish, oysters and fortified cereals.

Weightbearing exercise is important, and beginning a strength training program can be simple. Starting off with a difficult routine is associated with a higher dropout rate. The primary goal is to increase physical activity. Walking around the block, or taking longer walks at the local shopping mall, is a good start. Exercise with hand-held weights or resistance training (weight lifting) machines to build strength. Common household items (like small canned goods) can be used instead of hand weights. Swimming, although not a weightbearing exercise, is also an excellent choice as part of an exercise program. Ask your health care professional to prescribe an exercise program that matches your abilities.

Medication

Many medications are available for the prevention and treatment of osteoporosis, including estrogen, alendronate, residronate, reloxifene and calcitonin with new medications currently being developed. Your healthcare provider can help determine the correct treatment plan for you and prescribe any medications if necessary.

Conclusion

The key to the treatment of osteoporosis is preventing or slowing bone loss. Assess your risk factors and discuss with your healthcare provider appropriate steps for you to take. Everyone will benefit from a healthy diet with adequate calcium and vitamin D, cessation of smoking, low caffeine and alcohol intake and an exercise program appropriate to your age and health status.

What is it? How is it treated?

The spine is made up of a series of connected bones called "vertebrae." In about 5% of the adult population, there is a developmental crack in one of the vertebrae, usually at the point at which the lower (lumbar) part of the spine joins the tailbone (sacrum). It may develop as a stress fracture. Because of the constant forces the low back experiences, this fracture does not usually heal as normal bone. This type of fracture (called a spondylolysis) is simply a crack in part of the vertebra (Figure 1) and may cause no problem at all. However, sometimes the cracked vertebra does slip forward over the vertebra below it. This is known as adult isthmic spondylolisthesis.

What are the symptoms?

Isthmic spondylolisthesis may not cause any symptoms for years (if ever) after the slippage has occurred. If you do have symptoms, they may include low back and buttocks pain; numbness, tingling, pain, muscle tightness or weakness in the leg (sciatica); increased sway back; or a limp. These symptoms are usually aggravated by standing, walking and other activities, while rest will provide temporary relief.

Studies have shown that 5-10% of patients seeing a spine specialist for low back pain will have either a spondylolysis or isthmic spondylolisthesis. However, because isthmic spondylolisthesis is not always painful, the presence of a crack (spondylolysis) and slip (spondylolisthesis) on the X-ray image does not mean that this is the source of your symptoms.

How is it diagnosed?

Your doctor will begin by taking a history and performing a physical examination, and may order X-ray studies of your back. However, sometimes it is difficult to see a crack and/or slippage on an X-ray image, so additional tests may be needed. A computed tomography (CT) scan can show a crack or defect in the bone more clearly. A magnetic resonance imaging (MRI) scan may be ordered to clearly show the soft tissue structures of the spine (including the nerves and discs between the vertebrae) and their relationship to the cracked vertebra and any slippage. It also will show whether any of the nearby discs have suffered any wear and tear because of the spondylolisthesis (slippage).

If isthmic spondylolisthesis is present, it can be graded as I, II, III or IV (Figure 2) based on how far forward the vertebra has slipped.

What treatments are available?

If your doctor determines that a spondylolisthesis is causing your pain, he or she will usually try nonsurgical treatments first. These treatments may include a short period of rest, anti-inflammatory medications (orally or by injection) to reduce the swelling, analgesic drugs to control the pain, bracing for stabilization, and physical therapy and exercise to improve your strength and flexibility so you can return to a more normal lifestyle. If you are told to rest, follow your doctor's directions on how long to stay in bed. Generally, if recommended at all, this would be limited to a few days. (Strict bed rest is usually not necessary.) Ask your doctor whether you should continue to work while you are being treated.

Your doctor may also --- sometimes with the help of a nurse or physical therapist --- begin education and training in performing activities of daily living without placing added stress on your lower back.

If a combination of medication and therapy fails to provide relief, however, your doctor may order additional tests, which will provide greater detail so he/she can plan further treatment.

Medications and pain management

Your doctor may use one medication or a combination of medications as part of your treatment plan. Medications used to control pain are called analgesics. Most pain can be treated with nonprescription medications like aspirin, ibuprofen, naproxen or acetaminophen. Some analgesics, referred to as nonsteroidal anti-inflammatory drugs, or NSAIDs, are also used to reduce swelling and inflammation that may occur. These include aspirin, ibuprofen, naproxen and a variety of prescription drugs. If your doctor gives you analgesics or anti-inflammatory medications, you should watch for side effects like stomach upset or bleeding. Chronic use of prescription or over-the-counter analgesics or NSAIDs should be monitored by your physician for the development of any potential problems.

