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Pediatric Orthopedics


The treatment of children with musculoskeletal problems remains an integral part of modern Orthopaedic surgery. Many fractures and injuries occur in children due to their high activity level and unique immature skeleton. Treatment of fractures in children is different than adults due to active growth plates in their bones. Damage to the growth plate can lead to significant problems with later bone growth, and at-risk fractures have to be monitored with care.

The treatment of scoliosis is a mainstay of pediatric Orthopaedics. For poorly understood reasons, curvature develops in the spine of some children, which if left untreated leads to undesirable deformity and may progress to cause chronic pain and breathing problems. The treatment of scoliosis is quite complicated and often involves a combination of bracing and surgery.

Children have other unique musculoskeletal conditions that have been a focus of Orthopedics since Hippocrates, including conditions such as club foot and congenital dislocation of hip (also known as developmental dysplasia of the hip). In addition, infections in bones and joints (osteomyelitis) in children are common. In the US, specialized hospitals such as the Shriners hospitals have provided a substantial portion of treatment for children with musculoskeletal deformities and diseases.


Terminology


Nicholas Andry coined the word "Orthopaedics", derived from Greek words for "correct" or "straight" ("Orthos") and "child" ("paidion"), in 1741, when at the age of 81 he published Orthopaedia: or the Art of Correcting and Preventing Deformities in Children.

In the U.S. the spelling Orthopedics is standard, although the majority of university and residency programs, and even the AAOS, still use Andry's spelling. Elsewhere, usage is not uniform; in Canada, both spellings are common; Orthopaedics usually prevails in the rest of the Commonwealth, especially in Britain; see also spelling differences.

Arbeitsgemeinschaft für Osteosynthesefragen (commonly called AO) (German for Association for the Study of Internal Fixation) is a non profit organization dedicated to improving the care of patients with musculoskeletal injuries and their sequelae through research, development, education and quality assurance in the principles, practice, and result of fracture treatment.


Arthroscopy

Arthroscopy (also called arthroscopic surgery) is a minimally invasive surgical procedure in which a physical examination of the interior of a joint is performed using an arthroscope, a type of endoscope that is inserted into the joint through a small incision. Arthroscopic procedures can be performed either to evaluate, or to treat, many Orthopaedic conditions including torn floating cartilage, torn surface cartilage, ACL reconstruction and trimming damaged cartilage. Arthroscopy is used for joints of the knee, shoulder, elbow, wrist, ankle and hip.

The advantage of arthroscopy over traditional knee endoscopies is that the joint does not have to be opened up fully. Instead, only two small incisions are made - one for the arthroscope and one for the surgical instruments. This reduces the recovery time of the patient and may increase the rate of surgical success due to less trauma to the connective tissue. It is especially useful for professional athletes, who frequently injure knee joints and require fast healing time. There is also less scarring, because of the smaller incisions.

The surgical instruments used are smaller than traditional instruments. Surgeons view the joint area on a video monitor, and can diagnose and repair broken joint tissue, such as ligaments and menisci.


Gait Analysis


Gait analysis is the process of quantification and interpretation of animal (including human) locomotion. Pathological gait may reflect compensations for underlying pathologies, or be responsible for causation of symptoms in itself. The study of gait analysis allows these diagnoses to be made, as well as permitting future developments in rehabilitation engineering. Aside from clinical applications, gait analysis is widely used in professional sports training to optimize and improve athletic performance.


History


With the development of photography, it became possible to capture image sequences which reveal details of human and animal locomotion that are not noticeable by watching the movement with the naked eye. Eadweard Muybridge and Etienne-Jules Marey were pioneers of this in the early 1900s. It was photography which first revealed the detailed sequence of the horse "gallop" gait, which is usually misrepresented in paintings made prior to this discovery, for example.

Although much early research was done using film cameras, the widespread application of gait analysis to humans with pathological conditions such as cerebral palsy, Parkinson's disease, and neuromuscular disorders, began in the 1970s with the availability of video camera systems which could produce detailed studies of individual patients within realistic cost and time constraints. The development of treatment regimes, often involving Orthopaedic surgery, based on gait analysis results, advanced significantly in the 1980s. Many leading Orthopaedic hospitals worldwide now have gait labs which are routinely used in large numbers of cases, both to design treatment plans, and for follow-up monitoring.

The forefathers of this research are Murali Kadaba, HK Ramakrishnan, and Mary Wootten. Their main papers, dealing with Euler Angles, led to the development of a marker system. This marker system is the predecessor of modern marker systems, such as the ones used in movies.


