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Health Matters

Spine problems common in many people

Conway McLean, DPM, Journal columnist

I’d like to tell you a story, the sad, sordid tale of the spine. For thousands of years, from our early ancestors to the present day, humans have spent most of their waking time upright, bipedal, standing on two legs. (And let us not forget, on two feet!) From long hours on hard concrete, to sitting on stiff chairs, or slouching over a computer screen, all manner of activities put stress on our spine. Fighting the ever-present forces of gravity has been a difficult task required of our backbone since our distant ancestors became land-dwelling.

The complex anatomy of the human backbone allows us to keep our heads up and our legs underneath us. The vertebral column is a wondrous structure, with many critical functions. Still, taking us from quadrupeds (4 legged creatures) to walking erect is quite a leap of function. Simply put, it’s a whole different ball game. The mechanics of the simple act of standing are complex, requiring a balancing act to maintain a vertical position in space.

With such complexity and so many critical tasks, there are many different back problems experienced. At least 80 percent of Americans will experience low back pain at some point in their lifetime. Many experience this debilitating pain on a chronic basis. Approximately 10% of individuals suffering from LBP have symptoms that persist for longer than 3 month. It is most common in those between 30 and 50 years of age, primarily because of changes associated with aging. Most notable is a reduction in the height of the discs found between each backbone (called vertebrae). The financial burden of low back pain relative to health care costs is substantial: direct expenditures were reported to be more than $90 billion in 1998 in the US.

Naturally, there are a multitude of reasons someone develops low back pain. Perhaps the most common is a muscle strain, which may involve tearing of the muscle or connective tissue and is often the result of some minor trauma. Most people know someone diagnosed with sciatica or have experienced it themselves. This is a nerve impingement problem, where one of the nerves exiting the spine is being pinched, often by a disc which is torn or has slipped. An abnormal curvature of the spine often causes back pain, although gradually, because of the pressure placed on nearby structures.

Degenerative changes of the intervertebral discs is one of the most common findings leading to back pain. These act like shock absorbers between the bones of the spine. The structure and function of the spine allows twisting and bending motions, until years of use cause wear and tear of the discs. These discs are composed of a tough outer wall and a soft inner core, which is mostly made up of water. The discs lose fluid over time, causing them to flatten. When one is squeezed out of position, you are said to have a “slipped disc.”

Also common is cracking or tearing of the outer wall of one of these important structures. If a tear occurs near a nerve, it may put pressure on the nerve and physical impingement to a nerve is never a good thing. This same phenomenon is seen when a vertebral (spine) bone shortens, often resulting from tiny fractures over time or a sudden break from an injury.

Low back pain may also be the result of a poor foundation. The prevailing theory is that certain foot and ankle problems can cause misalignment of the back. When the arch rolls down excessively (a process called pronation), the leg rotates inward too much. A consequence is an alteration in pelvic positioning producing strain on the lower back muscles. Thus, over time, this change in alignment leads to pain, the result of abnormal arch motion.

Treatment of low back pain presents a considerable challenge since, most of the time (about 85%), we are unable to identify a specific anatomic structure as being the cause of the pain. The treatment options available to someone with chronic LBP are many, with the most appropriate dependent on the root problem.

Degenerative changes can be treated pharmacologically with opiates, steroids, or non-steroidal anti-inflammatories (eg ibuprofen). Likewise, other conservative measures such as physical therapy and corticosteroid injections are frequently prescribed. Yoga has been found to be of benefit as well. Acupuncture has also been used with some success but definitive studies have not been performed.

Perhaps the newest player in the treatment of low back pain is gene therapy and other methods termed “biologics.” Perhaps most exciting are the cell-based therapies, which use stem cells to stimulate the growth of new, healthier tissue. Total disc replacement utilizing tissue-engineering is also being explored.

There is considerable evidence that use of foot orthotics can benefit many patients experiencing low back pain. Although generally not a simple matter of sticking some pad or support under the arch, the right kind of support can make all the difference to those so affected. A properly prescribed pair of foot orthotics can control heel positioning and rotation, arch alignment, as well as positioning of the ball of the foot, preventing the increased, abnormal in-turning of the leg.

Any discussion of orthopedic complaints must include mention of surgical options. One operative method is the implantation of an electrical device which stimulates the appropriate nerve. This is considered a semi-invasive procedure and appears to be the most effective form of pain relief when the basic problem is predominantly a nerve problem. This technique is referred to as neuromodulation and appears to be superior to conventional medical management and even many types of surgical intervention.

Many surgical procedures have been performed over the years. Unfortunately, complications from spine surgery are not uncommon. Just over one-quarter of patients in one study developed complications. In this study, age, obesity, and other health issues were not associated with increased risk of complications after spine surgery.

Numerous factors influence low back pain, especially disc degeneration. These include biomechanical, immunologic, environmental, and genetic. The interaction between all of these issues is not well understood. Occupations that are physically demanding, like nursing or heavy industry, put employees at greatest risk for back injury. The use of ergonomic concepts, mechanical devices and good body mechanics should be instituted to reduce the incidence of back injuries.

Just as importantly, staying physically fit, strong and flexible, improves the likelihood of avoiding back injuries in all types of work environments. Many new and exciting methods of treatments for LBP are available. Still, as is generally the case, prevention is always better than finding a cure. Get fit, develop core strength, and your risk of chronic low back pain will be reduced. You might even benefit from prescription foot supports!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments at drcmclean@outlook.com.

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