help for chronic back pain

Orthopaedic Guide to Chronic Back Pain

Whether you’re a workout enthusiast or simply spend a lot of time sitting in an office chair, it’s likely that you’ve dealt with some degree of back pain in your day-to-day life. When pain strikes, it’s essential that you’re equipped to identify the cause of your condition and recognize your symptoms.

COMMON CAUSES OF BACK PAIN


Back pain may arise from everyday causes, especially for adults over the age of 35. Slouching in front of a desk is a common culprit, and being overweight is another risk factor.

Many people also experience issues due to prolonged stress or heavy lifting. The repetitive motions and impact of sports can cause back pain, but lack of exercise can also weaken muscles and make them more susceptible to injury.

Pain in the back may be linked to a medical condition that requires a doctor’s diagnosis. Back pain can have anatomic causes, such as scoliosis or weak core muscles. As the body ages, troublesome disc issues are more likely to occur as the soft matter bulges and presses on nerves, causing disc herniation, degenerative disc disease, or spinal stenosis.

Certain chronic issues, such as arthritis, can affect the back as well. Sciatica, nerve compression, kidney disease, or even tumors can be risk factors, and pregnancy often puts additional stress on the back muscles.

SYMPTOMS OF LOWER AND UPPER BACK PAIN

If you’re experiencing lower back or lumbar spinal pain, you may experience:

  • The inability to sit up straight or move with your full range of motion
  • Pain or discomfort when attempting to stand, sit, or walk
  • Pain when trying to lift a heavy object
  • A sharp pain in the back of the thigh or buttock
  • A dull ache in the lower back

If you’re experiencing upper back or thoracic spinal pain, you may experience:

  • Stiffness or tightness, especially when attempting to twist or fully straighten your upper body
  • Pain through your neck and shoulders
  • Weakness or a slouched posture
  • Numbness, tenderness, or muscle spasms in the back
  • Intense pain, in the case of vertebrae injury
THE INITIAL DIAGNOSIS

If you have chronic back pain, it’s important to consult your doctor. Some pain may indicate the need for simple lifestyle changes — better posture, more exercise, or a new mattress, for example. Most of the time, the pain can be traced back to a muscle injury or joint inflammation, which can respond well to more conservative treatments.

Only a doctor can help you determine if your discomfort is more serious. For instance, if you’re experiencing shooting or burning pain down the legs, numbness, or tingling, this may be the sign of a herniated disc or pinched nerve. Your doctor may recommend an MRI to rule out disc herniations and spinal stenosis, along with an EMG nerve test to identify any other underlying issues. For more urgent conditions, like a fracture due to direct impact, you should seek immediate medical attention.

SEEKING TREATMENT AND PAIN RELIEF

If you’re experiencing acute but manageable back pain, you can start with conservative treatment methods. For the first 48 hours you should rest, take anti-inflammatory medication, and ice the affected area for 20 minutes at a time. Rest is the most effective treatment for upper back pain, as long as you lie down in a way that doesn’t strain the spine.

If your pain persists, your doctor may suggest physical therapy, or changes like exercising and improving your posture. Exercise can prevent injury by strengthening the back and abdominal muscles, but be sure to warm up, stretch, and gradually increase activity.

Injections are another common treatment for back pain. Options include trigger point injections to relieve painful muscles, anti-inflammatory joint injections, epidural injections for spinal nerves, or nerve blocks. In more serious cases, your doctor may recommend surgery.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Understanding Low Back Pain

Understanding Low Back Pain

By Lynne K. Schneider, PhD | Reviewed By Forest Tennant, MD, DrPH | Article Featured on Practical Pain Management

At some point in our lives, up to 90% of us will have low back pain, or pain in the lumbar (lower) spine. However, the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM)1 assures us that in about 50% of these cases, the pain will resolve within 2 weeks, and in 80% of these cases, within 6 weeks.

However, one in five individuals will develop chronic back pain, which the National Institute for Neurological Disorders and Stroke (NINDS)2 defines as pain that lasts more than 12 weeks. It is difficult to determine which cases will become chronic, as chronic back pain isn’t necessarily related to the location, onset, or even the initial severity of the pain.

Most low back pain is caused by strains or sprains—people starting a new exercise routine, shoveling snow, or doing yard work. In general, overactivity back strains usually heal on their own, although you might need to use ice/heat packs and/or take over-the-counter anti-inflammatory medications.

Other important causes of back pain include osteoarthritis of the spine (or spondylosis), sciatica, and/or a herniated or bulging lumbar disc. Less frequently, notes the North American Spine Society (NASS),3 low back pain may be caused by something more serious, such as an infection, fracture, or cancer. Low back pain can also result from non-spinal causes, such as a kidney infection or stomach ulcer. In women, endometriosis, pregnancy, and fibromyalgia may cause low back pain.