If you have severe persistent pain that is not relieved by other analgesics or NSAIDs, your doctor might prescribe narcotic analgesics (such as codeine) for a short time. Take only the medication amount that is prescribed. Taking a larger dosage doesn't help you recover faster. Side effects include nausea, constipation, dizziness and drowsiness, and use can result in dependency. All medication should be taken only as directed. Make sure you tell your doctor about any kind of medication you are taking --- even over-the-counter drugs and supplements --- and inform your doctor whether or not your medication is working for you.

Other medications are available that also have an anti-inflammatory effect. Corticosteroid medications --- either orally or by injection --- are sometimes prescribed for more severe back and leg pain because of their very powerful anti-inflammatory effect. Corticosteroids, like NSAIDs, can have side effects. Risks and benefits of this medication should be discussed with your physician.

Selected spinal injections, or "blocks," may be used to relieve symptoms of pain. These are injections of corticosteroid into the epidural space (the area around the spinal nerves) or facet joint (between vertebrae) performed by a doctor with special training in this technique. The initial injection may be followed by one or two more injections at a later date. These are most often done as part of a comprehensive rehabilitation and treatment program.

Nonsurgical treatment

As you begin a physical therapy regimen and/or exercise program, your doctor may prescribe therapies like ultrasound, electric stimulation, hot packs, cold packs, and manual "hands on" therapy to reduce your pain and muscle spasms. At first, the exercises you learn may be gentle stretches or posture changes to reduce the back pain or leg symptoms. When you have less pain, more vigorous aerobic exercises (such as stationary bicycling or swimming) combined with strengthening/stretching exercises will likely be used to improve flexibility, strength, endurance, and the ability to return to a more normal lifestyle. Developing your back and stomach muscles will help stabilize your spine and support your body. Exercise instruction should start right away and be modified as recovery progresses. Learning and continuing an exercise and stretching program are also important parts of treatment, as is maintaining a reasonable body weight.

The presence of this "cracked vertebra" (spondylolysis) or "slippage" (spondylolisthesis) by itself usually does not represent a dangerous condition in the adult. Therefore, treatment is aimed at pain relief and increasing the patient's ability to function. Although none of the nonsurgical treatments will correct the "crack" or "slippage" they can provide long-lasting pain control without requiring more invasive treatment. A comprehensive program may require three or more months of supervised treatment.

What if I need surgery?

Surgery is reserved for that small percentage of patients whose pain cannot be relieved by nonsurgical treatment methods. The pain may be caused by a pinched nerve, movement of the unstable cracked vertebra, or from nearby discs which are being affected. If a spinal nerve is being compressed by the forward slip, surgery may be needed to reopen a "tunnel," or space, for the nerve.
In addition to relieving pressure on a nerve around the crack or slippage, a stabilizing procedure or fusion may be recommended. This will stop any further slippage of the vertebra and also will prevent recurrent nerve pressure from developing at this site. Occasionally the "crack" in the vertebra can be repaired by placing bone graft from the pelvis to the site of the crack. A fusion can be performed from the front (anterior approach) or the back (posterior approach). Both require the placement of bone graft or bone graft substitute and/or instrumentation between the vertebrae being fused. The choice of approach to the fusion (front or back) is influenced by many technical factors including need for spur removal, location of the spurs, anatomic variation between patients and the experience of your surgeon. The success rate of fusion surgery for relief of isthmic spondylolisthesis is over 75%. After surgery, you will remain in the hospital for at least a few days, and most patients are able to return to work within six to nine months. A thorough postoperative rehabilitation program is advisable to help you resume the normal activities of daily living.

What is a spinal cord injury?

Spinal fractures occur when an injury is sustained to the spine resulting in a break or disruption of the spinal vertebrae or the attached ligaments. The spinal column contains and protects the spinal cord and exiting nerve roots. Some injuries affect only the spinal column without disturbing the nerve elements – while other, more severe injuries to the spine can result in temporary or permanent damage to the spinal cord and/or exiting nerve roots. The diagnosis of such injuries relies upon radiological studies including x-rays, CAT scans and sometime magnetic resonance imaging studies (MRI) to visualize the damage. Treatment of such fractures may require a brace or surgery or both depending on the degree of instability.