Equipment and techniques


A modern gait lab has several (five or more) video cameras placed around the walkway, which are linked to a computer. The patient has markers applied to anatomical landmark points, which are mostly palpable bony landmarks such as the iliac spines of the pelvis, the malleoli of the ankle, and the condyles of the knee. The patient walks down the walkway and the computer calculates the trajectory of each marker in three dimensions. A model is applied to compute the underlying motion of the bones. This gives a full breakdown of the motion at each joint.

In addition, most labs have floor transducers (strain gauges) which measure the force between the foot and the floor, including both magnitude and direction. Adding this to the known dynamics of each body segment, enables the solution of equations based on Newton's laws of motion and enables the computer to calculate the forces exerted by each muscle group, and the net moment about each joint at every stage of the gait cycle. Some labs also use skin electrodes to detect the activity of each leg muscle. In this way, a complete mechanical description of locomotion is obtained. Deviations from normal patterns are used to diagnose specific conditions and predict the outcome of treatment. Orthopaedic surgery remains an art as much as a science and the outcome of each case still depends on the interpretation of results and the experience of the surgeon. Options for treatment of cerebral palsy include the paralysis of spastic muscles using Botox® or the lengthening, re-attachment or detachment of particular tendons. Corrections of distorted bony anatomy are also undertaken.


Biometric identification and forensics


Minor variations in gait style can be used as a biometric identifier to identify individual people. The parameters are grouped to spatial-temporal (step length, step width, walking speed, cycle time) and kinematic (joint rotation of the hip, knee and ankle, mean joint angles of the hip/knee/ankle, and thigh/trunk/foot angles) classes. There is a high correlation between step length and height of a person.  Gait analysis was proposed as authentication for portable electronic devices.


Hand Surgery


The field of hand surgery deals with both surgical and non-surgical treatment of conditions and problems that may take place in the hand or upper extremity (commonly from the tip of the hand to the shoulder). Hand surgery may be practiced by graduates of general surgery, Orthopaedic surgery and plastic surgery. Plastic surgeons receive significant training in hand surgery, with some graduates continuing on to do an additional one year hand fellowship. These fellowships are also pursued by general surgeons and Orthopedic surgeons. Plastic surgeons are particularly well suited to handle traumatic hand and digit amputations that require a "replant" operation. Plastic surgeons are trained to reconstruct all aspects to salvage the appendage: blood vessels, nerves, tendons, muscle, bone. Hand surgeons perform a wide variety of operations such as fracture repairs, nerve decompressions, and reconstruction of injuries, rheumatoid deformities and congenital defects.


Carpal tunnel


In the human wrist there is a sheath of tough connective tissue which envelopes and protects one nerve (median nerve) and tendons, which attach muscles to the wrist and hand bones. The carpal tunnel is the space between this sheath (above) and the bones (below) making up the wrist and hand (carpal bones). The term 'carpal tunnel' is also used quite commonly to refer to 'carpal tunnel syndrome' which is a condition where the median nerve is pinched within the tunnel and causes pain and/or numbness of the wrist/hand, once thought to be a result of repetitive motion such as painting or typing.


Traction (Orthopedics)


In Orthopaedic medicine, traction refers to the set of mechanisms for straightening broken bones or relieving pressure on the skeletal system. there are two types of traction skin traction and skeletal traction.

It is largely replaced now by more modern techniques, but certain approaches are still used today:

Buck's traction - hip fractures
Bryant's traction
Russell's traction

Spinal fusion

Spinal fusion, also known as spondylosyndesis is a surgical technique used to combine two or more vertebrae. Supplementary bone tissue (either autograft or allograft) is used in conjunction with the body's natural osteoblastic processes. This procedure is used primarily to eliminate the pain caused by motion of the vertebrae by immobilizing the vertebrae themselves.

While the two vertebrae that are joined rarely detach, it does create additional risk of damage to adjacent vertebrae.


Conditions where spinal fusion is used


Spinal fusion is done most commonly in the lumbar region of the spine, but it is also used to treat cervical and thoracic problems.


Conditions for which spinal fusion is most commonly done:

degenerative disc disease
discogenic pain
spinal tumor
vertebral fracture
scoliosis
spondylolisthesis
spondylosis
other degenerative spinal conditions
any condition that causes instability of the spine


Types of spinal fusion

There are two main types of spinal fusion, which may be used in conjunction with each other:


Posterolateral fusion places the bone graft between the transverse processes in the back of the spine. These vertebrae are then fixed in place with screws and/or wire through the pedicles of each vertebrae attaching to a metal rod on each side of the vertebrae.


