33 Vertebrae or I love my Osteochondrosis

This book will tell you about a part of your body that can’t be seen when you look in the mirror, but the role it plays in your health is very apparent.  This isn’t meant to be a textbook to teach how to treat spinal diseases, but after reading this book, you will no longer need to rely on others to tell you which movements and exercises are good for your back and which ones are harmful. You will know this yourself. You’ll know when your spine requires extra care and you’ll seek medical attention when you need it.  You will learn about the most advanced methods of treatment and the prevention of spinal column diseases and you will even be able to administer first aid to yourself or to other people in case of severe pain syndrome. And with the benefit of this knowledge you will know what to look for in finding a doctor for yourself.  One who will be effective in helping you. 

If you could see the diagnoses of all the people who consult primary care physicians (or as they are commonly called today, “general practitioners”), you would notice that after all the runny nose patients, there are martyrs who come into these clinics holding their bad backs. The diagnosis “osteochondrosis of the spine” takes pride in holding second place, after acute viral respiratory infection, in the number of visits made to general practitioners’ clinics.

 Most people think ‘osteochondrosis’ is a condition that only affects the spine and back. But this idea is not quite right. A lot of people also think there is no adult alive who does not have osteochondrosis in their spine, but this isn’t true either. There are some ethnic groups that only have extremely rare cases of vertebral osteochondrosis. Wouldn’t it be nice to be like them? But getting back to the first misconception, osteochondrosis can be found in areas of the body other than the spine.

If you open “The International Classification of Diseases” you will see osteochondrosis of many different bones: the tarsal (foot) bone, the ulnar and radial (arm) bones, patella (knee) osteochondrosis, osteochondrosis of the head of femur (hip) and several others. That’s why it is more correct to talk about vertebral osteochondrosis (osteochondrosis of the spine) and to use the two-word name for the disease. I’m sure that while you rarely, if ever, hear any mention of patella osteochondrosis, every day you read and hear advertisements about spinal diseases and osteochondrosis treatment. This widespread and significant disease is known by different names in different countries. For instance, in English-speaking countries, the terms ‘spondylosis’, ‘degenerative disk disease’ or just ‘back pain’ are used.  For our domestic readers, I use the term ‘osteochondrosis of the spine’ as it is more traditional and easier to understand.

When you ask people who are not in the medical field what osteochondrosis is, most of them will answer that it’s a condition related to the back or spine.  Even though appendicitis, for example, occurs less often than osteochondrosis, almost everyone is familiar with it, and knows that it is an inflammation of the appendix. Let’s set the record straight and clear up this confusion!  In medical Latin, all the terms ending in ‘osis’ indicate degenerative damage. In other words, aging!!  Think of the word regeneration. Most of us understand that word. It means “revival.”  So what is degeneration?! It is just the opposite of regeneration. Why we age has not been explained. Nobody knows the exact reason. Many different theories exist, but there is no definite answer yet! As sad as it is to admit, aging is inevitable.

If you ask a three-year-old to draw a person, the young artist will start creating a picture with a simple vertical line – the spinal column. 

Even a young child understands instinctively that the spinal column is one of the most important structures in our body. If you think your spinal column works only when you move, oops! You are wrong! Even when you are asleep you are performing micro-movements. And your spine is involved in every single one of them.  

The title of this book is “33 Vertebrae...” That’s because 33 is the exact number of bones that make up the human spinal column. If I had called it “43 Vertebrae” or “34 Vertebrae” the medical community would have had a hay-day investigating my credentials! Anyway, there are intervertebral discs between the vertebrae. So I like to use the right term: intervertebral discs. This is more correct than calling these inter-spinal discs. The spine is an axis that other bones are attached to! It’s a protective box for the spinal cord, which is the primary nerve of the whole body!  It is believed there are some people who even think by using their spine, perhaps through some type of intuition. So don’t ever doubt the importance of your spinal column.

So that you can understand what happens in different diseases and disorders of the spine, we need to take a close look at the intervertebral discs.  To get an idea of what they are like, feel your own ear. It has a hard part which is the cartilage, and a softer part, your earlobe. Your intervertebral discs are like this. They are made up of both hard and soft parts.  

The central part, the vertebral pulp, is the most elastic part of the discs. 95% of the vertebral pulp is an intercellular substance: jelly that absorbs water. That’s why the vertebral pulp is sometimes called the gelatinous nucleus. In science class you might have learned that liquids are difficult to compress. That’s why the vertebral pulp, which is close to being in a liquid state, is very elastic. It absorbs all the vibrations and shocks our back and vertebrae are exposed to.

If you look at a cross-section of an intervertebral disc, you will not find any blood vessels inside. That means, the disc gets its nutrients by soaking them up from the neighboring vertebrae. This process takes a long time. It is very slow. This is what causes the main problems of the disc cartilage: losing water for various reasons, the vertebral pulp loses its elasticity.  This is why with age, there is overloading on the fibrous ring of the intervertebral disc’s, multi-layer ligament. It then binds the neighboring vertebrae along the edge. The overloaded fibrous ring can then suddenly tear. At that moment, acute back pain occurs and there is one more new patient with the diagnosis “osteochondrosis of the spine!”

If you have back pain that forces you to take sick leave from your job, you’re probably asking, “Why did this happen?” and “Why did this happen to me?”  Of course, osteochondrosis of the spine often is the reason for your back pain, but it is not the only cause. Some diseases cause pain, but it’s not felt near the affected organ. It’s felt somewhere else in the body. When this happens, doctors will say the pain radiates, or they will call it “referred pain.”  The pain extends into neighboring parts of the body.  In some cases, an acute myocardial infarction, or heart attack, particularly when it occurs in the posterior wall, is manifested by severe pain in the thoracic spine.

 Another example is the well-known appendicitis. The appendix is located deep inside the belly and near the spine, but when it becomes inflamed, the pain can be felt both in the stomach and in the low back. Sometimes a perforated stomach ulcer is felt as more severe pain in the back than in the belly. These situations can sometimes slow down the process of making the right diagnosis.

When it comes to back pain, this can also happen in reverse. Painful impulses from an affected spine are felt, not in the back, but somewhere else. This often happens in the thoracic spine, when pain is felt in the chest, but the real reason behind it is thoracic spine osteochondrosis. 

Osteochondrosis is obviously not the only condition that can affect the spine. For example, if you develop constant spinal pain that you’ve never had before, and it continues for a month, it’s not pleasant, but a neoplastic process needs to be considered.  Cancer from other organs often metastasizes, or spreads, to the spine: breast cancer, thyroid cancer, prostate cancer and others. Primary neoplasms of the spine or the spinal cord also occur. 

I would like to especially talk to older people and the people who care for them. Older people many times get used to back pain, or “learn to live with it.” Many people even think that back pain, osteochondrosis, and aging are inseparable.  So they have been using different ointments to relieve their pain for years. But in the case of chronic and constant pain, you need to know how very important it is to pay attention to any change in pain. For example, the level of pain suddenly increases following a simple movement or a change in position.  If an elderly person has sudden increase in their usual pain and this pain does not subside, this is a warning sign. A big red flag!  In cases like this, the reason for pain is often not just common osteochondrosis, but the rupture of a vertebra that has became more fragile with aging. This disease is called osteoporosis.

 In the case of a vertebral rupture, no ointment can help. But there is good news! Tremendously good news!! Modern methods of medicine can help set our dear elderly people back on their feet. All that’s needed is the administration of special bone cement into the broken vertebra through a narrow needle under local anesthesia. In only two hours the pain starts to diminish and the patient can return to their normal life. This is why I urge everyone to visit a doctor. Don’t try to treat yourself for every disease with a magic ointment, even if it does have very convincing advertising.

At what age can osteochondrosis start? In my practice, I’ve seen teenagers who have back pain. At 15-17 years, especially if the spine is overloaded for instance by professional sports, symptoms of degeneration can start to occur and herniation of intervertebral discs can progress. In addition to these conditions, inflammatory diseases can also affect the spine directly or indirectly due to infection. For example, a combination of symptoms such as acute back pain, especially in areas where there was no pain before, and an elevated temperature (during a cold) can indicate that some pathogenic organism settled in the spine and caused an infection, in other words inflammation of a disc – discitis or inflammation of a vertebra – spondylitis.

There are also other microorganisms, for example, Chlamydia, that are sexually transmittable, or Yersinia, that causes diarrhea. Sometimes, after these infections have been successfully treated and even your sexual partner has been treated, the back pain comes back after a few months. It’s not acute pain, but your back feels stiff. “Stiffness” is the term most often used by doctors and patients to describe this condition, and it is almost always more severe in the morning. The patient has to be up and moving around for at least an hour before this feeling of stiffness and pain in the back is relieved. These diseases are not treated with the same methods used to treat osteochondrosis. They unfortunately require a visit to a rheumatologist. 

One more type of back pain that affects the intervertebral joints is gout. Several beverages and meats can cause an attack of gout. The uric acid crystals in these foods and beverages accumulate, not only in the big toe joint, but also in the joints of the spine, causing inflammation. Self-treatment is not helpful in this case, and it only makes the disease worse. 

Remember, DON’T LET YOUR FEAR OF TREATMENT AND YOUR LACK OF KNOWLEDGE STOP YOU FROM SEEING A DOCTOR.  

The most common reasons for pain and diseases that can affect your spine are listed below. Please remember them:

• Degenerative damage – vertebral osteochondrosis.
  
• Vertebral neoplasms, primary and metastatic.
  
• Injuries and ruptures of the spine.
  