Spinal cord injuries (SCI) remains a devastating condition for both patients and their families. There are approximately 10,000 new injuries in the United States each year with more than 200,000 people suffering from either paralysis of the arms or legs or both secondary to spinal cord injury. Males account for roughly 75% of patients treated with spinal cord injuries.

Improvement in the quality of care over the last few decades has dramatically improved the outlook and survival for patients with such injuries – but as yet there are no cures to treat all aspects of the injury including paralysis. Advances in acute treatment of spinal cord injury include more sophisticated prehospital care, prompt recognition of the signs of spinal cord injury, safer transportation methods and active resuscitation both in the field and in the emergency department. Improvements in the treatment of the chronic stages of the disease include the surgical management of syringomyelia, late post-traumatic deformity, and pain control has also been achieved.Increased survival for patients with spinal cord injury has focused the health care industry to develop strategies to enhance the quality of life via improvements, which range from lighter wheel chairs to development of fertility programs for the spinal cord injured patient.

What causes spinal cord injuries?

The causes of spinal cord injury are varied. With industrialization, motor vehicle accidents (MVA) have become the leading cause of spinal trauma. Spinal cord injury due to violence is on a dramatic rise as manifested by the proportion of individuals injured by assault including penetrating injuries such as gun and knife wounds. Sports related injuries, which include football, horseback riding, and hockey, often receive recent media attention.

Preventive programs, which encourage children and young adults to modify risky behaviors, have the greatest prospect of reducing the incidence of spinal cord injuries. These include, but are not limited to, the Think First program sponsored by the American Association and Congress of Neurological Surgeons and the “Feet First, First Time” program initially developed in Northern Florida which encourages water enthusiasts to jump feet first into unknown waters. Also, driver’s education courses and police patrols which arrest drivers in command of vehicles while under the influence of drugs or alcohol can contribute to a decrease the number of these unfortunate events. Finally, regulation of handguns and assault weapons, which have resulted in intentional and accidental injuries, can potentially reduce the number of injuries.

How are spinal cord injuries treated?

Determining the prognosis for a spinal cord injured patient on admission remains challenging. The clinician uses the patient’s neurological exam, age, magnetic resonance imaging (MRI) appearance of the spinal cord, and other clinical data to guide the patient and his family on the expected outcome for a specific injury. Some recovery is the rule for most patients who enter hospital with an incomplete spinal cord injury; however, when patients present with complete injuries, the chance of regaining ambulatory function remains slim. A complete spinal cord injury means that the spinal cord has absolutely no motor or sensory function below the affected area. While a partial or incomplete spinal cord injury means that the spinal cord transmits some information to move the limbs or provides some sensory information from the skin.

Treatment for patients with spinal cord injury often involves stabilizing the injured spine. This may accomplished by an external orthosis – such as collar, halo-vest or a body brace – but often may require surgical intervention. Surgery is usually performed by a neurosurgeon or orthopedic surgeon who has a special interest in spinal surgery. The surgical procedure often involves the placement of titanium plates or rods and screws and bone graft material to fuse the injured spine. As part of the surgical treatment the spine may be re-aligned or bone may be removed from the spinal canal to decompress the spinal cord. The acute stay in the hospital after the injury is focused on preventing and treating secondary issues which may surface as a result of the spinal cord injury, such as low blood pressure, respiratory failure, pressure sores of the skin, blood clots in the legs, etc. As soon as the patient is medically stable and is ready to be mobilized, he or she will start intensive therapy which includes physical and occupational therapy which is often best accomplished in a specialized rehabilitation center for such injuries. Objectives of these centers include muscle strengthening, teaching patients how to maximize their functional capacity and determining strategies for bladder and bowel care as well as sexual function. Treatment of spasticity and pain which frequently accompanies such injuries is also a priority. Counseling and support groups are extremely helpful in having the patient and the family cope with the stresses of the new situation.

Spinal cord injury research

Spinal cord injury research is an absolute priority of the National Institutes of Health. Models of spinal cord injury, mechanisms of secondary injury, treatment of the acute phase of spinal cord injury, as well as the development of transplantation strategies to repair the damaged spinal cord are on-going across the continent and around the world. Research focusing on treatment can be divided into two categories:

• drugs which can be given during the acute phase of injury and which may limit secondary injury mechanisms or promote regeneration.
• cellular therapies to treat the chronic injury. Cells of interest include Schwann cells, olfactory ensheathing glia, embryonic spinal cord and stem cells.