Interbody fusion
places the bone graft between the vertebrae in the area usually occupied by the intervertebral disc. In preparation for the spinal fusion, the disc is removed entirely. The fusion then occurs between the endplates of the vertebrae. This procedure may be done through the abdomen (Anterior Lumbar Interbody Fusion or ALIF) or through the back (Posterior Lumbar Interbody Fusion or PLIF). Using both types of fusion is known as 360-degree fusion.

In most cases, the fusion is augmented by a process called fixation, meaning the placement of metallic screws, rods or plates to stabilize the vertebra prior to bone fusion. The fusion process typically takes 3-6 months after surgery. During in this time external bracing (Orthotics) may be required. External factors such as smoking, osteoporosis, certain medications, and heavy activity can prolong or even prevent the fusion process.

Some newer technologies are being introduced which avoid fusion and preserve spinal motion. Such procedures, such as artificial disc replacement, are being offered as alternatives to fusion, but have not yet been adopted on a widespread basis in the US.


Laminectomy


Laminectomy is a surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The lamina of the vertebra is removed or trimmed to widen the spinal canal and create more space for the spinal nerves.

Upper view of a human vertebra, showing the lamina


The first laminectomy was performed in 1887 by Dr. Victor Alexander Haden Horsley, a professor of surgery at the University College London.

A common type of laminectomy is performed to permit the removal or reshaping of a spinal disc as part of a lumbar discectomy. This is a treatment for a herniated disc, bulging or degenerated disc.


Herniated intervertebral disc


One of the most common reasons for laminectomy is a prolapsed or herniated intervertebral disc. If the herniated disc is in the lumbar region, this can cause sharp and continuing back pain, a weakening of the muscles in the leg, and some loss of sensation in the leg and foot. It may also be difficult to raise the leg when it is held in a straight position. A herniated disc in the neck region can cause symptoms including pain, numbness and weakness in the arm. A herniated disc may be triggered by, for example, twisting the back while lifting something heavy. The surgeon will attempt to relieve the pressure on nerves and nerve roots by removing the pulpy material that is protruding from the disc.


Medical issues to consider


Tests are usually performed prior to surgery to aid diagnosis. These tests may include:

Spinal x-ray
Myelogram
Computerized tomography (CT) scan
Magnetic resonance imaging (MRI) scan.

Your surgeon should explain the nature of your operation, the reasons for it, the outcome and the possible risks involved. They should be able to tell you the approximate length of stay in hospital that will be required and the number of weeks you will need to recuperate before returning to work. Your anesthetist will visit you to see how suitable you are for surgery. Laboratory tests, including blood and urine samples, are taken before the operation.


Operation procedure


The patient will have 'nil by mouth' (nothing to eat) for a number of hours prior to surgery, and an enema to empty your bowel. A pre-medication injection is usually given to make you drowsy and dry up some internal secretions.


Laminectomy is usually performed under general anesthetic. The patient is placed face-down on the operating table. The exact procedure depends on the location of the herniated disc; e.g., if the disc is located in the neck, the head is clamped to prevent movement. The skin is marked for incision. The surgeon first cuts through the skin. The muscle is then cut, peeled back from the vertebrae and held in place with special instruments called retractors. The lamina, which is between the bony projection of the vertebrae (the 'points' that can be felt with fingers) and the transverse process or 'wing', is removed. What happens next depends on the problem. For example, the surgeon may then trim the protruding bits of a herniated disc. Once the surgery is completed, the muscle and skin are sutured (sewn) closed.


After the operation, the patient can expect:

Routine post-operative observations will be taken and charted, including temperature and blood pressure. The patient's wound is checked for redness, swelling and signs of infection.
Muscle spasms are quite common following laminectomy. Pain relief is ordered and given regularly. Note is made of ability to pass urine, as sometimes this may be affected immediately following surgery.
The patient may have intravenous fluids for a few days, which may include an antibiotic.
Initially, two people have to help the patient to roll over in bed. The patient is taught the proper method of rolling the body in order to maintain proper body alignment. This is most important for the first 48 hours or so.
The patient is assisted out of bed after a few days. A physiotherapist gives specific instructions on how to get out of bed properly in order to avoid stress and strain on the wound site.
The patient is encouraged to walk, stand and sit for short periods. The patient is taught how to prevent twisting, flexing or hyperextending the back while moving around.