How Do You Know If You Need To See A Doctor?

According to the American Association of Orthopedic Surgeons (AAOS),4 you will likely need medical attention if your back pain is accompanied by fever, chills, or if the pain doesn’t go away or worsens over a few weeks. Other indications of severe low back pain include weakness, numbness, or tingling in your arms, hands or in your groin or going down your leg, as well as swelling, or losing bowel or bladder control. You should also seek medical attention for low back pain that is severe enough to interfere with your ability to do your daily activities and/or preventing you from work.

NINDS, AANEM, and AAOS all mention things you can do to reduce your risk of low back pain, such as losing weight to put less stress and pressure on your back; learning correct exercise or weightlifting form (including shoveling and gardening); and doing exercises to help strengthen the surrounding low back muscles. While we can’t control the natural effects of aging that causes wear and tear on our spine, discs and ligaments, nor can we prevent accidents, injuries, or falls from happening, we can learn how to better deal with the stress on our backs and improving posture, both of which can help reduce the risk of low back pain. In addition, quitting smoking and removing inflammatory foods from your diet might also be beneficial. Making a few simple lifestyle changes can help reduce your risk for and help you deal with low back pain.

NINDS suggests that many cases of low back pain can be diagnosed by a physical examination and a review of your medical history. To help in the diagnostic process, you might think about what triggers your low back pain:

  • Does it get better or worse by rest or inactivity?
  • By prolonged sitting or standing?
  • By moving around?
  • By any specific movements?
  • Were you recently involved in an accident of some type?

Treatment*

Experts at Johns Hopkins Medicine5 suggest that once the cause of your back pain has been identified, your doctor might recommend rest, specific muscle strengthening exercises, diet and lifestyle changes, physical therapy, and OTC anti-inflammatory agents that may provide relief. The potential benefits of prescription drugs—muscle relaxants, anti-inflammatory drugs, and analgesics— need to be weighed against their side effects and risks. Opioid medications are never considered first-line therapy for low back pain.

Injection-based treatments, including epidural steroid injections, nerve blocks or nerve ablations, may be effective in lessening the pain in the short term, but do not address the underlying cause of the pain. The American Association of Neurological Surgeons (AANS)6 notes that surgery is often a last resort or used for people with serious complications such as loss of bladder or bowel functions, difficulty walking or standing, or progressive limitations due to the low back pain. A rehabilitation psychologist might recommend mindfulness, meditation, yoga or other relaxation strategies. Alternative treatments—acupuncture, biofeedback, transcutaneous electrical nerve stimulation (TENS), spinal manipulation/mobilization, and some laser therapies, may also be helpful with low back pain.

*Any treatment decision should be made after speaking with your spine or pain physician.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Quick Exercises to Reduce Sciatic Pain

Quick Exercises to Reduce Sciatic Pain

Article Featured on Spine Health Institute

Sciatic pain can stop you in your tracks. If you’re experiencing a flare due a recent or past back injury – or possibly from spinal stenosis or a herniated disk – you know that it can feel like a lightning bolt is running from your lower back all the way down your leg. When it strikes, there’s no ignoring it; you’ve got to stop what you’re doing, rest, and recover. But what then?

Read more

Surgery for Lower Back Pain

Surgery for Lower Back Pain

By John Peloza, MD | Article Featured on Spine Health

Surgery may be considered if for severe lower back pain that does not get better after a 6 to 12-week course of nonsurgical treatments. It is almost always the patient’s decision to have back surgery, and only in rare situations is immediate surgery performed for low back pain.

Some factors to consider before having back surgery include:

Ability to function. If it is possible to complete daily life activities with manageable pain levels, and if pain does not interrupt sleep or activity, nonsurgical treatments are usually recommended. Surgery is more likely to be recommended if the patient has limited ability to function in everyday life.

Healing process and lifestyle. Surgery vs. nonsurgical care require varying degrees of time commitment. It is important to consider how the healing process after surgery will affect the patient, as compared to continued non-surgical care.

Type of surgery. Some surgeries are considerably more invasive than others, and include lengthier healing periods, more or less significant pain during recovery, and varying inpatient hospital stays. With modern surgical approaches and an experienced surgeon, many types of spine surgery can now be done on an outpatient basis with a shorter recovery period.

Mental health. Several studies have indicated that mental and emotional well-being have a positive correlation to improvement and satisfaction after surgery. Patients who feel more in control of their health, for instance, report a more positive recovery and outcome after surgery.1 Understanding how a patient is likely to respond to surgery can help guide more effective post-operative care.

Spine surgery is usually not recommended for mild to moderate back pain, or for pain that has lasted for less than 6 to 12 weeks. Additionally, back surgery is not an option if the cause of the pain is not detectable through imaging tests.