Strategies, which combine a number of the aforementioned treatments, are most likely to have a beneficial effect in the future.

Treatment of Sports Injuries in the Young Athlete

Although not common, back and neck injuries can occur in young athletes who participate in sports. Though injuries that cause back pain are not the most common cause of injury in the young athlete, they can cause frustration. Most athletic injuries to the back are sprains of the ligaments or strains of the muscles. However, several more serious conditions can have symptoms similar to a routine sprain or strain. Many injuries occur after repetitive overuse of the structures of the spine. Therefore, proper treatment of a young athlete always includes a good physician evaluation with imaging studies when necessary.

Muscle Strains and Ligament Sprains

Muscle strains and Ligament sprains are the most common injuries that cause back pain in the young athlete. They can be caused by athletic overuse, improper body mechanics and technique, lack of proper conditioning, insufficient stretching, as well as trauma. The athlete will complain of back pain with activity and will feel relief with rest.

Initial treatment may require a period of rest and removing the athlete from sports participation. Treatments may include medication and special exercise. Ice can be used along with pain medications, which should be used sparingly. In addition, other measures to control pain and restore motion are commonly used. Initially, ice and medications such as nonsteroidal anti-inflammatories can be used. For persistent symptoms, particularly those associated with muscle spasm, heat may also be very helpful.

As pain decreases, the injured athlete should be shown proper exercise to assist recovery. An exercise program can be very beneficial to improve flexibility and strength of the appropriate muscles for athletic performance as well as to help decrease risk for another similar injury. It is also important to maintain aerobic conditioning during treatment for back pain. Aerobic exercise needs to be tailored to the athlete and performed as pain allows. The repetitive overuse of the spine (particularly rotation) should be avoided, at least initially. Before being released to return to play, sport-specific exercises that mimic activities of athletic competition are often included in the exercise program. It is also always important to evaluate and correct poor technique and mechanics that may have predisposed the athlete to the initial injury.

Spondylolysis & Spondylolisthesis

Defects of a vertebra's pars interarticularis (spondylolysis) and the slippage of one vertebra in relation to another vertebra (spondylolithesis) are common causes of back pain in the young athlete. These injuries are often seen in athletes who participate in sports that require twisting and hyperextension of the spine, such as in gymnastics. The athlete usually complains of pain that worsens when arching the back. The physician must be alert because these injuries often appear to be a sprain or strain. X-ray images are often normal and special imaging studies such as bone scan and CT scan may be required to confirm the diagnosis.

Recovery requires a period of relative rest, ice, medication and specific exercises. It is important that inflexible muscles are stretched and the trunk muscles strengthened. In some cases, bracing may be necessary to allow for proper healing. Progression back to sports is similar to that for sprains and strains.

A few special considerations are important in an athlete who has developed a spondylolisthesis. Athletes with 50% or less forward slippage can usually return to all sporting activities after pain resolves and appropriate rehabilitation has been completed. Athletes with 50% or greater forward slippage are encouraged to participate in less aggravating sports. Also, athletes with a spondylolithesis should be monitored every six months for progressive slippage as they go through any adolescent growth spurt.

What is a Stinger?

A stinger is a sports related injury to the nerves about the neck or shoulder. It is sometimes called a burner or nerve pinch injury, but the term stinger is most descriptive of the symptoms that the athlete experiences including painful electrical sensations radiating through one of the arms. While the stinger is usually a spine injury, it is never a spinal cord injury. The stinger occurs most commonly in contact and collision sports, but is not as catastrophic as a spinal cord injury and does not result in paralysis in the arms and legs. A stinger is often not reported by the athlete to the coaches or the athletic trainers since the symptoms can spontaneously resolve within a short period of time. However, stingers tend to recur and if not properly diagnosed and treated can lead to persistent pain or even arm weakness, which can eventually result in extended lost playing time.