Some of the possible complications of laminectomy include:

Infection of the wound
Blood clots in the legs
Splitting open of the wound (wound dehiscence)
Injury to the spinal cord
Paraplegia or quadriplegia (depending on the site and severity of the spinal cord injury)
Postlaminectomy syndrome, consisting of chronic back pain and spinal instability


Post-operative recovery


Although guided by a doctor, general suggestions include:

Continue to take your medications as ordered, especially the full course of antibiotics.
If the operation was performed on your neck, you will need to wear a collar for about six weeks.
Try to rest as much as possible for at least two weeks.
Avoid activities that strain the spine – such as sitting or standing for too long, flexing your spine, bending at the waist, climbing too many stairs or going for long trips in the car.
Avoid wearing high-heeled shoes.
Sleep on a firm mattress.
Continue with any exercises you were shown in hospital.
Beware of heavy lifting for a long period.
After two weeks at home, try to have a 10 minute walk each day, unless advised otherwise by your doctor.
Report to your doctor any signs of infection, such as wound redness or drainage, elevated temperature or persistent headaches.


Long term outlook


A regular exercise program following surgery is most important to increase your spinal muscle strength and flexibility, and to protect against future injury. Occasionally, the operation doesn't work and the original symptoms remain. At other times, the operation isn't expected to relieve symptoms, but is performed to prevent the area from deteriorating further. In this case, original symptoms will probably remain, but might not get any worse. Some patients may develop chronic back pain after laminectomy surgery, a medical condition known as "postlaminectomy syndrome." Some surgeons believe that the laminectomy procedure, by removing excessive amounts of bone and ligament from the spine, disturbs the biomechanical stability of the spinal column, resulting in pain. Alternative techniques for decompressing spinal nerves with minimal disruption of spinal stability have been developed and include microsurgical lumbar laminoplasty.


Other forms of treatment


Even with signs of spinal nerve pressure, such as sciatica, recovery without any treatment may occur. Alternative treatment to surgery isn't always possible, but generally should be tried first. This may include:

Stabilization exercises
Stretching and strengthening exercises
Training on how to safely use the back
(such as proper lifting techniques)
Chiropractic
Osteopathy
Physical therapy
Occupational Therapy
Switching to ergonomic furniture.

Discectomy without laminectomy may also be an option, and this can often be done as day surgery using arthroscopic microscopic discectomy.


Anterior cruciate ligament


Diagram of the right knee. (Anterior cruciate ligament
labeled at center left.)


Right knee-joint, from the front, showing interior ligaments.
(Ant. cruciate labeled at center.)


The anterior cruciate ligament (or ACL) is one of the four major ligaments of the knee. It connects from a posterio-lateral (back & outside) part of the femur to an anterio-medial (front & inside) part of the tibia. These attachments allow it to resist forces pushing the tibia forward relative to the femur.

More specifically, it is attached to the depression in front of the intercondyloid eminence of the tibia, being blended with the anterior extremity of the lateral meniscus.

It passes up, backward, and laterally, and is fixed into the medial and back part of the lateral condyle of the femur. Tearing of the ACL is a common injury among athletes.


Disc Herniation


Disc herniation can occur in any disc in the spine, but the two most common forms are the cervical disc herniation and the lumbar disc herniation. The latter is the most common, causing lower back pain (lumbago) and often leg pain as well, in which case it is commonly referred to as sciatica.

Lumbar disc herniation occurs 15 times more often than cervical (neck) disc herniation, and it is one of the most common causes of lower back pain. The cervical discs are affected 8% of the time and the upper-to-mid-back (thoracic) discs only 1 - 2% of the time.

The following locations have no discs and are therefore exempt from the risk of disc herniation: the upper two cervical intervertebral spaces, the sacrum, and the coccyx.

Most disc herniations occur when a person is in their thirties or forties when the nucleus pulposus is still a gelatin-like substance. With age the nucleus pulposus changes ("dries out") and the risk of herniation is greatly reduced. At the same time osteoarthritic degeneration makes its inroads.

Intervertebral disc

Intervertebral discs (or intervertebral fibrocartilage) lie between adjacent vertebrae in the spine. Each disc forms a cartilaginous joint to allow slight movement of the vertebrae, and acts as a ligament to hold the vertebrae together.

Discs consist of an outer annulus fibrosus, which surrounds the inner nucleus pulposus. The annulus fibrosus consists of several layers of fibrocartilage. The strong annular fibers contain the nucleus pulposus and distribute pressure evenly across the disc. The nucleus pulposus contains loose fibers suspended in a mucoprotein gel the consistency of jelly. The nucleus of the disc acts as a shock absorber, absorbing the impact of the body's daily activities and keeping the two vertebrae separated. The disc can be likened to a doughnut: whereby the annulus fibrosis is similar to the dough and the nucleus pulposis is the jelly. If one presses down on the front of the doughnut the jelly moves posteriorly or to the back. When one develops a prolapsed disc the jelly/ nucleus pulposis is forced out of the doughnut/ disc and may put pressure on the nerve located near the disc. This will give one the symptoms of sciatica.

