Gravity

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

The number one cause of lower spine problems is too much gravity, although you could throw in inertia, too.  There would be no inertia without gravity, I guess.  Anyway, the constant downward force of our upper body's weight on our lower spine squeezes discs, causing them to bulge.  No gravity, no squeezing, except for trauma caused by changes in inertia, changes in direction, and sudden stops.  Obviously, if you fall from a height, come to a sudden stop, or change direction violently in an accident, your spine can also be compressed, and the discs will bulge then also.  However, gravity is also a necessary part of normal disc function.

There is no escaping gravity, unless you have millions of dollars and can pay your way into space as a tourist or you are an astronaut, cosmonaut, or taikonaut.  But even space travelers have back pain.  Their back pain is caused by the lack of gravity. This situation also occurs on planet Earth, when you lie down for too long.  Gravity no longer compresses your spine.  The lack of compression allows the discs to expand.  This expansion is necessary on Earth because it allows nutrients to enter the disk.  Compression pushes waste products out of the discs.  In the outer space, zero-g environment (and if you lie in bed for too long) there is no compression of the spine to relieve the expansion of the discs.  Then expansion leads to pain.

The take home message here is that your spine needs active compression (standing or sitting in a gravitational field) and expansion (which occurs at rest).  Without both phases you decrease the well-being of your discs.  Be active.  Also, rest when needed.  Your lower back will thank you, and hurt much less often.

X-rays, MRIs, CAT scans

I'm late again for my self-posed deadline.  Tuesdays are the new Mondays, I guess.

As the fictional presentation below will show, x-rays, MRIs, and CAT scans are not very helpful in diagnosing joint pain (including backs).  It was just easier to construct a story around knees.  Enjoy.

            Dr. Evans used the remote to turn down the lights in the auditorium, and then turned on the first slide in his presentation.  “I’m going to show you three sets of bilateral knee x-rays,” he said.  “One set is from someone with severe arthritis, another from a person who has severe, incapacitating knee pain, and another from a marathon runner.  I want you to tell me which set of x-rays you think goes with each patient history.”

            The first set of x-rays towered over Evans, the projector showing twelve foot high x-rays on the screen.  In the shadows, Evans pointed his red laser at the x-rays, specifically at the joints.  “You can see here nice smooth cartilage on both femurs and both tibia in the anterior-posterior views.  Lateral views and tunnel views show no abnormal bone, bone spurs, or unusual calcifications.  Anyone see anything else I should point out?”

            There were no suggestions.  Evans continued, “Any of you think this is our marathoner?” 

            The show of hands was almost unanimous, with the exception of a few students who had been fooled by Evans in the past.  “Okay, the second set,” Evans said, pushing a button on the remote.  Two more large knee x-rays replaced the first ones on the towering screen.  “This left knee appears to be normal.”  Evans played the pointer across the joints.  “The right is a disaster, though.  Look.  No joint space medially.  Large bony spurs medially, with smaller spurs laterally.  Could this be our patient with severe, incapacitating knee pain?”  There was a murmur of assent, again with a couple students demurring.

            The third set of knee x-rays appeared on the screen.  “Now, this patient has narrowed joint spaces in both knees.  There are bony cysts underlying the cartilage in both joints, and small spurs medially and laterally in both knees.  Is this the arthritis?”

            “That wasn’t so hard, professor,” one of the skeptical students suggested.  “Are we treating x-rays now?”

            Evans smiled.  The student had heard Evans harp on just this point in the past.  “No, Tony, we are not treating x-rays, as you well know.  Let’s look at these again, and I’ll point out some things you, as a group, may have missed.”

            The first set of x-rays magically reappeared.  “As I said, these are totally normal x-rays.  However, this is not our marathoner.  It is our patient with severe, incapacitating knee pain.  What I did not point out, and what you did not see since no one else pointed it out, was this.”  Evans used the pointer to outline the soft tissue surrounding the knees.  The gray shadow was that of a huge, obese individual.  “Arthritis doesn’t show up on x-ray for years.  It takes sometimes a decade for cartilage and bone changes to be visible.  This patient never does any exercise, and eats way too well.  As a consequence, he weighs 373 pounds.  The compression of his joints will eventually destroy the cartilage.  His knees already hurt terribly.  He uses that as an excuse not to exercise.  Soon he will have severe osteoarthritis.  Not only will his x-rays remain normal for several more years, but all his lab tests will be normal for several more years.  Then he will become a Type II diabetic.  In order to save his knees and preserve his life, he needs to ignore the pain, exercise and lose weight.” 

            “The second set of x-rays,” Evans continued, pointing to the x-ray with one normal knee and one severely arthritic knee, “are from a patient with severe osteoarthritis.  He had a meniscus tear and a destroyed anterior cruciate ligament while playing football in high school.  This was in the days before anterior cruciate repair.  The medial meniscus was removed; the knee has collapsed on itself.  But, and this is a big but, this patient has very little pain.  He was told to keep exercising and to keep his leg strong, which he has.  He runs 4-5 miles 2-3 times a week, occasionally taking Ibuprofen or Naprosyn when he overdoes it.  Exercise protects joints, if it’s not overdone.”