Athletes competing in various sports (most common in football and wrestling), playing specific positions (such as defensive back, linebacker or offensive line) or performing certain athletic maneuvers (such as tackling, blocking or executing a take down maneuver) are at greatest risk of sustaining a stinger. The injury occurs in one of two ways: either one of the nerves off the spinal cord in the neck is compressed as the head is forced backward and toward that side; or the nerves in the neck and shoulder are over-stretched as the head is forced sideways away from the shoulder. The athlete will experience sudden and severe painful, stinging sensations in one of his arms frequently lasting from seconds to minutes, occasionally hours and less frequently days or longer. There is often associated weakness of the muscles in the shoulder and arm that are supplied by the injured nerve. The arm symptoms are usually more severe than neck pain. First time stingers will usually recover quickly even without treatment, but there is a greater risk of recurrent injury if left untreated. Each additional stinger will likely result in continued neurologic impairment including muscle weakness. Stingers do not affect both arms at the same time, although each arm can be affected with different injuries. If both arms are symptomatic at the same time after a neck injury, a spinal cord injury is likely to have occurred which leads to a much different treatment plan.

How is it diagnosed?

The diagnosis of the stinger requires the expertise of a medical professional. Ideally, the first evaluation of the athlete occurs at the time of injury at the game or match. Because these injuries are not catastrophic, the athlete often exits the "field of play" without assistance. A sideline evaluation will be conducted by the athletic trainer, physical therapist and/or team physician that will include: a determination of the mechanism of the injury, the symptoms experienced by the athlete, and the physical examination findings including assessment of muscle strength. A decision will be made whether or not the athlete is medically cleared to return to that contest. Persistence of symptoms, stiffness or loss of full range of neck motion, muscle spasm and weakness would usually keep the athlete out of competition.

Careful medical follow-up evaluations are important and necessary. These examinations should take place regularly until the athlete's condition has normalized. If the symptoms and/or neurologic findings worsen during the first few days after the injury or continue beyond two weeks, then further medical assessment is necessary. The physician may order specific tests such as X-ray examinations, magnetic resonance imaging (MRI), and an electromyogram (or EMG) which is designed to evaluate for nerve damage. Occasionally a stinger can result from a disk herniation in the neck. If so, this should be confirmed on the MRI.

No matter how trivial the injury may appear, in order for the physician to make the correct diagnosis and prescribe the appropriate treatment it is very important for the athlete not to withhold information. If the injury was not witnessed by the medical personnel covering the event, then it is the responsibility of the athlete to report the injury even if the symptoms disappear quickly. In some situations, the effects of the stinger can lead to permanent nerve damage if left undiagnosed and untreated.

What treatments are available?

The goals of treatment are to reduce the pain and abnormal sensations in the arm, regain the strength of weakened shoulder and arm muscles, and prevent further injuries.

There are several nonoperative options for the treatment of an acute stinger. The order in which these treatments are utilized depends largely on whether the primary complaint is pain or weakness.

Treatment for acute pain usually includes activity restriction, ice or heat, anti-inflammatory and pain medications, a cervical collar and cervical traction. Following an acute injury, the athlete is not allowed to return to competition to allow time for recovery. Modalities such as ice and heat can be used both for comfort and to reduce inflammation. Ice is usually applied about the neck and shoulder region up to 48 hours post injury after which time heat is substituted.

Nonsteroidal anti-inflammatory medications are frequently prescribed for both reduction of swelling and inflammation as well as pain relief. Stronger analgesics (pain medications) are not usually necessary, but muscle relaxants may be utilized for a short period of time to treat muscle spasm.

A cervical collar may also be used for a short period of time to prevent further nerve root injury or irritation. Cervical traction helps to reduce pressure on the nerve root. It can be applied manually or mechanically under the guidance of a physical therapist. Often, trunk strengthening and chest-out posture correction exercises are started.

For persistent pain, cortisone injection around the injured nerve root ("nerve root block") performed with X-ray guidance can be helpful to reduce inflammation of the nerve. If weakness is the main problem, then the acute treatment includes modified activities, ice or heat and anti-inflammatory medication.

The majority of stingers are treated successfully without surgery. Surgery is only considered if the injured nerve root is found to be severely compressed by either a disc herniation or bone spur and there is severe persisting pain or worsening weakness. The two surgical options are removal of the disc (discectomy) or bone spur, or discectomy followed by a fusion. In each case, the surgical decision is individualized to the athlete's symptoms and signs and the results of additional diagnostic tests.

Prevention

Many athletes who sustain a stinger are found to have substantial postural deviations which may interfere with full recovery. Some of these abnormal postures include the head jutting out too far forward from the neck and the shoulders too rounded. These postures will cause more pressure to be placed on some of the nerve roots in the neck making them more likely to be injured and to recover slower after injury.