• Ruptures of the spine after a minor injury, as a result of bone fragility (osteoporosis).
  
• Inflammatory infection of the spine – suppurative spondylitis and spondylodiscitis.
  
• Inflammatory rheumatical infection of the spine after infections with organism like chlamydia, salmonella, brucellosis and others.
  
• Pain reflected in the spine and connected with nearby internal organs (heart, lungs, stomach and others.)

“I managed to bend down, but I couldn’t straighten up any more...”

 “The pain in my back was so bad, that I wasn’t even able to turn over in bed, let alone get out of it...”

 “It felt as if somebody put a stake in my back and it became crooked...”

These words are used by patients to describe a condition that in medical terms is called lumbago. Simply put, it is a feeling of shooting or severe pain in the spine. When this pain is felt in the lower back, it is called lumbar lumbago. If the pain is in the thoracic or cervical parts of the vertebral column, it is called thoracic or cervical lumbago. If this pain was rated according to its intensity, it would be similar to the pain experienced with a broken bone. Many patients have never felt such severe pain before they experienced lumbar lumbago. It’s no coincidence that people use phrases like “shooting pain” or “pain that shoots down my leg” when describing the condition, because the pain is like being shot and then nailed down to the bed.  The person becomes unable to even get dressed and go to a doctor. Every little movement causes terrible pain. The person with lumbar lumbago can’t even sneeze or cough.  

This patient is the one who stays motionless in bed, trying to avoid a repeated attack of pain. And the attack could return with any simple movement. Bed rest is usually prescribed by a doctor in these situations, and it is STRICT bed rest. That’s the primary, chief, principle and most important part of treatment. Strict bed rest means that you should even be very careful when you move in bed. In a pinch, you can crawl to the bathroom and back. No sitting or half-sitting is allowed.   You can only lie in a horizontal position! Your spine must be kept in an absolute state of rest for 3 to 4 days. If you start to feel much better by the end of the first day, should you get up? NO!!! Do NOT get up!! Your spine MUST BE KEPT IN AN ABSOLUTE STATE OF REST FOR 3 TO 4 DAYS!! 

As you already know, severe and acute back pain, lumbago, is usually caused by either a new rupture in the intervertebral disc or by an existing rupture getting larger. What happens when a rupture occurs in an arm or a leg bone?  A plaster cast is applied so the pieces of the broken bone can be kept immobilized and healing can take place. But when a disc is damaged, like in the case of a ruptured intervertebral disc, it’s not practical to put the entire body in a plaster cast. So it’s important to immobilize the area as much as possible to let the disc recover and allow the rupture to heal. 

Your body is remarkable. (Thank you, Captain Obvious!) But wait! I’m about to reveal to you one of the ways in which your body is the most amazingly remarkable. I wish I had discovered this, but I didn’t. It was discovered in 1883 by the Great Russian scientist, Ilya Mechnikov.  Once any tissue in the body is damaged, the body activates the process of inflammation. Inflammation speeds to the scene of the crime and removes the pieces of damaged tissues and cells. Let’s imagine an intervertebral disc has started to rupture. At first, the rupture appears in its deep layers. This moment usually passes unnoticed. Because it isn’t noticed, the inflammatory process isn’t set in motion so no pain or other symptoms occur. This stage of the disease usually happens during long hard exercise or during vigorous household work. Physical overloading affects the body literally from the inside: from the deepest part of the intervertebral disc. The dense, strained nucleus pulposus (the gel-like center of the disk) bulges out into the rupture. Soon the rupture reaches the outer layers of the fibrous ring. These layers contain pain receptors so the acute pain, the lumbago, begins.  In addition to that, the inflammation caused by the damage to the disc causes more pain. This is because any inflammation is accompanied by a buildup of the pain mediators: inflammatory molecules. Part of the nucleus pulposus of the disc gets trapped and stuck in the rupture of the ring, and the pain becomes unbearable. Even though the size of the rupture doesn’t change during the next few hours or days, the inflammation makes the pain worse.  And the pain itself can cause more inflammation. Now you have an endless circle: the inflammation causes more pain which causes more inflammation. In medicine, this phenomenon is known as the pathologic circle of a disease. In this case, osteochondrosis of the spine is in the center of the circle.            

How can you help yourself in a difficult situation like this? What if you’re alone? Everyone knows things like this always happen at the worst possible time. The rest of the family already left on vacation while you’re finishing up some last minute work at home. What now? Of course you need to see a doctor. Or better yet, get to a hospital.  Are you going to crawl there?  Only a doctor can give you qualified help, but good Dr. Powderpill isn’t always there when you need him.  You often have to wait until morning or even several days to get an appointment with Hippocrates’ successor. That leaves you only one option: Learn how to help yourself!

You already know the first step: bed rest must be STRICT. Let me repeat this one more time: lumbar lumbago is a rupture or almost a break in the disc. As long as there is pain and inflammation, symptomatic treatment is the best. That means the symptoms are treated: inflammation should be reduced. Both doctors and patients can achieve this with the help of nonsteroidal anti-inflammatory drugs. There is a huge amount of this type of medications available. Any pharmacist can offer you dozens of drugs. It is important to understand that all these drugs work almost the same way. Trying to speed up this process by self-administrating intramuscular injections is not a good idea. I advise against it for two reasons. First, self-administering intramuscular injections frequently leads to post-injectional abscesses, which are infected areas of inflammation in the muscle as a result of non-sterile injection techniques.  Furthermore, a non-professional is likely to administer the injection in the wrong place, for example, into the sciatic nerve, which is located in the buttock, and then you can add leg paralysis to your problem of back pain. Secondly, you can obtain results that are equal to that of intramuscular injections by administering the medication by rectal suppositories. This method is less dangerous and relief comes just as quickly as it does when injections are used. 

Suppose your neighbor, who also suffers from lumbar osteochondrosis, lends you a rectal suppository with pain-relieving anti-inflammatory medicine, but you’re not getting any relief. Your pain is not getting better and your back stays almost immovable. What’s going on? The reason for this is because of a defense mechanism deep within your body.  Any distressed organ tends to be motionless. It stops working. So in order to make the spine motionless, your body tenses the muscles of the spine. Think about weightlifters that can lift more than two hundred pounds. They can set records because their muscles are so strong. But you need to remember, their muscle tension on the lifting platform lasts for only seconds. In our case, the muscle tension can last for hours, which is a real spasm. These spasms cause severe pain and strain, which can’t be reduced by pain-relieving medicine.

Anatomists and doctors tend to be very romantic people, which is why they like to compare organs and diseases with different animals, subjects and phenomena. Almost everyone has heard diagnoses like “harelip” and “cleft palate” which is also called “wolf mouth.” But some names of diseases are known only to specialists. For example, peritonitis is sometimes called “falling drop sound symptom” or “dead silence symptom.” Intracranial hypertension syndrome is sometimes called “sunset eyes symptom.” Even the term “appendix” is called “vermiform appendix” which in Latin is “appendix in the form of a worm!”  If you do not know where a horse-tail is located on a human body, don’t panic, we’re not going to bother any horse. A horse-tail (in Latin, cauda equina) is a cluster of nerve roots in the lumbar region of the vertebral canal. Since this canal is formed partly, but not exclusively, by intervertebral discs, it only makes sense that if a disc is damaged, the nearby nerve structures can be affected too.

It used to be impossible to see inside the body without making an incision.  Now it’s easy to do this by using an endoscope.  I always an endoscope when I perform surgery to remove an intervertebral hernia. If you could look through an endoscope with me into the body of a patient with a damaged intervertebral disc, you would see that its roots are red or bluish-red. This means they are irritated by inflammatory substances that are coming out of the damaged disc. So you can imagine, that even with a small vertebral hernia, the inflammatory molecules can cause severe pain and irritation of the root. But we’ll get to that story later. For now, our patient does not have a hernia and the disc rupture was small. Most likely, a few days of bed rest, use of pain-relieving medicine and the use of a heating pad will help relieve the pain. 

But wait a minute. The question of the rupture in the disc still remains. What happens to it? Unfortunately, it stays there. The intervertebral disc can be compared to a ligament that never heals after it’s been damaged. A fragment of the nucleus pulposus that partially came out from the disc can get entrapped in this rupture. This fact explains why many disc ruptures do not heal: the fragment of the nucleus obstructs the healing process. Because nature does not like emptiness, the nerves and vessels will start growing in this rupture. This means that this area will be not the same as it was before the injury occurred. “A pain generator” is formed inside the disc. Even a long time after the initial injury, and even without an obvious reason, this pain generator can transmit pain impulses. A man will feel lumbago again, even with mild exertion, such as when driving during traffic-jams or when tying his shoelaces.

In some cases, chronic pain syndrome develops, which is often associated with osteochondrosis of the spine. The reason for this is that an old rupture in the intervertebral disc develops ossification symptoms. These changes are noticed and then treated: the inflammatory membranes between the nerve root and the inflamed disc can be separated with the help of the endoscopic surgery, and this relieves the pain. 