Decompression Surgeries

A decompression surgery removes whatever is pressing on a nerve root from the spinal column, which might include a herniated portion of a disc or a bone spur. There are two primary types of decompression for low back pain.

  • Microdiscectomy is a minimally invasive procedure for patients with a lumbar herniated disc causing radicular leg pain (sciatica).
  • Laminectomy removes part of the layer of the bone or soft tissue that is compressing a nerve or multiple nerve roots. A laminectomy will typically be performed for someone with leg pain and/or weakness from spinal stenosis caused by changes in the facet joints, discs, or bone spurs.

A decompression surgery can be performed with open or minimally invasive techniques with relatively small incisions, and minimal discomfort and recovery before returning to work or other activities. Most of these procedures are now being done as day surgery or with one overnight stay.

Lumbar Spinal Fusion Options

Fusion surgery basically removes the soft tissues between two or more adjacent vertebral bones and replaces them with bone or metal. This procedure enables the bones to grow together over time—typically 6 to 12 months—and fuse into one long bone to stabilize and eliminate motion at those spinal segments.

In the lumbar spine, fusion can be done from the back (posterior approach), the front (anterior approach), the side (lateral approach), or combined. Modern techniques, implants, navigation, and biologics have made the surgery more predictable with easier recovery and return to normal activity and work.

The most reliable indications for lumbar spinal fusion include spondylolisthesis, fracture, instability, deformity, degenerative disc disease, and stenosis. For lower back pain caused by sacroiliac joint dysfunction, fusion of the sacroiliac joint is an option. Tumors and infections are also treated with fusion surgery, but these conditions are far less common.

Other Surgical Options

Some newer surgical options that are being used for some cases of low back pain include:

  • Lumbar artificial disc. For some patients, disc replacement is a potential alternative to fusion surgery for symptomatic degenerative disc disease. This procedure has the potential for a quicker recovery and to maintain more spinal motion than lumbar fusion. Long-term data is still being collected.
  • Posterior motion device. The Coflex inter-laminar device is an alternative to fusion for stenosis and mild degenerative spondylolisthesis. The goals of this approach are for similar results as fusion but with a smaller surgery and faster recovery. Long-term data is still being collected.

This is not a complete list of surgical options. Several others exist or are in development. Technologies that are being utilized today and in development include stem cells, nanotechnologies, and robotics.

Lower Back Surgery Post-Operative Care

The recovery period after low back surgery depends on a number of factors, including the patient’s condition before the surgery, the extensiveness of the surgery, and the surgeon’s skill and experience. For example:

  • A microdiscectomy for a lumbar herniated disc is considered minimally invasive, and the patient usually has no overnight hospital stay and recovery time is about a week.
  • A lumbar fusion may involve an overnight hospital stay, slow return to everyday activities, and possibly some activity restrictions as the fusion sets up over the next 3 to 12 months.

Physical therapy is typically prescribed to rebuild strength, range of motion, and encourage healing. Patients are also commonly prescribed painkillers or muscle relaxants, and some patients may be advised to use a back brace or special beds, shower stools, or supportive pillows to ease the healing process.

Patients in recovery are typically advised to take a short period of rest while the spine and surrounding tissues heal. Most patients take brief time off from work—a few weeks to a couple months—to avoid overexertion of the spinal structures.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

All About Sacroiliitis

Article Featured on Spine Health | By Amish Patel, MD | Image Credit: Veritas Health

The term sacroiliitis is used to describe any inflammation in the sacroiliac joint, which is located on either side of the sacrum (lower spine) that connects to the iliac bone in the hip.

Sacroiliitis is often found as part of a feature of inflammatory conditions of the spinal column. As a group, these conditions and diseases are termed a “spondyloarthropathy” and include conditions such as ankylosing spondylitis, psoriatic arthritis, and reactive arthritis, among others.

Sacroiliitis may also be a component of other types of arthritis, such as ulcerative colitis, Crohn’s disease, or osteoarthritis.

Sacroiliitis is also a term that is sometimes used interchangeably with the term sacroiliac joint dysfunction, as technically either term can be used to describe pain that stems from the sacroiliac joint (or SI joint).

Sacroiliitis vs. Sacroiliac Joint Dysfunction

Both sacroiliitis and sacroiliac joint dysfunction are a common cause of sacroiliac pain, low back pain, and leg pain.

However, there are differences between the two conditions:

  • Sacroiliitis. In medicine, the term “itis” refers to inflammation, and sacroiliitis describes inflammation of the sacroiliac joint. The inflammation may or may not be caused by sacroiliac joint dysfunction.
  • Sacroiliac Joint Dysfunction. This condition generally refers to pain in the sacroiliac joint region that is caused by abnormal motion in the sacroiliac joint, either too much motion or too little motion. It typically results in inflammation of the SI joint, or sacroiliitis.