A comprehensive physical therapy treatment program will be of value to correct the various areas of muscular and soft tissue tightness and weakness throughout the neck, upper back and shoulder region. Trunk stabilization and chest-out posture correction exercises are usually the basis of the treatment program.

Physical therapy may also include manual therapy treatments in which the therapist provides deep tissue massage to release tight soft tissues and joint mobilization to loosen stiff spinal joints. Forceful spinal manipulation should be avoided so as not to further injure the cervical nerve root. Therapy includes specific exercises to strengthen the weak muscles of the neck, upper back and arms. Athletes who undergo surgery must also complete a full rehabilitation program.

Return to Play

Before the athlete can return to regular athletic competition, several goals must be met.

• First, the athlete must be completely free of pain and weakness and must regain full range of motion of the neck.
• Second, the diagnostic tests such as the EMG and/or MRI should not reveal any active nerve damage or severe nerve compression.
• Third, the athlete must be reconditioned for the sport especially if he has not competed for awhile.
• Fourth, improvement in the athlete's playing technique (such as blocking and tackling) and equipment modifications should be made to protect the athlete from further injury.

In football, special pads and neck rolls can be fitted to the helmet or shoulder pads, which can help prevent re-injury. However, this type of equipment change does not replace the most important part of prevention, which is building strength and endurance of the neck and shoulder muscles. That is why athletes who have had surgery will usually take longer to return to play.

Finally, in some cases, the decision to return to play must be delayed especially if the athlete has suffered several stingers in the same season. Healing is usually slower after multiple injuries. The key concern is to avoid permanent nerve damage, which could cause problems in the young athlete's personal as well as athletic life. Rarely does a history of multiple stingers signal the end of an athletic career. The sports medicine physician, working together with the athletic trainers, should provide counseling regarding how serious the injury is and discuss early or delayed return to play.

Disc Injury

Though it is a common cause of back pain in the adult population, disc injury is relatively uncommon in the young athletic population. Back pain from a disc injury may or may not be associated with sciatica (pain that shoots down the leg). A careful history and examination is very important in determining if a disc problem may be the cause of the athlete's complaints. Magnetic resonance imaging (MRI) can also be helpful in determining if a disc is a cause for the pain and to rule out other potential causes that may mimic disc injury in an adolescent.

Treatment is similar to treatment of a disc herniation in the adult population. (See the NASS Patient Education Brochure on Herniated Disc for more information about this condition.) Injections (epidurals) can be used but are not necessary in most cases. If symptoms do not improve with a comprehensive rehabilitation program, then surgery may be indicated. This is necessary only in a small percentage of young athletes with disc injury.

Scheuermann's Disease (juvenile kyphosis)

Another common problem seen in the young athlete with back pain is juvenile kyphosis, known as Scheuermann's Disease. Pain associated with this occurs during puberty and is in the mid back, rather than the low back. The athlete demonstrates a roundback deformity that worsens to a "dome" appearance of the back with bending forward. Diagnosis is made by X-ray examination that shows at least three consecutive vertebra show a wedging of 5° or more.

Treatment in most cases is aimed at relieving symptoms. Extension-based back exercises and postural exercises are essential. These can provide significant symptomatic relief, but it is important to note that the structural curve cannot be corrected with these exercises. For curves of 50° or greater, bracing can be helpful if the athlete is able to tolerate wearing the brace. For athletes with severe curves who continue to have debilitating pain despite bracing, surgical correction and stabilization may be required. It is important to note that this may limit the athlete's ability to return to their given sport. As with all spine-based injuries, a complete rehabilitation program is essential prior to return to athletic competition.

Background: anatomy of the neck

The spine is a long chain of bones, discs, muscles and ligaments that extends from the base of the skull to the tip of the tailbone. The cervical spine (neck region) supports the head, protects the nerves and spinal cord, and allows for smooth function of the neck during activity. The major structural support is from the vertebrae (bones). Between two adjacent vertebrae is a disc. In the back of each vertebra are two facet joints, one on each side. The facet joints are designed to allow smooth motion for bending forward. backward and rotating, but also limit excess motion. Muscles and ligaments surround and support the spinal column. All of these structures have nerve supplies, and injury to any one can cause pain.

What causes chronic neck pain?

It is usually not possible to know the exact cause of neck pain in the days or weeks after a car accident. We know the muscles and ligaments get strained and are probably inflamed, but they usually heal within six to ten weeks. Pain that lasts longer is usually a result of deeper problems such as injury to the disc or facet joint, or both.