Let us continue our investigation. Now we have a man with hooked back: he was “warped”, and he limps to get to the chair, he has to lean on the furniture around. This diagnosis can usually be made right off the bat, when you enter the doctor’s door: an experienced doctor will instantly define that there is a patient with intervertebral disc hernia. If we look through our endoscope we might not see the nerve roots. Instead, we will see white dense tissue: the hernia. It is so huge that it pressed the roots and shifted them aside. It is surprising that some “medical” workers promise (except for surgery) to solve such a problem by means of any method, and that looks like a real tumor! By the way, at the dawn of the disc surgery, the intervertebral disc hernia was taken for cartilage tumor, that pressed the nerve root. Moreover, the density of this ‘tumor’ is quite high and can be compared with an ear pavillion cartilage! As the nerves are roughly pressed by this ‘tumor’, they lose the capacity to normally transmit electrical 

impulses, which is, as a matter of fact, a function of the nerve roots. That is why when the sense impulses are not transmitted the capability to perceive pain and other tactile senses is disrupted in one or in a few toes. If the impulses of movement are blocked, the muscles that move feet and toes do not work: the patient usually cannot easily walk on his toes or heels.  If there is such a picture that means only one thing: paresis (weakness of muscles) or paralysis (complete loss of muscle function). In mild cases the nerve keeps its ability to transmit the impulses, but its squeezing leads to the emergence of severe pain not only in the back, but also in the leg or in the part of it.  

In some cases a hernia is so large that it squeezes not just one nerve root, as it occurs in 90 % of cases, but a few or even most nerves in the vertebral canal. It afflicts the nerve roots that transmit the impulses to the pelvic organs, urinary bladder, rectum, genitals and perineum. In this casethe horse-tail syndrome or cauda equina syndrome develops. This patient has difficulties with urinating, a sense disturbance appears, and pain affects not only one leg, but both of them. Cauda equina syndrome serves as a cause for neurosurgical intervention. The matter is that the nerve fibers that go to the pelvic organs are very vulnerable. And if the squeezing lasts for a long time, they may never regenerate, even after a successful but late surgery. 

Considering all the data, the doctor will then decide whether your disc hernia will possibly lead to paralysis: whether it requires urgent surgery, or if it is treatable with a conservative approach and continued observation.

If you were told to get a magnetic resonance tomography, this means your body will be magnetized for a several minutes inside a huge tube. Unlike the radiation you are exposed to when X-rays are taken, this magnetic irradiation is not dangerous. So MRT’s can be conducted very often, as often as necessary. But there are contraindications for these studies. For example, people who have magnetic implants or a cardiac stimulator in their body cannot undergo an MRT.  

Just by thinking about the name of the process, “magnetic resonance tomography” you can probably figure out quite a lot about how the study is done. I’m not going to get into the particular details of an MRT, but I’ll just mention, that in the course of it, the nuclei of hydrogen atoms are magnetized. The MRT gives us the ability to examine any part of the body quickly and safely. Multiple MRT centers are found in large cities.  In some countries, MRT centers can even be found in big shopping centers. This is very convenient! You can go shopping and get your health testing completed all in one place!

 “Tomography” refers to examination by layers. This means the MRT examiner can make a virtual “incision” anyway he chooses: far and wide and in any direction. Inside the enormous magnet where you are for the study, all the nuclei of the hydrogen atoms are magnetized. Most of these atoms are be found in water or in structures like water. After magnetizing, a period of de-magnetizing follows. During this time, the nuclei give off energy which is caught by the detectors and transformed into an image.  The parts of the body containing a lot of water have a stronger signal. So a healthy disc looks bright, almost white, on MRT pictures in some cases.

To find intervertebral discs on MRT pictures, imagine the toy children play with that looks like a multi-colored pyramid with an axis and colored rings. The vertebrae are the rings of the pyramid, and the tight spaces between the rings are the discs. If most of the healthy discs on the MRT picture are light or white, but one of them is grey or black, you will instantly know that this cartilage is affected. If you remember what happens in vertebral osteochondrosis, you know that the affected intervertebral disc dries out, its cartilaginous tissue contains less water, which is why it is less elastic and it appears darker on the MRT picture. This is what the discs affected by osteochondrosis look like.

A lot of patients try hard to detect the hernial protrusion, but this is very difficult to do yourself. It’s more important to assess the degree of the rupture of the intervertebral disc. If the ruptures in the disc are perforating, and a part of the nucleus comes out through them, this state is called extrusion. Extrusion usually causes squeezing or compression of the nerve root. This requires surgical intervention.  If the rupture of fibrous ring is not complete, then this is a protrusion, which has a more favorable prognosis. In most cases protrusion can be treated conservatively. Ask your consulting doctor these questions. Together you can assess the degree of the rupture of the disc, the size of the hernial protrusion, its direction and its influence on the nerve roots. Then you will be able to come to an informed decision about the suggested treatment.  

Patients often try to explain to themselves and to other people what has happened to their own health and spine. This is understandable. Putting the condition into the correct logical order helps us to take the next step toward recovering from a disease. This is why pain in the spine is sometimes explained as “salt deposits.” Doctors sometimes laugh at patients for this explanation, but are these “salt” explanations really so far from the truth?

We know that the spine, just like every other part of the body, does not go through the life cycle unchanged. With growing and aging, everything in the spine changes, both soft and dense structures. Some parts of the spine grow quickly, like the ligaments. The yellow ligament plays special role in this process. It gets its name from the yellow pigment it contains. It is located between the vertebral arches and with these arches it forms the posterior wall of the vertebral canal. The yellow ligament looks like an elastic, flexible rubber band that stretches and shrinks. This example helps to explain what happens to this ligament and to the spinal canal when the vertebrae move.

As the ligament stretches, it becomes thinner. This happens every time we lean forward, for example, to put our shoes on or to lift something heavy from the ground. When we straighten up, the ligament relaxes and gets thicker again. If these kinds of movements don’t happen very often, the ligament can handle it. But when the cycle of leaning and stretching happens on a regular basis, the ligament grows. Just like any other tissue, it hypertrophies with exertion, in other words, it gets larger. Everybody knows that muscles grow as a result of training. The ligaments can grow the same way. This growth helps the ligament cope with exertion.

When the vertebrae move, the exertion is distributed not only to the ligaments, but also to the intervertebral joints. The joints also grow as a result of exertion.  What exactly is spinal exertion? It’s simply living life. Constant physical activity, especially when we’re leaning forward. Any sports activity related to exertion on the spine and even sedentary work in an office. All these present a serious challenge for the intervertebral discs and joints. This exertion causes their growth. In some areas, there can be found calcification and ossification. These are the areas where the “salts” mentioned above are deposited.

An old proverb says “one man’s meat is another man’s poison.” Growth of muscles is good, but growth of ligaments and vertebral joints is very bad, because when this happens, the tissue grows in the direction of the vertebral canal. As a result of hypertrophy or growth of the yellow ligament and intervertebral joints, the canal, which is close to them, constricts. This condition is called spinal stenosis.

Of course, spinal stenosis or constriction of the vertebral canal progresses very slowly, over a few dozen years. Year after year as the canal gets narrower, our body is using its inner reserves. When these reserves are worn out, the narrowing reaches the critical size and the disease starts to manifest itself. Patients usually notice symptoms of the disease after a minor injury like slipping and falling, or after psychological stress. These factors usually become the last drop that makes the cup run over. Afterward, the disease starts to actively manifest itself, even though there were no prior symptoms.  

As you already know, leaning forward decreases the narrowing of the canal. That’s why these patients walk bent over and sometimes lean on a cane. The narrowed vertebral canal doesn’t have enough room for the nerve roots and blood vessels, so blood supply is abruptly interrupted, especially during walking. So these patients have to stop every 300-600 feet and sit down or lean forward. Doing this makes the vertebral canal a little bit wider and improves the blood circulation to the nerve roots. This syndrome is called neurogenic intermittent claudication. This disease is typical in the elderly, but it and can affect younger people too.

So spinal stenosis can occur in the body of a healthy and active forty year old man, especially if his vertebral canal is naturally not wide enough, and was further narrowed due to the growth of his ligaments and joints. This thriving young man then complains that he not only has lumbar pain, but he also has “weakness” and “numbness” in his legs and “burning” in his buttocks and hips. The pain can even expand to the pelvic areas.

Imagine what happens an intervertebral hernia occurs in such a narrow vertebral canal. Now imagine it in children from 0 to 2 years old!  In other cases, a disc hernia this size would not be dangerous, but in the case of such a narrow vertebral canal, it can be like a bomb that could completely destroy the squeezed nerve roots. That’s why it is important not only to measure the size of the hernial protrusion, but also to correlate it to the size of the canal, the position of the nerve root and the condition of the nerve itself. Following the advice of a neighbor or of a family doctor to “... put up with the pain and not pay attention to a ‘small’ disc hernia... ” might not only lead to many years of excruciating pain for the patient, but can also cause serious complications, such as paralysis.

So don’t forget about the “salt” in the spine. Don’t be “narrow-minded” when it comes to the “narrow” vertebral canal.

Do you know which types of disc hernias occur most often? They happen most frequently in the discs of the most flexible areas of the spine: the cervical and lumbar regions of the vertebral column. There are more common discs among them also, in which hernias occur more frequently than in others. These are the discs:  C5-C6 and L4-L5 and L5-S1. If you have not been familiar with these denominations in the past, you will be from now on.  The numeration of the vertebrae starts at the top end of the spine, and the vertebrae are called with the first Latin letters of their names: C – cervical (neck), T – thorax (chest), L – lumbus (low back). 

Because the discs are located between the vertebrae, they are named by the two neighboring vertebrae: disc L4-L5, C5-C6 and so on. Two cervical and lumbar discs are subjected to the greatest stress and exertion (discs of the vertebrae C5-C6, C6-C7 and L4-L5, L5-S1). That’s why ruptures and hernias occur more often in them. If a fragment of the nucleus protrudes in the direction of the nerve, this can eventually lead to disablement or the need for a crutch. The nerve cannot tolerate the pressure or squeezing for very long before it stops transmitting electrical impulses. The outcome of this is a leg or an arm becomes thinner and “shrinks” as people sometimes say. A foot becomes hard to control and weakens, and toes or fingers feel like they’re not part of the body, they become numb.