There is one disc between each pair of vertebrae, except for the first cervical segment, the atlas. The atlas is a ring around the roughly cone-shaped extension of the axis (second cervical segment). The axis acts as a post around which the atlas can rotate, allowing the neck to swivel. There are a total of twenty-three discs in the spine, which are identified by specifying the particular vertebrae they separate. For example, the disc between the fifth and sixth cervical vertabrae is designated "C5-6".

Medical conditions related to the intervertebral disc

As people age, the nucleus pulposus begins to dehydrate, which limits its ability to absorb shock. The annulus fibrosus gets weaker with age and begins to tear. While this may not cause pain in some people, in others one or both of these may cause chronic pain.

Pain due to the inability of the dehydrating nucleus pulposus to absorb shock is called axial pain or disc space pain. One generally refers to the gradual dehydration of the nucleus pulposus as degenerative disc disease.

When the annulus fibrosus tears due to an injury or the aging process, the nucleus pulposus can begin to extrude through the tear. This is called disc herniation. Near the posterior side of each disc, all along the spine, major spinal nerves extend out to different organs, tissues, extremities etc. It is very common for the herniated disc to press against these nerves (pinched nerve) causing radiating pain, numbness, tingling, and diminished strength and/or range of motion. In addition, the contact of the inner nuclear gel, which contains inflammatory proteins, with a nerve can also cause significant pain. Nerve-related pain is called radicular pain.

Herniated discs go by many names and these can mean different things to different medical professionals. A slipped disc, ruptured disc, or a bulging disc can all refer to the same medical condition. Protrusions of the disc into the adjacent vertebra are known as Schmorl's nodes.


Spinal disc herniation

A spinal disc herniation is a pathological condition in which a tear in the outer, fibrous ring (annulus fibrosus) of an intervertebral disc allows the soft, central portion (nucleus pulposus) to be extruded (herniated) to the outside of the disc.

It is normally a further development of a previously existing disc protrusion, a condition in which the outermost layers of the annulus fibrosus are still intact, but can bulge when the disc is under pressure.

Terminology

Some of the terms commonly used to describe the condition include herniated disc, prolapsed disc, ruptured disc, and the misleading expression "slipped disc." Other terms that are closely related include disc protrusion, bulging disc, pinched nerve, sciatica, disc disease, disc degeneration, degenerative disc disease, and black disc.

The popular term "slipped disc" is quite misleading, as an intervertebral disc, being tightly sandwiched between two vertebrae, cannot actually "slip," "slide," or even get "out of place." The disc is actually grown together with the adjacent vertebrae and can be squeezed, stretched, and twisted, all in small degrees. It can also be torn, ripped, herniated, and degenerated, but it cannot "slip."

The spelling "disc" is based on the Latin root discus. Most English language publications use the spelling "disc" more often than "disk." Nomina Anatomica designates the structures as "disci intervertebrales" [plural form] and Terminologia Anatomica as "discus intervertebralis/Intervertebral disc".


Cervical disc herniation

Cervical disc herniations occur in the neck, most often between the sixth and seventh cervical vertebral bodies. Symptoms can affect the back of the skull, the neck, shoulder girdle, scapula, shoulder, arm, and hand. The nerves of the cervical plexus and brachial plexus can be affected. [3]


Thoracic disc herniation


Thoracic discs are very stable and herniations in this region are quite rare. Herniation of the uppermost thoracic discs can mimic cervical disc herniations, while herniation of the other discs can mimic lumbar herniations. 


Lumbar disc herniation


Lumbar disc herniations occur in the lower back, most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum. Symptoms can affect the lower back, buttocks, thigh, and may radiate into the foot and/or toe. The sciatic nerve is the most commonly affected nerve, causing symptoms of sciatica. The femoral nerve can also be affected. [5]


Causes


Causes of a disc herniation can include general wear and tear on the disc over time, repetitive movements, stress on the disc that occurs while twisting and lifting, or other injuries.


Symptoms


Symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue that become involved. They can range from little or no pain if the disc is the only tissue injured to severe and unrelenting neck or back pain that will radiate into the regions served by an affected nerve root when it is irritated or impinged by the herniated material. Other symptoms may include sensory changes such as numbness, tingling, muscular weakness or paralysis, and affection of reflexes. Unlike a pulsating pain or pain that comes and goes, which can be caused by muscle spasm, pain from a herniated disc is usually continuous.