• Facet joint pain is the most common cause of chronic neck pain after a car accident. It may occur alone or along with disc pain. Facet joint pain is usually located to the right or left of the center back of the neck. The area might be tender to the touch, and facet pain may be mistaken for muscle pain. We cannot tell if a facet joint hurts by how it looks on an X-ray image or MRI scan. The only way to tell if the joint is a cause of pain is to perform an injection called "medial branch block (MBB)," which is discussed below.
• Disc injury can also cause chronic neck pain. The disc allows motion of the neck, but at the same time keeps the neck from moving too much. The outer wall of the disc (called the annulus) can be torn by a whiplash injury. This usually heals, but in some people, the disc does not heal. In that case, it might get weaker and hurts when stressed during normal activities. The pain comes from the nerve endings in the annulus. The disc is the major cause of chronic neck pain in about 25% of patients, and there can be both disc pain and facet pain in some people. Less often, a disc can herniate and push on a nerve. This usually causes more arm pain than neck pain.
• Muscle strain of the neck and upper back can cause acute pain. However, there is no evidence that neck muscles are a primary cause of chronic neck pain, although muscles can hurt if they are working too hard to protect injured discs, joints or the nerves of the neck, or if something else is wrong that sustains the muscle pain, such as poor posture and work habits.
• Spinal nerves and the spinal cord can be compressed by a herniated disc or bone spur. This usually causes arm pain, but there can also be neck pain. (If you are diagnosed with a herniated disc, see the NASS Patient Education Brochure on Herniated Cervical Disc for more information.)

What are the symptoms of whiplash?

• Headache caused by neck problems is called cervicogenic or neck-related headache. It may be caused by injury to an upper cervical disc, facet joint or higher joints called the atlanto-occipital or atlanto-axial joints. Cervicogenic headache can also make migraines worse.
• Arm pain and heaviness may be caused by nerve compression from a herniated disc, which is easy for your health care professional to diagnose. More commonly, arm pain is "referred" from other parts of the neck. "Referred pain" is pain that is felt at a place away from the injured areas but not resulting from pressure on a nerve. Pain between the shoulder blades is usually a type of referred pain.
• Low back pain is occasionally seen and is quite common after whiplash and may be caused by injury to the discs, facet joints of the low back or sacroiliac joints.
• Difficulties with concentration or memory can be attributed to the pain itself, medications you are taking for the pain, depression or mild brain injury. You might also experience irritability and depression.
• Sleep disturbance can be a result of pain or depression. Other symptoms might include blurry vision, ringing in the ears, tingling in the face and fatigue.

How is whiplash diagnosed?

Your health care professional will ask you about your symptoms and how the injury occurred, and then perform a physical examination. This will allow the health care professional to know if you need any tests immediately or if they can wait, and also how to best treat your problem. In patients who do not get better after about 12 weeks, more detailed evaluation might be needed and some of the tests are described below. Not all patients need all tests.

• X-ray imaging is used right after injury if the health care professional suspects there may be a fracture or that the spine is not stable. X-ray images also show disc height and bone spurs. Otherwise they are often used in patients who do not get significantly better by about 12 weeks. If an MRI is performed, X-ray examination is usually also done to look at the bone anatomy.
• Magnetic resonance imaging (MRI) scan is necessary if the health care professional suspects a disc herniation, disc injury or compression of a nerve or the spinal cord. (See the NASS Patient Education brochure on Magnetic Resonance Imaging for more information if this test is prescribed for you.)
• Medial branch block (MBB) is an injection done to determine whether a facet joint is contributing to neck pain.
• Discography is an injection into the disc itself to determine if a disc may be contributing to the pain. Discography is only used for patients with severe pain that has not improved with good treatment, and for whom surgery is being considered. (See the NASS Patient Education brochure on Discography for more information if this test is prescribed for you.)
• Computed tomography (CT scan), usually combined with myelogram (dye or contrast injected into the spinal canal) can also be used to help diagnose neck pain that does not respond to treatment.
• Electromyography and nerve conduction velocity (EMG/NCV) might be used if there is suspicion that a nerve is being trapped (such as in carpal tunnel syndrome) or there is nerve damage. (See the NASS Patient Education brochure on EMG for more information if this test is prescribed for you.)

Treatment of whiplash

The treatment of whiplash in the first few weeks and months usually involves strength training and body mechanics instruction. Patients who do not get better after about 12 weeks require specialized treatment, often from a spine specialist, based on the cause of the pain.