The more patients a doctor has, the more diseases he probably sees, and no two diseases are exactly alike. But there are similar symptoms. Symptoms help a doctor know, even before an MRT, which nerve or nerve root is affected, and in which disc there is a hernia. So in some ways, a doctor’s work can be compared to the job of a detective. A doctor finds the cause of a disease by looking at separate clues. In the case of spinal nerve disruptions, these clues are sense and motor functions, in other words, the way you feel and move separate parts of your body. 

To begin with, let’s test the lumbar region of the spine and the lumbar roots. To do this, try walking on your toes and on your heels. In addition to that, take a pin and check to see if you can feel a pin prick in your big toe and in your little toe. If you complete these two tests without any problems you can be sure that the major lumbar roots are alright. But if you have difficulty standing up on the toes of one foot and at the same time don’t feel the prick in the little toe as strongly, then there is a possibility of a hernia of the disc of vertebrae L5-S1. If you have difficulty walking on your heels, because the foot is weak and “slaps” the floor, and also your big toe is numb, then you are likely to have a hernia of the disc of vertebrae L4-L5.  

To test the cervical nerves, pay attention to your hands. The root that controls the triceps strength and sensitivity in the middle finger is located near disc C6-C7. So if you cannot perform push-ups on both hands with equal ease because of weakness of one of the triceps, and your finger is numb, you might find a hernia between the vertebrae C6-C7. The backward movements test the root near disc C5-C6: if you cannot chin up because of the weakness of a biceps and your thumb is numb, there is a possibility of a hernia between vertebrae C5 and C6.

It would be naive to assume that everything is so easy: just perform a few push-ups, one or two chins up, walk on your toes and heels, prick yourself with a needle, and ab-ra-ca-dab-ra! The diagnosis is ready. It doesn’t work quite that way. Diseases usually only partially manifest themselves. The symptoms of disease rarely occur all at one time, full-blown.  For example, the sense disturbances develop while the movement symptoms have not yet erupted. That’s why only a specialist can grasp the full extent of a disease, and can answer for you whether or not your hernia is dangerous and give you guidance on what to do next. So, full speed ahead! Find the right doctor!

The tail of many animals is the longest part of their spine. For example, the marmoset uses his tail as a fifth paw. Pets, like cats and dogs, use their tail to express their mood. A delighted dog wags his tail, but a cat with a shaking tail is angry or about to cause trouble. People have to express their moods in other ways, because instead of being the longest section of our spine, ours is the shortest: the tailbone (sometimes referred to as the coccyx).

 Our tailbone consists of three bones. They are attached to the sacrum by intersecting ligaments.  The top of the tailbone is also attached to other pelvic bones and muscles by ligaments. Yes, indeed, you read that right. Your tailbone is attached to muscles. This is why, after special training, you can even move your tailbone. The tailbone can be in different positions: its top is often directed forward and down, but it can be directed vertically down and vice versa. It can also be bent at right angles to the sacrum or and even be directed upwards! All these positions are mostly normal variations.

In spite of its small size and its relatively simple structure, the tailbone can cause tremendous pain which is known in medical terms as coccygodynia. This word tells nothing about what causes it. It only indicates that there is pain in the tailbone. Coccygodynia can be caused by different things, but most often it occurs because of trauma. Falling on the buttocks is the most common reason for coccyx pain and women complain of pain in the tailbone more often than men. Fractures or dislocations of the tailbone don’t often occur, but this type of traumatic pain can be excruciating, and it makes sitting unbearable! Who can possibly stand up or lay down the whole day long! The poor patient with coccygodynia is forced to find a comfortable position on a chair, try sitting on different pillows or just avoid sedentary work.

When these types of injuries occur, the ligaments of the tailbone are usually damaged. A microscopic tear occurs, which is exactly the same thing that happens to the ligaments of the ankle when it is twisted.  X-rays or tomography is commonly used to examine these patients. Many times the tailbone is bent forward or upward, so the logical conclusion is that the tailbone is “fractured” or “dislocated.” But there’s no point in jumping to conclusions like that.  In most cases, these are normal variants (as I already said), and only the ligament of the tailbone is damaged. So don’t be in a hurry to REMOVE a normal tailbone. Other possible reasons for coccygodynia include a tumor or inflammation in the area of the tailbone.  All of these conditions can be easily detected with an MR examination.

There’s a condition that really has nothing to do with coccygodynia, but it may be mistaken for a problem with the tailbone, so I mention it here.  The sacrococcygeal duct is located in the tailbone area. This is a “tunnel” located under the tissues near the tailbone. It generally doesn’t cause any trouble. In fact, you probably don’t even know it’s there.  But it can become inflamed, and then it gets red and swollen and causes pain in the inter-gluteal crease. Sometimes it even drains purulent material. It is surgically treated as an abscess.

99% of the time, coccygodynia occurs due to damage of ligaments. In some cases, it’s obviously due to trauma, even though the patient can’t remember any accident or injury.  But doesn’t sitting on a chair for 8 to 10 hours straight overload and injure the ligaments of the tailbone?! Of course it does! The tailbone objects to this! This is why many office-workers who sit all day develop coccygodynia “for no reason.” Treating coccygodynia in cases like this involves using the whole arsenal of conservative methods:

• Epidural injections: Injecting analgesic and anti-inflammatory medicines directly into the region of the ligaments of the tailbone
  
• Ultrasound treatments
  
• Massage therapy
  
• Hot baths with chamomile or sea-salt
  

These treatments, in most cases, will provide relief within a few weeks, although sometimes the treatments may need to be continued for months.  

Sometimes the source of tailbone pain is located in another place. If pain is radiating downward, a person may only feel it in the tailbone. The source of pain may be gynecological disorders, rectal diseases, urological conditions or osteochondrosis of the lumbar region of the spine. Some say it is possible for osteochondrosis to occur in the tailbone, but I have not seen any cases of this in my practice. 

What do you think is the most common reason for spinal surgery? It is most often performed due to a hernia of an intervertebral disc.  But thankfully, only 1% of all hernia protrusions require surgery.  Think about this: An inflamed appendix is removed 100% of the time.  It’s a good thing that not all hernias are “cut out.” If they were, every person over the age of forty would end up on a surgical table for removal of an intervertebral hernia. So who should be operated for a herniated intervertebral disc?  Since you’ve read the previous chapters, you can already partially answer this question. The patient with cauda-equina syndrome should be operated on instantly. This complication of vertebral osteochondrosis can disrupt the complex processes of urination, defecation, sexual functions, and, needless to say, movement and sensation in the legs forever.   

Patients with symptoms of neurological disorders should be treated.  Nikolay Burdenko, the head surgeon of the Soviet Army during The Great Patriotic War (1941-1945), is believed to have coined the phrase that surgery on a disc hernia should only be performed “when a patient crawls on his knees and pleads for poison.”  People don’t die from pain, but unbearable pain drives them to a surgeon. Nowadays, there are very strong and effective pain-relieving medications, including narcotic drugs that can ease pain. But even if medications relieve pain, more critical symptoms of the disease continue. In cauda equina syndrome, sense and motor functions of the nervous system should be assessed.  In previous chapters you learned how to do this. So if you notice weakness in an arm or leg or disruption of sensitivity in the hand or foot, this can mean there is partial paralysis, and when the nerve transmitter suffers, it literally dies.

Today, the situation is different. Patients tell their friends how they got rid of problems that had been chasing them for decades, and how their health was restored, thanks to surgeons and an excellent clinic. Favorable results of treatment are not only the result of a combination of surgical skills, but also what is described in the proverb “it is good to have mustard in time, not after dinner.” Any surgical intervention must be performed in time. So if you notice even little problems like:

• your foot not pressing down on the accelerator as strongly when you’re driving
  
• your fingers fumbling with the buttons on your shirt
  
• you can’t run to catch the bus anymore
  

Find out if your problems are related to nerve damage. It is not likely that you will be among the unfortunate 1% of patients who need instant surgical removal of a hernia. It’s much more likely that you will have a wide variety of conservative treatment options.

Insufficient awareness of patients and doctors leads to unreasonable prolongation of ineffective conservative treatment and late performance of surgical intervention!  

So, if you have serious problems with your spine, take an interest in modern advancements in medicine, pursue additional specialized medical consultations and become aware of the advanced techniques and technologies. Medicine does not stand still!

The opposite situation is also common. The patient has been well-informed but is afraid to put himself in the surgeon’s hands. These patients try to be treated by any and all non-surgical methods. They even use even traditional or home-made remedies. This can and does go on for months and years. During this precious time, the nerve cells, cell processes and fibers DIE.

It’s important to know that the progression of a disease does not usually progress in a straight line. At first, the symptoms develop slowly, almost unnoticeably. But over the course of time, the disease turns a corner, and the symptoms suddenly increase. Once the body’s reserves are depleted, blood flow and nerve tissue reserves are worn out, the neurological disorders can rapidly progress, in a few weeks or even within days.  Then the fear of becoming disabled becomes stronger than the fear of visiting a surgeon. The patient decides to be operated on, but in this condition, surgery is very risky. Not only a dislocation of the nerve root is possible, but even the slightest touch to it could cause serious problems and paralysis.  In addition to that, scar tissue forms in the spine near a disc hernia, making it more difficult for the surgeon to operate at this late stage of the disease.  These operations have a very high risk of post-surgical complications. So, as the proverbs say, “all in good time” and “an umbrella is needed on a rainy day.”  Surgery is good at the appropriate time.  