It is possible to have a herniated disc without any pain or noticeable symptoms, depending on its location. If the extruded nucleus pulposus material doesn't press on soft tissues or nerves, it may not cause any symptoms. It has been estimated that as many as 50% of the population have focal herniated discs in their cervical region that do not cause noticeable symptoms. [6]

Typically, symptoms are experienced only on one side of the body. If the prolapse is very large and presses on the spinal cord or the cauda equina in the lumbar region, affection of both sides of the body may occur, often with serious consequences.


Diagnosis


Diagnosis is made by a practitioner based on the history, symptoms, and physical examination. At some point in the evaluation, tests may be performed to confirm or rule out other causes of symptoms such as spondylolisthesis, degeneration, tumors, metastases and space-occupying lesions as well as evaluate the efficacy of potential treatment options. These tests may include the following:

X-ray: Although traditional plain X-rays are limited in their ability to image soft tissues such as discs, muscles, and nerves, they are still used to confirm or exclude other possibilities such as tumors, infections, fractures, etc.. In spite of these limitations, X-ray can still play a relatively inexpensive role in confirming the suspicion of the presence of a herniated disc. If a suspicion is thus strengthened, other methods may be used to provide final confirmation.
Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads x-rays. It can show the shape and size of the spinal canal, its contents, and the structures around it, including soft tissues.
Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. It can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. It shows soft tissues even better than CAT scans.


MRI Scan of lumbar disc herniation between
fourth and fifth lumbar vertebral bodies.

Myelogram: An x-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces. By revealing displacement of the contrast material, it can show the presence of structures that can cause pressure on the spinal cord or nerves, such as herniated discs, tumors, or bone spurs. Because it involves the injection of foreign substances, scans are now preferred when available, although myelograms still provide excellent outlines of space-occupying lesions.
Electromyogram and Nerve conduction studies (EMG/NCS): These tests measure the electrical impulse along nerve roots, peripheral nerves, and muscle tissue. This will indicate whether there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether there is another site of nerve compression.

Treatment

The majority of herniated discs will heal themselves in about six weeks and do not require surgery. Your doctor may prescribe bed rest (usually for no more than two days), or advise you to maintain a low, painless activity level for a short period. If your doctor recommends physical therapy, this may include pelvic traction, gentle massage, ice and heat therapy, ultrasound, electrical muscle stimulation, and stretching exercises. [7] Pain medications are often prescribed to alleviate the acute pain and allow the patient to begin exercising and stretching.

The presence of cauda equina syndrome (in which there is incontinence, weakness and genital numbness) is considered a medical emergency requiring immediate attention and possibly surgical decompression.

There are a variety of non-surgical care alternatives to treat the pain, including:

    Physical therapy
Osteopathic/chiropractic manipulations
Massage therapy
Non-steroidal anti-inflammatory drugs (NSAIDs)
Oral steroids (e.g. prednisone or methyprednisolone)
Epidural (cortisone) injection
Intravenous sedation, analgesia-assisted traction therapy (IVSAAT)

If pain is severe and continuous, or if there are neurological deficits, surgery may be recommended. Surgical options include:

Microdiscectomy
Lumbar fusion
Disc arthroplasty
Dynamic stabilization

Surgical goals include relief of nerve compression, allowing the nerve to recover, as well as the relief of associated back pain and restoration of normal function.

Future treatments may include stem cell therapy. Doctors Victor Y. L. Leung, Danny Chan and Kenneth M. C. Cheung have reported in the European Spine Journal that "substantial progress has been made in the field of stem cell regeneration of the intervertebral disc. Autogenic mesenchymal stem cells in animal models can arrest intervertebral disc degeneration or even partially regenerate it and the effect is suggested to be dependent on the severity of the degeneration." 


Back pain

Back pain (also known as "dorsopathy") is pain felt in the human back that may come from the muscles, nerves, bones, joints or other structures in the spine. The pain may be constant or intermittent, stay in one place or refer or radiate to other areas. It may be a dull ache, or a sharp or piercing or burning sensation. The pain may be felt in the neck (and might radiate into the arm and hand), in the upper back, or in the low back, (and might radiate into the leg or foot), and may include symptoms other than pain, such as weakness, numbness or tingling.

Back pain is one of humanity's most frequent complaints. In the U.S., acute low back pain (also called lumbago) is the fifth most common reason for all physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year .

The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, and all are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities.