Sacroiliitis Symptoms

The most common symptoms of sacroiliitis include some combination of the following:

  • Fever
  • Pain, usually low back pain, leg pain (may be in the front of the thigh), hip pain, and/or buttock pain
  • Pain that is worse when sitting for a long time, and worse when rolling over in bed
  • Stiffness felt in the hips and low back, especially after getting out of bed in the morning or after sitting still for a prolonged period.

A wide range of factors may cause sacroiliitis or predispose one to developing sacroiliitis:

  • Any form of spondyloarthropathy, which includes ankylosing spondylitis, arthritis associated with psoriasis, and other rheumatologic diseases, such as lupus
  • Degenerative arthritis, or osteoarthritis of the spine, causing degeneration of the sacroiliac joints and in turn leading to inflammation and SI joint pain
  • A trauma that affects the lower back, hip or buttocks, such as a car accident or fall
  • Pregnancy and childbirth, as a result of the pelvis widening and stretching the sacroiliac joints during childbirth
  • Infection of the sacroiliac joint
  • Osteomyelitis
  • Urinary tract infection
  • Endocarditis
  • IV drug use/drug addition

If a patient has pain in the sacroiliac area and any of the above conditions, he or she may have sacroiliitis or sacroiliac joint dysfunction.

Sacroiliitis Treatment

The specific sacroiliitis treatments will be determined primarily by the type and severity of the patient’s symptoms, and the underlying cause of the sacroiliitis.

There is a wide range of nonsurgical options available. Most patients find that a combination of two or more of the following nonsurgical treatments can be effective in managing their symptoms:

Rest
A short period of rest may help calm the inflamed sacroiliac joints.

Heat and/or ice
Warmth or cold applied to the area will provide local pain relief. Application of a cold pack will help reduce the inflammation in the area. Application of warmth, such as a heating pad or hot tub, will help stimulate blood flow and bring healing nutrients to the area.

Sleep position
Changing one’s sleep position can help alleviate pain while sleeping and at waking. Most patients find it best to sleep on the side, with a pillow placed between the knees to keep the hips in alignment.

Medications
For many, over-the-counter pain medications, such as acetaminophen, and/or anti-inflammatory medications, such as ibuprofen, provide sufficient pain relief. Prescription medications may be recommended, such as tramadol (brand name Ultram), or a short course of narcotic pain medications, or muscle relaxants to help reduce painful muscle spasms.

Sacroiliac joint injections
For severe pain, a sacroiliac joint injection may be recommended both to confirm the sacroiliac joint as the source of the pain and to introduce the anti-inflammatory medication directly into the joint. The injection is done with fluoroscopic guidance, which is a type of live x-ray, to ensure correct placement of the needle in the joint. The injection typically includes both a numbing agent, such as lidocaine, and a steroid, which is a strong anti-inflammatory medication.

Injections can typically be done up to three to four times in one year, and should be accompanied by physical therapy and/or chiropractic or osteopathic manual manipulation to restore proper range of motion and rehabilitation.

Sacroiliitis exercises
A prescribed physical therapy program of stretching, strengthening and low impact aerobic conditioning is usually a part of most sacroiliitis or sacroiliac joint dysfunction treatment regimens. The therapy may be done by a physical therapist, chiropractor or other appropriately trained health specialist.

Other Sacroiliitis Treatments

As part of treatment for another condition
If sacroiliac joint mediated pain is a result of another condition, (such as ankylosing spondylitis, osteomyletis, etc.), then additional treatments will focus on treating the underlying cause of the SI joint symptoms as well.

Sacroiliac joint surgery
The vast majority of cases of sacroiliac joint mediated pain are treated with nonsurgical options. For severe, intractable pain that is unresponsive to nonsurgical options and interferes with the patient’s everyday life, surgery may be considered an option. The surgery is a sacroiliac joint fusion, which is designed to fuse the SI joint to stop the motion in the joint.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Kyphosis (Roundback) of the Spine

Article Featured on AAOS

Kyphosis is a spinal disorder in which an excessive outward curve of the spine results in an abnormal rounding of the upper back. The condition is sometimes known as “roundback” or—in the case of a severe curve—as “hunchback.” Kyphosis can occur at any age, but is common during adolescence.

In the majority of cases, kyphosis causes few problems and does not require treatment. Occasionally, a patient may need to wear a back brace or do exercises in order to improve his or her posture and strengthen the spine. In severe cases, however, kyphosis can be painful, cause significant spinal deformity, and lead to breathing problems. Patients with severe kyphosis may need surgery to help reduce the excessive spinal curve and improve their symptoms.

Anatomy

Your spine is made up of three segments. When viewed from the side, these segments form three natural curves.

The “c-shaped” curves of the neck (cervical spine) and lower back (lumbar spine) are called lordosis. The “reverse c-shaped” curve of the chest (thoracic spine) is called kyphosis.