What should a person do, when his neuropathologist discourages him from having surgery, while his surgeon is convinced that surgery is necessary?

The major problem is that nobody can guarantee that there won’t be any complications of the disease without an operation, or that the operation will not cause even more problems. To make the right choice, one should reasonably assess the risks of both the surgical and the non-surgical treatment. If a surgeon informs you with confidence, that in your specific case the complications are unlikely to occur, and your state of health is getting worse from day to day despite the conservative treatment, you should choose the surgery. If the risks of surgery are high for whatever reason and some primary methods of conservative treatment have not yet been used, you might continue with further non-surgical treatment. But if you have symptoms of nerve death – cauda equina syndrome: weakness or paralysis in your leg or hand, thinning or loss of weight in a limb, a change in the sensitiveness of your hands or feet – there is nothing to think about! The surgeon holds your only chance for recovery in this case. It is much more difficult to make a decision when pain is mild, but it lasts for years. When this happens, there are many options available of less invasive spinal surgeries. We’ll talk about those methods in another chapter.

How pleasant it is to feel the flexibility and mobility of your own spine! 

“Life consists in movement” ancient wise men said. We can move individual parts of our arms or legs or even wiggle one finger, but our spinal column moves as a single unit.  Remember that during general movement, each vertebra moves separately as well: it can follow your body forward and backwards, and even turn. Your vertebrae and intervertebral discs also experience a huge axial load, especially if the weight of your body is close to 200 pounds and you stand only 5 feet tall! To make your spine work effectively, your vertebrae connect with each other in a movable way. You already know the intervertebral discs respond mainly to gravity. They spread out load in a vertical direction. Other structures, the intervertebral joints, stabilize the vertebrae and prevent them from shifting from side to side, they hold them in line. Because of these structures, our spine is a real pyramid. It’s pretty much straight in young bodies, but looks more like a coiled Chinese dragon in aged ones. If you have an opportunity to look at the spinal x-rays of an elderly person, you can use a weighted thread and a ruler to check if all the vertebrae keep to the general plumb-line. In most cases you’ll see that some vertebrae have significantly shifted from the axis of the spine.    

Scoliosis is one type of abnormal spinal curvature.

 It can be caused by different things, but in more than 90% of all cases, a doctor cannot define the reason, and so the scoliosis is called “cause unknown” or idiopathic. Children and adolescents, girls more often, have this spinal deformity. Parents usually start noticing that their child stoops over or even has a “hump.” It is especially important to notice this disease in the very early stages, so steps can be taken to prevent its progression. The test for scoliosis is very simple, but it’s very effective. All parents need to do this from time to time and watch their children’s spines. To detect even small scoliotic deviations, turn the back of the child or an adult toward you and bend the person forward at the waist, so that his or her arms are hanging down freely. Now, squat slightly and start sliding your gaze along the spine from the bottom to the top, raising yourself while examining the spine. You will see both sides of the back and shoulders.  If they are on the same level, there is no scoliosis. But if one part of the back is higher than the other, or one shoulder is higher than the other one, this person has the disease.  

This test is based on the fact that when scoliosis is present, not only a spinal inclination to one side is developing, but rotation is also. This is because the turned vertebrae pull some of the ribs to their side, causing a “hump” to appear on that side of the back. It is well known that there is a connection between a child’s scoliosis and increased requirements for the child’s life and study. When you think about it a little, you can understand that nature sometimes punishes us for limiting spiritual freedom by inflicting physical diseases.

Young people are totally obsessed with today’s tablet computers and “smart phones.” These devices replace natural communication with short written messages and constant, often aimless wandering around on the Internet. A typical situation finds a tall young man with a hunched back sitting at the computer all day long. His parents are convinced his bad posture developed only because he sits there at the computer, texting and surfing the internet all day.  But a hunched back is often related, not only to computerization, but also with Scheuermann’s disease. This condition is also called juvenile kyphosis. The disease varies in severity, from slight stooping to a disfiguring hump. It is a genetic disease in which some of the vertebrae, usually the third and fourth middle thoracic vertebrae, become shaped like a wedge or a trapezoid.  These patients also frequently have changes in many of their intervertebral discs. The discs can be curved, deformed, and also have what are called Schmorl's nodules. A famous German pathologist, Christian Schmorl, discovered that if a person has this disease, cartilaginous knots of intervertebral discs protrude into a neighboring vertebra. These protrusions are not connected to the spinal cord or nerve roots, so they’re not dangerous. Schmorl's nodules seldom cause pain, only if the knot is gigantic and damages a considerable part of a vertebra.

Scheuermann’s disease can be combined with scoliosis. Sometimes Schmorl's nodules can be present in the spine without essential curvature, but they indicate the person is predisposed to different spinal conditions. So don’t blame your son or daughter for stooping over! They may have inherited your genes that are carrying Scheuermann’s disease!

Even without looking at their face you can usually tell who a hand belongs to: a young man or an elderly person. Not only the wrinkled skin, but also the joints have much to say about a person’s age. An elderly person’s joints are often twisted, enlarged and deformed.  Overload, hard manual labor and age-related changes lead to arthrosis. In this condition, not only does the cartilaginous layer in the joints become thinner, bone spurs or osteophytes also begin to form.  These same changes occur in the spinal joints. When loaded spinal ligaments become thinner, the vertebral joints twist and cannot hold the vertebrae on one main axis of the spine. That causes one vertebra to begin shifting, relative to the one next to it. The overlying vertebra usually shifts forward relative to the underlying one. This deformity of the spine is called spondylolisthesis.  It’s also possible for a vertebra to shift backwards and even to the side. 

People employed in jobs that require hard manual labor or athletes can have a chronic split in an inter-articular part of the spinal curve. For example, wrestlers, gymnasts or manual laborers sometimes overload their spinal columns to such an extreme that even bone cannot tolerate it. At that point, a split in the vertebral curve or near its joint appears. A split is an actual fracture and the main component of treatment for a fracture is immobility of the fragments. That’s why a broken arm or leg is placed in a plaster cast. But how can you encase the whole body in plaster, especially since this split can’t be seen on X-ray pictures? This is exactly why these people “buck up” under severe back pain and continue to train or work, telling themselves:  “The most important competition of the season is right around the corner.”  Or “A well-paying client has asked me to carry  a piano to the eighth floor of a building that has no elevator.”  What happens then? When severe back pain is ignored?

 Between immovable bone fragments, a callus appears. This callus turns into a normal bone later on. But in our case, the fragments, that is, the parts of vertebral curves, continue being loaded and microscopic movements continue. So at the moment of the next load, the split becomes bigger and a callus does not form. Instead of a callus, a scar forms and the fracture itself is called fatigue. Of course, this scar can’t hold a vertebra in place, so the vertebra shifts. At first, it only shifts one millimeter, but later, as the load becomes bigger, the vertebra shifts more and more, right up to the moment when two neighboring vertebrae can lose their connection with each other.

Sometimes, at the initial stage of the disease, a “shifting” vertebra can be returned to its normal position if a certain pose, usually bending backwards, is struck. That’s why, when people with this condition walk, they avoid bending forward. They throw back their head and chest. This unstable vertebra can prevent a correct and timely diagnosis. A patient complains of back and leg pain, but there are no shifts visible on an X-ray or MR-images which are taken with the patient lying on their back, which is how these images are obtained in most cases.  In this horizontal position, the vertebra just “fell” back into place and the spondylolisthesis disappeared. To diagnose these shifts, it’s necessary to examine the spine under load. To do this, functional testing should be completed: X-rays are taken in positions of maximal bending and unbending. In addition, special MR equipment exists that is able to take images of the body in a lying position and in a standing position under vertical load. This MRI equipment might not be available to everyone, but an X-ray can be completed in any hospital.

                If a person suffers from spondylolisthesis, they feel pain not only in their back. The shifted vertebra stretches the vertebral ligaments and joints and, as you know, nerve roots and the spinal cord are inside the spinal column. While they are slightly shifting, the vertebrae will trap these nervous structures like tongs. That’s why pain will occur in one or both legs in addition to pain in the spine.  

It’s natural for any person who is having pain to be eager to improve their situation. They want to “put the vertebrae back in the right spot” immediately after they learn the bones have shifted or curved. But not every deformity needs such radical treatment.  Remember that curvatures and spinal deformities developed over several years and even decades. The body gets used to them and adapts to them. It strengthens the changes spinal parts with bone growths and scar tissue. So when someone tries to change the situation all at once, the outcome is often negative. The curvature may be corrected, but now pain exists, because the spinal ligaments are injured. If someone promises to “set” your vertebrae by one or two sessions of manual manipulation or osteopathy think about this before you allow it! These methods of conservative treatment of spinal disorders can effectively relieve a muscle spasm and sometimes even (really? in one hour) improve the mobility of the spinal column for awhile.  But, unfortunately, they cannot really correct spinal deformity or eliminate the slippage of a vertebra. Concerning Scheuermann’s disease, in most cases, surgery is not required.   The same is true with the initial stages of scoliosis. It is almost never possible to “set” a spine or correct a curvature. At the same time, in most cases, spondylolisthesis can only be treated with surgery, especially when nerve roots are trapped.