• Strength training is necessary to develop sufficient muscle strength to be able to hold the head and neck in positions of good posture at rest and during activity. Strengthening the muscles will also improve their range of motion.
• Body mechanics describes the interrelationship between the head, neck, upper body and low back during movement and at rest. Training in proper posture decreases the stress on muscles, discs and vertebrae, giving damaged tissue the chance to heal. Poor posture and body mechanics unbalance the spine and create high stress on the neck, which may impede healing.
• Medications are helpful for symptom control. They never solve the problem and should be used as just one part of a total treatment program. There is no best medicine for neck pain. The choice of medication depends on the type, severity and duration of the pain as well as the general medical condition of the patient. Types of medications that are most often prescribed for acute neck pain include antiinflammatory drugs and opioid (narcotic) pain relievers. Additionally, your health care professional may prescribe the use of muscle relaxants. For chronic and severe neck pain, the opioid analgesics and antidepressants are generally most helpful.
• Spinal injections can be helpful in carefully selected patients. Again, injections do not cure the problem and should be only one part of a comprehensive treatment program. Epidural injections into the spinal canal can provide short-term relief in cases of nerve compression with arm pain, but are rarely effective for pure disc pain without radiating symptoms. Facet (zygopophysial) injections may help temporarily with neck pain and are usually tried before radiofrequency neurotomy. Radiofrequency neurotomy (RFN) is a procedure that heats the nerves to stop them from conducting pain signals but is only useful for facet joint pain. It can help for about nine to 18 months and then can be repeated if needed and should only be considered in chronic situations with significant pain.
• Spinal manipulative therapy (SMT) is usually provided by chiropractors, osteopaths or specially trained physical therapists. SMT can provide relief from symptoms for many patients and is generally safe. SMT should be combined with strength training and body mechanics instruction.
• Surgery for chronic neck pain is hardly ever necessary. However, surgery can be helpful when there is severe pain arising from one or two discs and the patient is very disabled, psychologically healthy and has not gotten better with nonoperative care. Surgery is done more often when there is pressure on a nerve or the spinal cord.

If you have whiplash ...

• A spine care specialist can help relieve the pain of whiplash and regain range of motion. Follow your healthcare professional's instructions carefully.
• Remain active and do the exercises that you are taught to improve your posture and reduce the strain on your neck.
• Remember that, with proper care and patience, you are likely to recover from whiplash

All of these recommendations are intended to reduce the emotional concerns and stress most patients experience with pain. If you are not satisfied with the treatment and explanations you receive, consider getting a second opinion from another health care provider. Anxiety and stress can actually increase your perception of pain and reduce your pain coping skills.

It is important to remember that there is a dynamic relationship between your state of mind (eg, stress level) and your physical condition (eg, pain). Pain can cause stress, which causes more pain, which causes more stress, and so on. The more chronic this vicious cycle becomes, the more likely your emotional distress will increase. This cycle can be very difficult to break.

Emotional suffering can lead to loss of sleep, inability to work as well as feeling irritable and helpless about what can be done. You may feel desperate and attempt to relieve the pain at any cost including the use of invasive medical procedures. Although invasive approaches may be beneficial for some conditions (such as a herniated disc), often they can be avoided if stress and pain are managed at an early point in time.

Education and reassurance from your healthcare provider goes a long way in preventing or relieving a great deal of stress and anxiety. You also need to be proactive about your condition and treatment. These naturally occurring feelings of anxiety and stress may cloud your judgment. Your goal is to avoid getting into a chronic pain cycle. Reassurance from your health care provider that the pain is only temporary can go a long way to help you avoid becoming preoccupied with pain, and prevent unnecessary worry about the symptoms. Fortunately, there are a number of psychological therapies that have been successfully used in the management of pain and anxiety. These include stress management, relaxation training, biofeedback, hypnosis and cognitive-behavioral therapy (a method to reduce feelings of doom and helplessness). There are also medications available to help with sleep problems, anxiety and depression. Such comprehensive pain management programs, when integrated with your medical care, can be quite successful.

Your healthcare provider can refer you to a psychological management program if it is deemed necessary. Participation in such a program does not mean the pain is “all in your head” - it is meant to teach you methods to cope with the pain. Remember, pain is a complex experience that includes a close interaction of physical and psychological factors! But together, you and your health care provider can help you manage and overcome your pain.