This natural curvature of the spine is important for balance and helps us to stand upright. If any one of the curves becomes too large or too small, it becomes difficult to stand up straight and our posture appears abnormal.

Side view of the spine

When viewed from the side, a normal spine has three gentle curves.

Other parts of your spine include:

Vertebrae. The spine is made up of 24 small rectangular-shaped bones, called vertebrae, which are stacked on top of one another. These bones create the natural curves of your back and connect to create a canal that protects the spinal cord.

Vertebrae and intervertebral disks

Vertebrae and intervertebral disks in a healthy spine.

Intervertebral disks. In between the vertebrae are flexible intervertebral disks. These disks are flat and round and about a half inch thick. Intervertebral disks cushion the vertebrae and act as shock absorbers when you walk or run.

Description

Although the thoracic spine should have a natural kyphosis between 20 to 45 degrees, postural or structural abnormalities can result in a curve that is outside this normal range. While the medical term for a curve that is greater than normal (more than 50 degrees) is actually “hyperkyphosis,” the term “kyphosis” is commonly used by doctors to refer to the clinical condition of excessive curvature in the thoracic spine that leads to a rounded upper back.

Kyphosis can affect patients of all ages. The condition, however, is common during adolescence—a time of rapid bone growth.

Kyphosis can vary in severity. In general, the greater the curve, the more serious the condition. Milder curves may cause mild back pain or no symptoms at all. More severe curves can cause significant spinal deformity and result in a visible hump on the patient’s back.

Types of Kyphosis

There are several types of kyphosis. The three that most commonly affect children and adolescents are:

  • Postural kyphosis
  • Scheuermann’s kyphosis
  • Congenital kyphosis

Postural Kyphosis

Postural kyphosis, the most common type of kyphosis, usually becomes noticeable during adolescence. It is noticed clinically as poor posture or slouching, but is not associated with severe structural abnormalities of the spine.

The curve caused by postural kyphosis is typically round and smooth and can often be corrected by the patient when he or she is asked to “stand up straight.”

Postural kyphosis is more common in girls than boys. It is rarely painful and, because the curve does not progress, it does not usually lead to problems in adult life.

Scheuermann’s Kyphosis

Scheuermann’s kyphosis is named after the Danish radiologist who first described the condition.

Like postural kyphosis, Scheuermann’s kyphosis often becomes apparent during the teen years. However, Scheuermann’s kyphosis can result in a significantly more severe deformity than postural kyphosis—particularly in thin patients.

Scheuermann’s kyphosis is caused by a structural abnormality in the spine. In a patient with Scheuermann’s kyphosis, an x-ray from the side will show that, rather than the normal rectangular shape, several consecutive vertebrae have a more triangular shape. This irregular shape causes the vertebrae to wedge together toward the front of the spine, decreasing the normal disk space and creating an exaggerated forward curvature in the upper back.

Illustration and x-ray of vertebral wedging

Illustration and x-ray show the vertebral wedging that occurs in patients with Scheuermann’s kyphosis. (Right) Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010

The curve caused by Scheuermann’s kyphosis is usually sharp and angular. It is also stiff and rigid; unlike a patient with postural kyphosis, a patient with Scheuermann’s kyphosis is not able to correct the curve by standing up straight.

Scheuermann’s kyphosis usually affects the thoracic spine, but occasionally develops in the lumbar (lower) spine. The condition is more common in boys than girls and stops progressing once growing is complete.

Scheuermann’s kyphosis can sometimes be painful. If pain is present, it is commonly felt at the highest part or “apex” of the curve. Pain may also be felt in the lower back. This results when the spine tries to compensate for the rounded upper back by increasing the natural inward curve of the lower back. Activity can make the pain worse, as can long periods of standing or sitting.

Clinical photos of a boy with severe kyphosis

Clinical photos taken from the side and front of an adolescent male with an abnormally rounded upper back. His severe kyphosis is most obvious when bending forward. Courtesy of Texas Scottish Rite Hospital for Children

Congenital Kyphosis

Congenital kyphosis is present at birth. It occurs when the spinal column fails to develop normally while the baby is in utero. The bones may not form as they should or several vertebrae may be fused together. Congenital kyphosis typically worsens as the child ages.

Patients with congenital kyphosis often need surgical treatment at a very young age to stop progression of the curve. Many times, these patients will have additional birth defects that impact other parts of the body such as the heart and kidneys.