You have already learned in the previous chapters that the most frequent surgery on the spine is the removal of a herniation of a lumbar intervertebral disc. From the 1930’s until the 1970’s this operation was carried out in a very simple way: a part of the vertebra, mainly its curve, was removed; all the membranes of the spinal cord were opened, and a small piece of cartilaginous tumor (that was the name of the intervertebral herniation) was removed through these openings. I think an operation like this gave the creeps to many people who aren’t easily creeped out! It’s no wonder that complications after these operations were common and patients tried to avoid them. It wasn’t until the late 1970’s that micro-surgical removal of a hernia, micro-discectomy, was offered. This means that the entire procedure is carried out through a tiny incision, not more than 1 inch long, with the help of an operating microscope, using special surgical techniques and instruments. If these conditions are followed then this “gold standard” of herniation of intervertebral disc removal gives excellent results. After this type of surgery, a patient can get up to a chair several hours after surgery and is ready for discharge from the hospital within 2 days. The scar on his skin looks like a thin white line in several months. But if all the conditions are not followed, it is very likely this operation will resemble the old one. The incision will be large and the procedure itself traumatic. Some post-operative pain is unavoidable, even after the most meticulous micro-surgical operation. But since the incisions are usually so small, they do not cause serious amounts of discomfort.  In rare cases, especially when there is a tendency toward healing pain, surgical recovery can be a reason for pain syndrome to develop in the postoperative period. 

Over the last decade, surgical standards have been changing. In all kinds of surgery, minimally invasive, that is non-traumatic, techniques have been introduced. The size of incisions has diminished until they are almost miniscule and operations can be performed through only a puncture. Special spinal endoscopes are used for those types of micro-surgeries. “Endoscopy” means examination on the inside. Using an endoscope makes it unnecessary to make a large incision to reach an internal part of the body. It’s enough to make a small puncture no larger than a pencil in diameter. A spinal endoscope is a complicated device that has both “eyes” (fiber optics) and “arms.” Surgical endoscopic equipment is inserted through it. The whole operation is carried out in an airless environment. The surgical area is constantly washed with a transparent liquid. That’s why there is very little scaring. To reach the spinal structures natural openings, the spaces between the vertebral curves or intervertebral foramens, are used. This eliminates the need to cut away a part of a vertebra to get to a hernia or a nerve. Endoscopic removal of a disc hernia completely saves all the spinal muscles and ligaments. That’s why a patient can be discharged within a day after surgery and is able to resume their exercise routine or even return to a physically demanding job within 2 months. It’s possible to complete endoscopic surgery without general anesthesia, using only a local anesthetic. The patient stays conscious and is able to communicate with the surgeon. This is especially important for elderly patients with other medical conditions who are not always able to tolerate general anesthesia.

n the last year, new technology was introduced that is even more miniscule than endoscopic surgery. Water is used for the removal of disc herniation! Of course, it’s not just plain water. A special probe only 0.1 inch in diameter is inserted directly into the disc to the area where the hernia protrudes.  A stream of water pulsates from the end of this probe at a very high frequency. It dissects the hernial tissue like a razor blade and aspirates it, or is sucks it away to a special reservoir. This method is called “hydro-discectomy” and is carried out under local anesthesia. Not all kinds of intervertebral hernias can be removed by this method. But often athletes, adolescents and young patients with new hernias which have not yet protruded beyond the intervertebral disc are excellent candidates for this surgery.  At a certain stage of the disease, hydro-discectomy allows for surgery through a puncture only one-tenth of one inch in diameter! That is removing a hernia without a cut!     

You have already learned that a hernia shows up when an intervertebral disc splits or tears. I said earlier that not more than 1% of all intervertebral hernias are operated on or removed. So what happens to the other 99%? As a general rule, these are small disc protrusions. They don’t trap nerve roots or the spinal cord, but they can cause a great deal of suffering. According to the latest statistical data, losses connected with treatment and disability due to back pain take first place when compared with cardiovascular diseases and even cancer. The first reason for this is that traditional methods of treating back pain don’t work. In a typical situation, a patient reports that he or she has been suffering from constant pain for several years and that sometimes this pain becomes more acute. When it starts, massage, physiotherapy and other conservative treatments help these patients. But as the disease progresses, the acute pain attacks become more frequent and the more mild or “light” intervals, when the pain disappears or becomes bearable become shorter. Patients cannot stand such chronic pain. It can lead to depression or even suicide. Right at this moment light can help. Light can treat the cartilage of an intervertebral disc. I said earlier that water can remove a hernia, and now I’m telling you that light can restore a disc! This is not usual light, but laser light.  A laser beam can stimulate cells. External laser therapy is based on this.  Laser energy can remove tissues. This is the way laser scalpels work. It is possible to operate with a laser beam by controlling its power and the direction of the radiation. This is very important, because it is a matter of influencing living cells. In 2002, a group of scholars, doctors and medical physicists, studied what effect a particular laser radiation would have on stimulating growth in cartilaginous tissue. I was happy to take part in this study. Earlier, it had been considered impossible to create conditions for cartilage regeneration. After some successful tests on animals, the disc appeared to be capable of being restored. It also appeared that tears and splits in discs can be restored with new fibro-hyaline cartilage. This method of treatment is called laser disc reconstruction. The procedure is done through a puncture in the skin with a needle. Under X-ray control, the needle is inserted in the very center of the disc. The procedure is conducted in an operating room, under totally sterile conditions. Talking with the patient several times throughout the procedure ensures safety as much as possible, and eliminates the possibility of nerve trauma.
 

The surgeon radiates the disc in several areas through the needle with the help of a special device. Heating is strictly controlled by the device according to a reverse control system. This ensures that overheating and thermal injury of disc tissue is also impossible. Impulses, emitted through a laser light guide, stimulate beneficial effects to occur in the disc. The cartilage cells divide and fill in the splits in the fibrous ring. At the same time, the permeability of the cartilaginous disc plate increases, through which the whole disc is fed. This method is an authentic method of tissue engineering which is able to create new systems and tissues. As a result, in several months, nearly 80% of patients will be able to report that their attacks of pain have diminished, become less frequent or have totally disappeared.  Almost all the patients agreed to repeat this operation, and that’s the main criteria on which the least invasive type of surgery is judged.

It’s no secret that people try to hold on to success once they’ve achieved it.  A good paying job, secure family relationships…This kind of stability gives us confidence. It lets us plan for the future. Political and social polls show that the word “stability” always refers to the positive side of life. When we talk about the spine, the opposite term, the antonym, “instability,” is used. Many patients learn from their doctors they have “instability” in their spine. This word has such a negative charge that a patient tries to get rid of instability by any possible means. Doctors persuade their patients and so they begin to believe, that most of their problems and concerns are caused by “spinal instability.” Let’s figure out what instability of the spine really is.  

If you think of the definition of “instability” you can understand that it’s connected with the usual activity of a human being. So we can talk about instability when a person’s spine cannot bear a typical physiological load without pain or a problem in the way it works. That’s simple to understand. The problem is that a flare up of almost any spinal disease causes pain and functional disturbances, even under the lightest of loads. Bending to tie your shoe-laces or walking down the grocery aisle is typical and normal work for your back and spine. But you can’t do even these simple tasks when you’re suffering, for example, from osteochondrosis of the lumbar spine. That’s why it isn’t true that every person who suffers from back pain has spinal instability.

The spine is a very unusual organ. (Thank you, Captain Obvious!) The strength and resistance of the separate parts are combined with mobility toward each other. The vertebrae are connected to each other with ligaments, joints, intervertebral discs and muscles. That’s why they follow each other so smoothly when they’re moving. If any of these many connecting parts that hold the vertebrae together becomes weakened or damaged, the vertebrae start moving on their own. The most understandable example of a connecting part becoming weak or damaged is spondylolisthesis. In translation, this word means “slipping of a vertebra.” X-ray pictures of this condition don’t show a spinal column with all the bones connected. Instead, there’s “a step” where one or even several vertebrae have shifted relative each other and have created real stair steps.

At first, common sense might tell you that the solution to this problem is to correct the vertebral shift and fasten the loose vertebra so it can’t move. But we know that spondylolisthesis (slipping of a vertebra) does not happen in overnight or even in a month. The vertebra is gradually shifting over several or even many years.  During this time, the patient may have no pain. They don’t even suspect anything is wrong.  This is because the body strives to protect and heal itself. It seeks balance and equilibrium.  It tries to strengthen the vertebrae because the ligaments have stretched. Extra bone and osteophytes have formed that connect the vertebra, and adhesions appear between vertebrae. This process can hold vertebrae in the correct position for years, and the person will have no problems with their spine. The disease slows down and stops progressing.  The body is remarkably amazing!  

If you think that an MR scan is able to detect any spinal disease, you’re wrong. It isn’t always possible to detect spinal instability with an MRT. To detect it, the spine has to be examined while loaded, so functional X-rays are used.  This is one of those cases when an X-ray is needed to make a correct diagnosis. A patient has to bend und unbend as far as possible, and X-ray pictures must be taken in these extreme positions. If such load shows a shift of one or several vertebrae, spinal instability exists to a variable degree. 

The question of spinal instability is very important because progress in spinal surgery has been closely associated with the appearance and improvement of spinal fixators over the last 20 years. 