While it is rare, back pain can be a sign of a serious medical problem:

Typical warning signs of a potentially life-threatening problem are bowel and/or bladder incontinence or progressive weakness in the legs. Patients with these symptoms should seek immediate medical care.
Severe back pain (such as pain that is bad enough to interrupt sleep) that occurrs with other signs of severe illness (e.g. fever, unexplained weight loss) may also indicate a serious underlying medical condition, such as cancer.
Back pain that occurs after a trauma, such as a car accident or fall, should also be promptly evaluated by a medical professional to check for a fracture or other injury.
Back pain in individuals with medical conditions that put them at high risk for a spinal fracture, such as osteoporosis or multiple myeloma, also warrants prompt medical attention.
In general, however, back pain does not usually require immediate medical intervention. The vast majority of episodes of back pain are self-limiting and non-progressive. Most back pain syndromes are due to inflammation, especially in the acute phase, which typically lasts for two weeks to three months.

Underlying causes

Muscle strains (pulled muscles) are commonly identified as the cause of back pain but in fact muscle imbalances are by far the most common cause of low back pain, and pain from such an injury will often hang around for as long as the muscle imbalances persist. The muscle imbalances cause a mechanical problem with the skeleton which leads to pressure building up at certain points along the spine.

When low back pain lasts more than three months, or if there is more leg pain than back pain, a more specific diagnosis can usually be made. There are several common causes of low back pain and leg pain: for adults under age 50, these include spinal disc herniation and degenerative disc disease; in adults over age 50, common causes also include osteoarthritis (degenerative joint disease) and spinal stenosis. Non-anatomical factors can also contribute to or cause back pain, such as stress, repressed anger, or depression (mood).

Back pain is frequently experienced when no underlying anatomical problem is apparent. Some believe this pain to be caused by tension myositis syndrome.

Treatment

The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible; to restore the individual's ability to function in everyday activities; to help the patient cope with residual pain; to assess for side effects of therapy; and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery.

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. Only a minority (most estimates are 1% - 10%) require surgery.

Cold compression therapy is useful for a strained back or chronic back pain as it reduces pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting.
Heat Therapy is useful for back spasms or other conditions, often used in conjunction with a pain reliever or muscle relaxer.
Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. Bed rest is rarely recommended, and when necessary is usually limited to one or two days. Strengthening the core body muscles, such as the stomach and low back muscles, is a typical part of any back therapy.
Injections, such as epidural steroid injections or facet joint injections.
Medications, such as muscle relaxants, narcotics, non-steroidal anti-inflammatory drugs (NSAIDs/NSAIAs) or paracetamol (acetaminophen).
Manipulation, as provided by an appropriately trained and qualified physical therapist, osteopath, physiatrist, or a chiropractor.
Education, and attitude adjustment to focus on psychological or emotional causes (e.g. TMS).

In addition, most people will benefit from assessing any ergonomic or postural factors that may contribute to their back pain, such as improper lifting technique, poor posture, or poor support from their bed or office chair, etc.


Surgery


There are a number of different types of spine surgery to treat a variety of back conditions. Some of the more common forms are:

Artificial disc replacement, a relatively new form of surgery in the U.S. but has been in use in Europe for decades, primarily used to treat low back pain from a degenerated disc.
Discectomy/microdiscectomy, usually used to treat pain (especially pain that radiates down the arm or leg) from spinal disc herniations.
Kyphoplasty and Vertebroplasty, minimally invasive procedures designed to treat pain from osteoporotic compression fractures and sometimes other forms of fracture, such as a fracture caused by certain types of cancer.
Spinal cord stimulation, where an electrical device is used to interrupt the pain signals being sent to the brain.
Spinal fusion, usually to treat chronic, severe pain from degenerative disc disease, spondylolisthesis, or deformity, such as from scoliosis.


Weight Control


Weight control is an important part of our culture. We are reminded daily in our society that being overweight is not "in" or fashionable. Just look at TV or any type of media advertising and you will soon see that being thin and in good shape is what is popular.

Your primary goal should be to have a healthy body. Healthy bodies come in different shapes and sizes. Weight control is just a part of having a healthy body. Other factors include your diet, nutrition and the amount and kind of exercising you are getting. Displayed later on in this chapter is a height/weight chart that will serve as a guideline.

When you see your family doctor they will check your height, weight, and blood pressure, blood lipids, (cholesterol, triglycerides), and blood sugar (for people with diabetes). All of these involve medical conditions related to weight. Proper weight control and weight management can help provide for a healthy body.


Obesity

Obesity is basically a medical condition that signifies the excess storage of body fat. It is normal for the body to store fat tissue under the skin and around joints and organs. Fat is essential for good health because it provides energy when the body demands it and provides insulation and protection for vital organs. It is the accumulation of too much fat that poses the health problems of obesity. These health problems include diabetes, hypertension , stroke, heart disease and arthritis.