Clinical photo and MRI of a child with congenital kyphosis

(Left) Clinical photo of a child with congenital kyphosis in his thoracic spine. (Right) An MRI of his spine shows spinal cord compression. This can lead to neurological symptoms like weakness and numbness in the legs. Courtesy of Texas Scottish Rite Hospital for Children

Symptoms

The signs and symptoms of kyphosis vary, depending upon the cause and severity of the curve. These may include:

  • Rounded shoulders
  • A visible hump on the back
  • Mild back pain
  • Fatigue
  • Spine stiffness
  • Tight hamstrings (the muscles in the back of the thigh)

Rarely, over time, progressive curves may lead to:

  • Weakness, numbness, or tingling in the legs
  • Loss of sensation
  • Shortness of breath or other breathing difficulties

Doctor Examination

Mild kyphosis often goes unnoticed until a scoliosis screening at school—and this prompts a visit to the doctor. If changes to the patient’s back are noticeable, however, it is usually quite troubling for both the parents and the child. Concern about the cosmetic appearance of the child’s back is often what leads the family to seek medical help.

Physical Examination

Your doctor will begin by taking a medical history and asking about your child’s general health and symptoms. He or she will then examine your child’s back, pressing on the spine to determine if there are any areas of tenderness.

In more severe cases of kyphosis, the rounding of the upper back or a hump may be clearly visible. In milder cases, however, the condition may be harder to diagnose.

During the exam, your doctor will ask your child to bend forward with both feet together, knees straight, and arms hanging free. This test, which is called the “Adam’s forward bend test,” enables your doctor to better see the slope of the spine and observe any spinal deformity.

Clinical photo of Adam's forward bend test

To assess for a curve, your doctor will ask your child to bend forward at the waist.
Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010

Your doctor may also ask your child to lay down to see if this straightens the curve—a sign that the curve is flexible and may be representative of postural kyphosis.

Tests

X-rays. These studies provide images of dense structures, such as bone. Your doctor may order x-rays from different angles to determine if there are changes in the vertebrae or any other bony abnormalities.

X-rays will also help measure the degree of the kyphotic curve. A curve that is greater than 50 degrees is considered abnormal.

Pulmonary function tests. If the curve is severe, your doctor may order pulmonary function tests. These tests will help determine if your child’s breathing is restricted because of diminished chest space.

Other tests. In patients with congenital kyphosis, progressive curves may lead to symptoms of spinal cord compression, including pain, tingling, numbness, or weakness in the lower body. If your child is experiencing any of these symptoms, your doctor may order neurologic tests or a magnetic resonance imaging (MRI) scan.

Treatment

The goal of treatment is to stop progression of the curve and prevent deformity. Your doctor will consider several things when determining treatment for kyphosis, including:

  • Your child’s age and overall health
  • The number of remaining growing years
  • The type of kyphosis
  • The severity of the curve

Nonsurgical Treatment

Nonsurgical treatment is recommended for patients with postural kyphosis. It is also recommended for patients with Scheuermann’s kyphosis who have curves of less than 75 degrees.

Nonsurgical treatment may include:

Observation. Your doctor may recommend simply monitoring the curve to make sure it does not get worse. Your child may be asked to return for periodic visits and x-rays until he or she is fully grown.

Unless the curve gets worse or becomes painful, no other treatment may be needed.

Physical therapy. Specific exercises can help relieve back pain and improve posture by strengthening muscles in the abdomen and back. Certain exercises can also help stretch tight hamstrings and strengthen areas of the body that may be impacted by misalignment of the spine.

Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, including aspirin, ibuprofen and naproxen, can help relieve back pain.

Bracing. Bracing may be recommended for patients with Scheuermann’s kyphosis who are still growing. The specific type of brace and the number of hours per day it should be worn will depend upon the severity of the curve. Your doctor will adjust the brace regularly as the curve improves. Typically, the brace is worn until the child reaches skeletal maturity and growing is complete.

X-rays of a kyphotic spinal curve before and after bracing

(Left) This patient has a 65° curve in the thoracic spine. (Right) Although it cannot be seen on x-ray, the patient is now wearing a back brace that has helped to reduce the excessive curve.
Reproduced from Pizzutillo PD: Nonsurgical treatment of kyphosis. Instructional Course Lectures, Pediatrics. Rosemont IL, American Academy of Orthopaedic Surgeons, 2006, pp. 181-187.

Surgical Treatment

Surgery is often recommended for patients with congenital kyphosis.

Surgery may also be recommended for:

  • Patients with Scheuermann’s kyphosis who have curves greater than 75 degrees
  • Patients with severe back pain that does not improve with nonsurgical treatment

Spinal fusion is the surgical procedure most commonly used to treat kyphosis.

The goals of spinal fusion are to:

  • Reduce the degree of the curve
  • Prevent any further progression
  • Maintain the improvement over time
  • Alleviate significant back pain, if it is present

Surgical Procedure

Spinal fusion is essentially a “welding” process. The basic idea is to fuse together the affected vertebrae so that they heal into a single, solid bone. Fusing the vertebrae will reduce the degree of the curve and, because it eliminates motion between the affected vertebrae, may also help alleviate back pain.