There is a whole “tool box” among them: screws that are twisted into vertebrae, brackets that are hooked on vertebral curves, various plates, rods, and other “assembly kit” items. These implants, which usually remain in place for life, are often insufficiently grounded. For example, a young patient with an ordinary hernia of an intervertebral disc might be offered, not only removal of a disc protrusion, but also vertebral fixation. He is offered a “cure” for his “spinal instability.”  Remember, more complicated surgery leads to more extensive trauma and greater risk for surgical complications from which you cannot totally insure yourself. Besides, if two or more vertebrae become forever “fixed” and immobile, according to the law of biomechanics, load will be redistributed and so increased on the neighboring movable parts, that is, on the adjoining intervertebral discs and joints. That explains why, in last decade, the term “adjacent segment syndrome” appeared. This term refers to the fact that the process of aging and degeneration is accelerated in the discs and joints located next to the immovable spinal parts. That’s why several years ago at the World Congress of Spinal Surgeons, a reporter asked EuroSpine when spinal surgeons were going to stop fusing vertebrae so often and so needlessly.  In modern surgical environments, a popular proverb has emerged: “refuse to fuse.” This means the decision to fuse two or more vertebrae together must only be made after careful and wise deliberation. It must take into account all the pros and cons, because the overload on neighboring spinal segments speeds up the development of intervertebral osteochondrosis and leads to new problems. Before making the decision to stabilize the spine, X-rays and MRTs must indicate instability, and the patient’s age and occupation must be taken into account. The presence of osteochondrosis of the spine is not enough.

Fixators for the vertebrae have saved lives and have restored the working capacity of millions of people with spinal injuries and tumors. But many times, if vertebral fixation has already been done, a surgeon is left with no other treatment options. The next operations, performed when fixators are already in place, are usually accompanied by the risk of huge surgical complications.  This is because scar tissue has formed since the previous surgery and complicates repeated operations. Many patients with back pain continue suffering, and pain even intensifies after stabilizing surgery. There is a term “failed back surgery syndrome” among surgeons. A detailed discussion with a surgeon to discuss various treatment options before an operation can prevent a failure after it. Non-traumatic surgery using endoscopic or micro-surgical techniques allows a surgeon to both remove an intervertebral disc hernia and enlarge a spinal canal without disturbing spinal stability or intensifying instability. If later on, fixation is required, it can still be completed without problems.

Of course, this argument isn’t true in every single case. It also doesn’t mean that you have to refuse stabilization at all. In many cases, such as a traumatic spinal injury, spondylolisthesis or scoliosis, the only possible way to save the spine and help the patient is by using modern fixation techniques. So the good common sense of the doctor and the patient when making a decision about fixation of the vertebrae is the corner stone for a successful surgical procedure.

Successful management does not only guarantee the prosperity of a state or company. Pain management is also a permanent and essential part of medicine. By the way, the English term “pain management” is also expressed in Russian with the same English words. Feelings of pain are always a signal that something is wrong in the body. That’s why we try to get rid of them as soon as possible. And that’s why pain medications (analgesics) that are sold over-the-counter are the best. These are mostly nonsteroidal anti-inflammatory drugs or NSAIDs.

They work by getting rid of or reducing inflammation. By the way, tea with raspberry contains a natural anti-inflammatory substance, acetylsalicylic acid or aspirin, that’s why it helps reduce fever. When osteochondrosis is present, the inflammatory component of pain is very important. That’s why these NSAIDs are so effective against acute painful syndromes and every emergency team keeps them available. But as we know, a spinal disease can become chronic. Then pain starts attacking more frequently or even becomes constant. When this happens, the continuous use of nonsteroidal anti-inflammatory drugs can lead to serious complications. An ulcer and bleeding can start in the stomach, liver and kidney functioning may be disrupted and bone marrow and blood cell formation can be affected.

In addition to those problems, non-steroidal analgesics can become addictive just like narcotic drugs do. This is true! Ordinary analgin or a similar medication can cause addiction. Imagine a person who takes this drug because of back pain or headaches every day for several years. Nonsteroidal anti-inflammatory drugs plug into a metabolic biochemical process of the body so well, that if you stop taking the medication, pain begins. This is what commonly happens in classical pain syndrome when a person stops taking analgesics. 

This is why pain management is not only a matter of reducing inflammation, but also a matter of slowing down the transmission of pain information to the brain. This means blocking the nerve conductors that control pain impulses. In simple terms this procedure is called a “nerve block.” To do this effectively, the drug must be administered to the very nerve itself or to the nerve root, which are located deep inside the spine. Only a specialist can perform a spinal nerve block, and a special X-ray device is often used for this. In the course of this procedure, a steroid anti-inflammatory drug is usually used, and sometimes it is combined with local analgesic. The term “steroid” means this is a hormonal remedy, and there is no need to be afraid of it. One or two injections of steroids during a 6-month period is permitted and has no critical side effects. This becomes a different issue if a steroid drug is injected incorrectly. If a trained doctor who can inject a hormonal drug into the peri-dural spinal area is not available, then neurologists and other “specialists” inject the drug into the spinal muscles. When this happens, the whole benefit of using the steroidal drug is lost. The effect of the injection is then just the same as a simple intramuscular injection into the buttock.

The steroid does not affect the nerve directly. Instead, it is absorbed into the blood and spread around the body. That is why it’s necessary to repeat nerve blocks many times to achieve at least a little pain relief. This leads to side effects because of a surplus of the steroid hormonal drugs. As a result of this increased use of these hormonal steroid blocks, the arterial blood pressure increases, the patient puts on weight, breaks out in blackheads and develops other obnoxious side effects. So the drug we expected to be helpful, became instead a poison that polluted the body.

Pain management is a real science. It’s “making a deal” with pain; blocking pain information by influencing both nerve conductors and the nerve centers of the brain and spinal cord.

When osteochondrosis is present, intervertebral joints are often injured. If the nerves leading to the joints are blocked, the patient can be free of the pain connected with them for a long time. To do this, nerve blocks of intervertebral and facet joints are carried out. This procedure requires an operating room and X-ray to control the needle position.  In addition to a nerve block, there is another procedure that can provide extended pain relief without the use of injected medications. Rather than an anesthetic being inserted to the nerve through a needle, an electric probe that switches off the nerve with the help of electricity is inserted. This procedure is called radio frequency de-nervation.

A specialist in controlling pain syndromes will attempt various nerve blocks first. It is possible to block any nerve in the human body with the help of a needle, which is the main “weapon,” if you have X-ray available and know anatomy perfectly. The patient will no longer need to constantly be taking pain pills. Osteochondrosis will be silent. 

There are other ways to manage pain. Punctures and nerve blocks are not the only available options. Pleasant procedures also exist, for example, massage.

 There are a lot of different types of massage: medicinal, Thai, nerve-point, sports and others. When massage is done correctly, it doesn’t only improve your mood; it also increases the general tone of your body and relieves pain. The primary target of massage is the muscles. That’s why if the main cause of your pain is muscle spasms, massage helps splendidly. Myotonic and myofascial syndromes develop because of chronic diseases.  Let’s look at an example of how this happens. If you clench your fist and don’t relax it for 10 minutes you won’t be able to uncurl your fingers without pain. This tells you that a muscle cannot relax on its own after such a forced contraction. A spasm occurred. This same spasm occurs when you have pain. The body always tries to make any injured or diseased part of it, including the spine, motionless. So as muscle tension continues, not for hours, but for days and years in this case, muscles start to change. In areas where muscles are attached to bones (like the pelvic bones, the sacral bone, shoulder-blades, protuberant vertebral outgrowths) muscles knots are formed. 

These muscle knots, over the years, start to form scar tissue. When the spine is diseased for many years it can often provoke muscle pain and spasms. The tired muscles shrink, and you are left with actual “tumors”: myofascial knots, instead of muscles. A lot of patients really think they have tumors. These knots can cause pain by themselves. They become trigger zones that produce pain syndromes. Even if a masseur is extremely skilled, it is usually impossible to knead out these knots, even after ten long sessions.  That’s why a specialist who manages pain syndrome comes to the rescue. To start with, he has to find and anesthetize these knots. A local anesthetic that relaxes muscles is injected directly into the knots. With the help of this muscle block, massage can work much more effectively. A doctor who performs muscle blocks evaluates the whole body and makes a map. He finds where primary, secondary, and other less significant knots are located. Only after he has done this, he unwinds the tangled web of spasms, and performs block after block to eliminate pain. 

Special electrical neuro-stimulators are among the other methods of fighting against pain. They are usually implanted into the body, and electrodes are introduced to the spinal cord and nerve roots. These devices transmit electrical impulses that block the nerve conduction pain signals along the spinal cord. Pain is actually present, but a person can’t feel it because it stops at the level of the spinal cord. This method of treatment is usually used in cases of severe pain syndromes: inoperable tumors, phantom limb pain syndrome after an amputation, neuropathic pain after shingles (herpes zoster) and in other cases of intractable pain.  

                So as you already know, medicine uses both surgical and conservative methods of pain control. Treatment for pain has become an exact science. There is no pain that cannot be overcome!

Almost all my patients who have had spinal surgery ask the same question: “What can I do to prevent this problem from happening again?” My answer is always the same:  “Take preventive measures.” Everyone knows the flu can be prevented by getting a flu shot. But a vaccine against osteochondrosis of the spine does not exist. We inherit genes from our parents that have both negative and positive characteristics. They can predispose us to some diseases, including spinal ones. Even in this advanced stage of modern medicine it is still impossible to completely alter an adult’s genes. As a rule, people can’t usually change an occupation that is negatively affecting their spine. It’s also very hard for us to change our way of life. Laziness is a widespread “disease.”

So what should we do? Where do we start? When taking into account all the factors that influence the condition of the spine we come to the conclusion that posture has the greatest affect. Think about a military parade. Marching soldiers’ posture is almost perfect.