The United States has one of the highest percentages of obese adults. It is estimated that over 36% of adults in America are obese. Obesity is most common among minorities, especially minority females. Over 50% of African-American and Mexican-American women are obese. Over 20% of children between the ages of 6 to 17 fit in the obese category.

A primary concern of obesity is the risk of developing disease. Obese people are twice as likely to develop high blood pressure and over 70% of heart disease cases are linked to excess body fat. Obese women are twice as likely to develop breast cancer and 40% more likely to develop colon cancer. Close to 80% of Type II or non-insulin dependent diabetics are obese.

Obesity is partially determined by genetic makeup. Research has revealed that basal metabolic rate and the size and number of a person's fat cells help in determining the amount of weight loss that is possible. When calories from food intake equal the amount of energy that the body requires to function the weight remains the same. However, when more calories are consumed than the body needs, the body will store the extra calories, resulting in weight gain.


Diet

Diets are the most common treatment for obesity. There seem to be countless diets that are promoted and it is recommended that your weight control diet be supervised by a your family doctor. Most health care professionals will recommend a diet that consists of 1200 - 1500 calories per day. People who are over 40 pounds overweight may require a more aggressive approach and may be put on a restricted diet of 500 to 800 calories per day.

There many types of weight loss medications on the market today but there are also many side effects that include insomnia, anxiety and irritability. Your family doctor can evaluate your particular condition, health issues and can  recommend weight-loss medications under the right circumstances. Used correctly, they can be very effective in the treatment of overweight people.


Exercise

Exercise should be an important part of your weight management plan. Calorie reduction alone is not a complete plan will not result in long-term weight loss. Regular exercise is a long-term plan for continuing weight reduction. Exercise will also improve some of the medical conditions associated with obesity which include high cholesterol levels, high blood pressure and diabetes.

A long-term exercise plan sometimes requires lifestyle and behavior modification, which can be hard for many obese people to accept. Successful weight management plans require strong discipline to control eating urges and to implement exercise plans. New habits need to be learned and many old bad habits need to changed, such as food types consumed and unproductive eating habits.

When choosing an exercise program, the person should consult their family doctor. The exercise program will be designed around the person's work capacity, which will be determined by your doctor. Exercise tests using the treadmill or stationary bicycle are the most common ways to determine and measure work capacity. Once your work capacity has been determined, an exercise program can be recommended. The formula will include what your training heart rate should be and how much intensity should be expended during your work out.

An exercise program can be the most important part of your weight management program because it will give you so many other added health benefits. Many studies show a direct correlation between physical fitness and mental achievement.


Weight Chart


The following chart provides healthy weight ranges for different body sizes and builds:

WOMEN

Height Small Frame Medium Frame Large Frame
4' 10" 102 - 111 109 - 121 118 - 131
4' 11 103 - 113 111 - 123 120 - 134
5' 0" 104 - 115 113 - 126 122 - 137
5' 1" 106 - 118 115 - 129 125 - 140
5' 2" 108 - 121 118 - 132 128 - 143
5' 3" 111 - 124 121 - 135 131 - 147
5' 4" 114 - 127 124 - 138 134 - 151
5' 5" 117 - 130 127 - 141 137 - 155
5' 6" 120 - 133 130 - 144 140 - 159
5' 7" 123 - 136 133 - 144 143 - 163
5' 8" 126 - 139 136 - 150 146 - 167
5' 9" 129 - 142 139 - 153 149 - 170
5' 10" 132 - 145 142 - 156 152 - 173
5' 11" 135 -148 145 - 159 155 - 176
6' 0" 138 - 151 148 - 162 158 - 176

MEN

Height Small Frame Medium Frame Large Frame
5' 2" 128 - 134 131 - 141 138 - 150
5' 3" 130 - 136 133 - 143 120 - 134
5' 4" 132 - 138 135 - 145 140 - 153
5' 5" 134 - 140 137 - 148 144 - 160
5' 6" 136 - 142 139 - 151 146 - 164
5' 7" 138 - 145 142 - 154 149 - 168
5' 8" 140 - 148 145 - 157 152 - 172
5' 9" 142 - 151 156 - 160 155 - 176
5' 10" 144 - 154 151 - 163 158 - 180
5' 11" 146 - 157 154 - 166 161 - 184
6' 0" 149-160 157 - 170 164 - 188
6' 1" 152-164 160 - 174 168 - 192
6' 2" 155-168 165 - 178 172 -197
6' 3" 158-172 167 - 182 176 - 202
6' 4" 162-176 171 - 187 181 - 207

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