During the procedure, the vertebrae that make up the curve are first realigned to reduce the rounding of the spine. Small pieces of bone—called bone graft—are then placed into the spaces between the vertebrae to be fused. Over time, the bones grow together—similar to how a broken bone heals.

Before the bone graft is placed, your doctor will typically use metal screws, plates and rods to increase the rate of fusion and further stabilize the spine.

Exactly how much of the spine is fused depends upon the size of your child’s curve. Only the curved vertebrae are fused together. The other bones in the spine can still move and assist with bending, straightening, and rotation.

X-rays of a kyphotic curve before and after spinal fusion

(Left) Preoperative x-ray of a 17-year-old boy with a painful 80° curve caused by Scheuermann’s kyphosis. (Right) After spinal fusion and stabilization with plates and screws, the curve has been reduced to 38°.
Reproduced from Wood KB, Melikian R, Villamil F: Adult Scheuermann kyphosis: valuation, management, and new developments. J Am Acad Orthop Surg 2012; 20:113-121

Long-Term Outcomes

If kyphosis is diagnosed early, the majority of patients can be treated successfully without surgery and go on to lead active, healthy lives. If left untreated, however, curve progression could potentially lead to problems during adulthood. For patients with kyphosis, regular check-ups are necessary to monitor the condition and check progression of the curve.

Cervical Spondylotic Myelopathy (Spinal Cord Compression)

Cervical Spondylotic Myelopathy (Spinal Cord Compression)

Article Featured on AAOS

Cervical spondylotic myelopathy (CSM) is a neck condition that arises when the spinal cord becomes compressed—or squeezed—due to the wear-and-tear changes that occur in the spine as we age. The condition commonly occurs in patients over the age of 50.

Because the spinal cord carries nerve impulses to many regions in the body, patients with CSM can experience a wide variety of symptoms. Weakness and numbness in the hands and arms, loss of balance and coordination, and neck pain can all result when the normal flow of nerve impulses through the spinal cord is interrupted.

Anatomy

Your spine is made up of 24 bones, called vertebrae, that are stacked on top of one another. The seven small vertebrae that begin at the base of the skull and form the neck comprise the cervical spine.

The areas of the spine

Cervical spondylotic myelopathy occurs in the cervical spine—the seven small vertebrae that form the neck

Other parts of your spine include:

Spinal cord and nerves. The spinal cord extends from the skull to your lower back and travels through the middle part of each stacked vertebra, called the central canal. Nerves branch out from the spinal cord through openings in the vertebrae (foramen) and carry messages between the brain and muscles.

Spinal nerve root

Spinal nerve root.

Intervertebral disks. In between your vertebrae are flexible intervertebral disks. They act as shock absorbers when you walk or run.

Intervertebral disks are flat and round and about a half inch thick. They are made up of two components:

  • Annulus fibrosus. This is the tough, flexible outer ring of the disk.
  • Nucleus pulposus. This is the soft, jelly-like center of the disk.

Cause

Cervical spondylotic myelopathy (CSM) arises from degenerative changes that occur in the spine as we age. These degenerative changes in the disks are often called arthritis or spondylosis.

Cervical Disk Degeneration

Bone spurs. As the disks in the spine age, they lose height and begin to bulge. They also lose water content, begin to dry out, and become stiffer. This problem causes settling, or collapse, of the disk spaces and loss of disk space height.

As the disks lose height, the vertebrae move closer together. The body responds to the collapsed disk by forming more bone—called bone spurs—around the disk to strengthen it. These bone spurs contribute to the stiffening of the spine. They may also make the spinal canal narrow—compressing or squeezing the spinal cord.

Illustrations of a healthy cervical vertebra and disk and a disk that has collapsed

(Left) Side view of a healthy cervical vertebra and disk. (Right) A disk that has degenerated and collapsed.

Herniated disk. A disk herniates when its jelly-like center (nucleus pulposus) pushes against its outer ring (annulus fibrosus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When a herniated disk bulges out toward the spinal canal, it can put pressure on the spinal cord or nerve roots.

As disks deteriorate with age, they become more prone to herniation. A herniated disk often occurs with lifting, pulling, bending, or twisting movements.

Cross-section and side views of a herniated disk

Herniated disk (cross-section and side views)

Other Causes of Myelopathy

Myelopathy can arise from other conditions that cause spinal cord compression, as well. Although these conditions are not related to disk degeneration, they may result in the same symptoms as CSM.

Rheumatoid arthritis. Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In rheumatoid arthritis, immune cells attack the synovium, the thin membrane that lines the joints.

As the synovium swells, it may lead to pain and stiffness and, in severe cases, destruction of the facet joints in the cervical spine. When this occurs, the upper vertebra may slide forward on top of the lower vertebra, reducing the amount of space available for the spinal cord.