            The projector advanced to the third slide.  “Here is our marathoner.  Notice, he has mild osteoarthritis in both knees.  He has absolutely no pain in his legs.  The x-rays were taken as part of a knee study in geriatric patients, which will be published in an orthopedic journal next year.  I shouldn’t say he has absolutely no pain.  He does complain about knee stiffness after 3-4 days if he is unable to run.  Again, exercise protects joints.”

            Evans eyed the students with a smile.  “Okay, anyone up for treating the x-rays?”  There were no hands raised.  “Good.  X-rays confirm diagnoses.  They do not make diagnoses.”  He paused to make certain the point was absorbed by all.

            “Now we are going to look at another set of x-rays.  I’ll give you a history and you tell me what the x-rays confirm.  Fair enough?”  Most of the students nodded, with the exception of the skeptical students.

            This is a 19 year old volleyball player.  She missed half the season with a severe ankle sprain.  After returning to the sport, she has practiced for one week and now complains about severe knee pain when getting up from a seated position or running down hill.  The first x-ray flashed on the screen was a chest film.  With the students’ new found appreciation of soft tissue shadows, it was apparent to most of them that this patient was tall, thin, and had large dense breasts.  “Okay,” Evans laughed and spoke in a high falsetto voice, “Doctor, my knees are down here!”  The class laughed.

            Evans hit the remote and a set of knee x-rays appeared on the screen below the chest x-rays.  “They are normal,” a bewildered student said.

            “Correct,” Evans agree.  “But what does that confirm?”

            “Nothing,” another suggested.

            “Wrong,” said Evans.  “It confirms she has Patello-Femoral Syndrome.  I gave you the classic history: athlete sidelined for an injury, pain on rising from a seated position, and pain running downhill.  The x-ray shows there are no other lesions that might cause similar symptoms.  Now you could order an MRI to look at the soft tissues.  Would you want to?  MRIs are expensive.”

            “Be better to treat her for PFS.  Save the MRI in case she doesn’t improve,” one of the skeptics suggested.

            Evans beamed.  “Don’t treat x-rays, MRIs, CAT scans, blood tests, etc.  Use these tests to prove or disprove the diagnosis if the treatment isn't working.”

Drugs

To relieve discomfort, mankind has relied on medications and herbs for thousands of years.  At the present time we most commonly rely on medications in four classes for pain relief: acetaminophen, NSAIDs, steroids, and narcotics.  The potency of these medications follows in about the same order, with Tylenol (acetaminophen) being the least and narcotics being the most powerful.  The side effect profile also follows in about the same order, fewest for Tylenol and most for narcotics.  An overdose of Tylenol can damage or destroy your liver.  NSAIDs include aspirin, ibuprofen, naprosyn and about fifty other drugs.  The most common side effects include stomach upset: gastritis and ulcers, decreased kidney function, and increased blood pressure.  As such they should be used sparingly by diabetics and people with stomach issues.  Steroids can cause the same issues with greater severity.  Narcotics cause constipation and sedation and can be addictive.  Make sure you understand what your doctor is trying to accomplish with the medications he gives you.  If you are medicating yourself, remember that all medications have side effects.  Follow the directions carefully.  Don't hurt yourself while trying to help yourself.

More Travel

My wife and I flew to Denver to see youngest son last week, and flew home this week.  More reminders that sitting is not good for backs.  Fortunately, we had to walk and wait for about thirty minutes for our baggage, so our lower backs were ready for the challenge of lifting suitcases when they arrived.  If you have read  the book, you know that I suffer with spinal stenosis and several herniated discs.  The discs are worse when seated; the stenosis is better.  And the discs are better standing and the stenosis is worse standing for long periods of time.  As you may be guessing, it is important for everyone to change positions frequently, in order to avoid discomfort if you have back issues, and to prevent back issues.  This is not easy on an aircraft flying through turbulence.

Update: Travel

I have been out of town for the last week.  Went to Houston to pick up a used van I bought on the web and drove home (950 miles).  There's nothing like a long drive to remind me that sitting is the worst thing for your lower back.  It is important to stop frequently, walk around, extend (lean backward) your lower spine, and do some knee bends.  Sitting increases the pressure on the anterior (frontal portion) discs tremendously.  It is no coincidence that most disc ruptures are posterior (rearward).  The increased anterior pressure over a lifetime causes migration of the nucleus of the disc backward.  The posterior longitudinal ligament isn't very thick or strong at the posterior margins of the disc and this is where most ruptures occur.  Getting out of the seated position and leaning backward helps to relieve that pressure and slow the migration.

Another suggestion is you walk around for an hour or so after arrival at your destination before you lift heavy objects (known as luggage).  This hour allows your discs to recover before you overload them with even more pressure.