Injury. An injury to the neck—such as from a car accident, sports, or a fall—may also lead to myelopathy.

For example, a “rear end” car collision may result in hyperextension, a backward motion of the neck beyond its normal limits, or hyperflexion, a forward motion of the neck beyond its normal limits. Because these types of injuries often affect the muscles and ligaments that support the vertebrae, they may lead to spinal cord compression.

Symptoms

Typically, the symptoms of CSM develop slowly and progress steadily over several years. In some patients, however, the condition may worsen more rapidly.

Patients with CSM may experience a combination of the following symptoms:

  • Tingling or numbness in the arms, fingers, or hands
  • Weakness in the muscles of the arms, shoulders, or hands. You may have trouble grasping and holding on to items.
  • Imbalance and other coordination problems. You may have trouble walking or you may fall down. With myelopathy, there is no sensation of spinning, or “vertigo.” Rather, your head and eyes feel steady, but your body feels unable to follow through with what you are trying to do.
  • Loss of fine motor skills. You may have difficulty with handwriting, buttoning your clothes, picking up coins, or feeding yourself.
  • Pain or stiffness in the neck

Doctor Examination

Physical Examination

After discussing your medical history and general health, your doctor will ask you about your symptoms. He or she will conduct a thorough examination of your neck, shoulders, arms, hands, and legs, looking for:

  • Changes in reflexes—including the presence of hyper-reflexia, a condition in which reflexes are exaggerated or overactive
  • Numbness and weakness in the arms, hands, and fingers
  • Trouble walking, loss of balance, or weakness in the legs
  • Atrophy—a condition in which muscles deteriorate and shrink in size

Tests

X-rays. These provide images of dense structures, such as bone. An x-ray will show the alignment of the vertebrae in your neck.

Magnetic resonance imaging (MRI) scans. These studies create better images of the body’s soft tissues. An MRI can show spinal cord compression and help determine whether your symptoms are caused by damage to soft tissues—such as a bulging or herniated disk.

MRI scan of a herniated disk pressing on spinal cord

This MRI image shows herniated disks pressing on the spinal cord (red arrows). Reproduced from Boyce R, Wang J: Evaluation of neck pain, radiculopathy and myelopathy: imaging, conservative treatment, and surgical indications. Instructional Course Lectures 52. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp.489-495.

Computed tomography (CT) scans. More detailed that a plain x-ray, a CT scan can show narrowing of the spinal canal and can help your doctor determine whether you have developed bone spurs in your cervical spine.

CT scan showing narrowing of the spinal canal due to bone spurs

This CT scan shows bone spurs that have led to narrowing of the spinal canal (arrows).

Myelogram. This is a special type of CT scan. In this procedure, a contrast dye is injected into the spinal column to make the spinal cord and nerve roots show up more clearly.

Treatment

Nonsurgical Treatment

In milder cases, initial treatment for CSM may be nonsurgical. The goal of nonsurgical treatment is to decrease pain and improve the patient’s ability to perform daily activities. Nonsurgical treatment options include:

Soft cervical collar. This is a padded ring that wraps around the neck and is held in place with velcro. Your doctor may advise you to wear a soft cervical collar to allow the muscles of the neck to rest and limit neck motion. A soft collar should only be worn for a short period of time since long-term wear may decrease the strength of the muscles in your neck.

Physical therapy. Specific exercises can help relieve pain, strengthen neck muscles, and increase flexibility. Physical therapy can also help you maintain strength and endurance so that you are better able to perform your daily activities. In some cases, traction can be used to gently stretch the joints and muscles of the neck.

Medications. In some cases, medications can help improve your symptoms.

  • Nonsteroidal anti-inflammatory medications (NSAIDs). Drugs like aspirin, ibuprofen, and naproxen can help relieve pain from reduce inflammation.
  • Oral corticosteroids. A short course of oral corticosteroids may help relieve pain by reducing inflammation.
  • Epidural steroid injection. Although not often used to treat CSM, in this procedure, steroids are injected into the space next to the covering of the spinal cord (the “epidural” space) to help reduce local inflammation. Although a steroid injection may temporarily help relieve pain and swelling, it will not relieve pressure on the spinal cord.
  • Narcotics. These medications are reserve for patients with severe pain that is not relieved by other options. Narcotics are usually prescribed for a limited time only.

Although people sometimes turn to chiropractic manipulation for neck and back pain, manipulation should never be used for spinal cord compression.

Surgical Treatment

If nonsurgical treatment does not relieve your symptoms, your doctor will talk with you about whether you would benefit from surgery. The majority of patients with symptoms and tests consistent with CSM are recommended to have surgery.

There are several procedures that can be performed to help relieve pressure on the spinal cord. The procedure your doctor recommends will depend on many factors, including what symptoms you are experiencing and the levels of the spinal cord that are involved.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

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