Classical dancers hold their bodies in perfect alignment as well. In these examples, the position of the body maintains the natural spinal curvatures that developed during the first year of life. Think of a newborn child who cannot even roll over onto his stomach by himself. During the first months of life, a small child learns how to raise his head. At that time cervical flexion (cervical lordosis) develops.  Healthy children can sit up at the age of 6 months. The sitting position forms thoracic kyphosis or the curvature of thoracic spine backwards. Somewhere around the age of 9 to 12 months, a child starts walking. At this time the third spinal curvature, lumbar lordosis, appears. These gentle curvatures serve us throughout our entire lives. They help our brain and spinal cord cope with the vibration and jolts caused by walking, and they are also indicators of correct posture. If any of these curvatures are too severe or if they disappear, the spine ages very fast, rapidly degenerates and osteochondrosis of the spine develops. 

Now, think about yourself. How do we sit when we’re in front of a computer? With our back crooked, of course! And the longer we sit there, the closer and closer our head bows toward the monitor. Sometimes people even have to support their head with their hands, so they look like the sculpture “The Thinker” by Auguste Rodin. It’s a miracle we can process any thoughts at all in this hunched over position! Sitting like this impairs blood flow in the spinal arteries and vessels that nourish the brain. All the inward and outward curves the spine relies on for support disappear and the spine resembles a snake that is trying to bite its own tail.  Because the bones (vertebrae) cannot correctly distribute the weight when we sit like this, the muscles and ligaments have to take over the work. Muscles and ligaments aren’t as strong as bone, so they have to strain as hard as they can, and pretty soon we end up with a painful spasm.   This is why, at the end of the working day, a bookkeeper or a systems administrator or an accountant has a “bad” neck. These spasming muscles can’t relax by themselves.

Besides the muscles and the ligaments, the lumbar intervertebral discs are also overloaded to an extreme. In such a crooked pose, they become strained and sometimes even tear. Disc ruptures often occur in the posterior sections where the spinal cord and its roots are located. When a disc splits, this is the beginning of an intervertebral hernia. In my book “Simple Carriage” I mention body mechanics and simple reflexes that control our posture.  The most important of these is the position of the head and neck. You can even check this out on your pet. If you bend the neck and head of your cat, you will see that its paws will become straightened. If you then tilt its head up, the cat will sit on its back paws and straighten the front ones. This is because the position of the head is the most important, and it determines correct posture. You can do the same experiment on yourself. Bend your neck and press your chin to the chest. It’s impossible to hold your back straight in this position. It will bend, following your head and neck.  A golden rule results from these experiments: you have to hold your head in such a way that your ears are situated in the same plane with your shoulders. Pretend you’re a king or a queen, (or a prince or a princess). In any case, pretend you’re sitting on a royal throne or standing on your beautiful balcony.  Other people may not be willing to bow before you, but at least your posture will be correct.

It’s much harder to keep your posture correct when you’re in a sitting position. We all sit in a way that quickly tires our back muscles and lumbar lordosis, (curvature of the lower back forward), disappears. The back becomes flat or even curves backwards like a wheel. It is much more complicated to try to correct poor sitting posture than standing posture.  But it can be done!  I’m about to teach you something magical. Even Harry Potter would not dream of this! You can learn how to correct your sitting posture with only one movement!  To do this, raise the heel of one of your feet, leaving your toes on the floor. You will feel how your  spine immediately straightens. If your heel gets tired, raise the other one.  By alternating heels and feet, you can keep your back straight over the course of the whole day. While you’re at work. While you’re on the subway or bus. Or even when you’re sitting on a soft sofa, slowly slurping soup. Why this “magic” works is because of your spinal reflexes. It’s important that you know how to support your spine. When you’re standing and when you’re sitting.

If you’ve learned how to hold your posture correctly in a motionless, static position, then you have done half the work. It’s no less important to maintain the natural spinal curvatures while you’re moving. What’s the point of being careful to watch your position while you’re sitting, only to injure your back while tying your shoes? This happens to people all the time. When we’re trying to lift something off the ground, pick up a child, or weed the garden. We bend over, the normal curvatures of our spine disappear and it curves like an arch instead. In addition to the bending, the weight that we now have in our hands, be it a 20 pound baby or a pen that was lying on the floor, creates a load on the spine, especially on the intervertebral discs, and it is multiplied by ten according to the trigger law. The discs cannot stand such load. So they break. Pressure in the discs in such a compromised position is high. The elastic disc core tears the fibrous ring and bulges out as a hernia of the intervertebral disc. To avoid this trauma to the disc you must learn not only how to sit and stand correctly, but also how to bend correctly.  Despite popular opinion, bending forward occurs because of movement in the hip joints. 

That’s why patients who have arthrosis of the hip joints can’t bend forward to cut their toenails. You have to bend forward with the help of your hip joints. Look how weight lifters do it. They move their buttocks backwards and hold their backs straight. They even put on a special belt to do this. Learning how to bend this way will help you avoid split discs and intervertebral hernias.

When people ask how much weight they can safely lift, I tell them it doesn’t really matter. It’s not important how much you lift. It is important how you lift. If you bend down to lift a sheet of paper and curve your back like an arch, your spine will suffer as much overload as if you lifted 100 pounds. So don’t count pounds, learn how to bend.

One of the most frequently used solutions for solving spinal problems is visiting a fitness club. A person who does this often thinks this way: “I will ‘beef up’ my back and abdominal muscles and then everything will be all right with my spine.” That’s why methods of treatment with the help of training equipment are so popular. But people who succeeded in “beefing up” still visit me complaining of back pain. Of course, if you sit in the office the whole day, then training like this can be helpful. But if you already have problems with your back, and if osteochondrosis has already started to affect your spine, then training with bars or with dumbbells will end up creating new problems for you.  There’s a reason that injuries sustained in a gym are a major cause of osteochondrosis of the spine. My patients often tell me that the first pain in their spine happened when, in their younger days, “something cracked in my back” while doing exercises or “while doing abdominal crunches, my back did not ache, but severe pain in my spine developed later in the evening.” Commercials for myostimulators are also popular. These are training devices that “strengthen muscles” and provide “healing” from hernias of intervertebral discs and osteochondrosis of a spine. So who or what can you believe?

So what should be done? I hope by now you are frightened enough to avoid such overloading movements and exercises. There is only one choice for the spine: to strain targeted muscles without movement. This is called an isometric variant of exercise. For example, you are hanging on a bar, raising your legs at an angle and holding this position for 10-30 seconds. Are your abdominal muscles strained? Yes! Are your back muscles working? Yes! But overload of the discs and joints is absent. In my books, “The Smart Neck”, “The Smart Loin” and “The Smart Back,” I describe in detail CORRECT EXERCISES that are done as ISOMETRIC POSITION-STATIC GYMNASTICS WHICH SAVES YOUR SPINE AND JOINTS. You are welcome to use them!

Your fitness plan must include cardio load! Just doing special exercises for the spine is not enough. Our intervertebral discs and joints are fed through a process called diffusion. This means they soak up nutrients from neighboring vertebrae through hyaline cartilage disc plates. This process is very slow.  If the general metabolism in your body is very slow (and of course it is, if you are sitting in an office or in a car the whole day) then the exchange in the discs falls below the allowable level. As a result, waste is not removed from the disc, and the disc cartilage doesn’t get enough nourishment. So it… “Disappears.” You might say: “the disc was killed.” Of course, disc cartilage does not actually get killed. Its cells die and new ones do not form. That’s why activity that increases your blood flow is necessary to keep the body’s metabolism quite high. Jogging, swimming, walking (especially Nordic walking with sticks), an exercise bicycle, a running track or an elliptical training device  are some alternatives that can increase your heart rate to not less than 120 times in a minute for 30 minutes, at least three times a week. 

So now you can understand how exercise can be either a friend or a foe for you. Everything depends on how you load your spine while you’re exercising. If you’re into sports at a gym and you do all the exercises in a position that’s neutral for your spine, you can enjoy it. You can have many years of pain-free health. But if you do exercises that overload your spine, then you’re taking a chance of injuring an intervertebral disc one day. And then you’ll have to give your gym subscription to a more experienced friend.

You already know from the previous chapters that osteochondrosis of the spine is not some special disease. It is a natural process that occurs with aging. When aging or degeneration occurs unnaturally or with complications it is called osteochondrosis. That’s why the older a person is the more likely he is to have osteochondrosis of the spine. It rarely happens, but I do have to sometimes operate on 14-year-old adolescents who have a hernia of an intervertebral disc.  The most probable cause of a herniated disc in these cases is domestic or sports overload or trauma. In the elderly, abnormal growth of tissues in the intervertebral joints develops because of arthrosis. As a result, the canal between these joints narrows and spinal stenosis develops. Bones also become more fragile with age because of osteoporosis. 

A hernia of an intervertebral disc can occur even without preceding osteochondrosis. The cause is often a sudden overload on an intervertebral disc following trauma. For example, if a traffic accident occurs, during emergency braking or a collision, the head and neck bend and unbend sharply and forcibly. This is a so-called “whiplash” injury. At this moment, not only a vertebra can break, but also an intervertebral disc can split. A post-traumatic hernia of the disc then appears. The same thing happens when a bar at a gym is lifted incorrectly. The disc tears and a hernia of the disc appears, like we mentioned earlier.  

Is osteochondrosis of the spine ever present at birth? Fortunately, no. But diseases and a predisposition for spinal problems can be inherited. Some examples of these are Schmorl's nodule, Scheuermann’s disease and scoliosis.

Your occupation has special meaning for your spine. Many of us spend a big part of our lives working. It’s no wonder that a whole field of medicine exists that is related to occupational health. For people who are employed as manual laborers, such as masons, construction workers, and in similar careers, osteochondrosis of the spine is an occupational disease. But secretaries and accountants suffer from this disease just as often. Sedentary work disrupts blood flow in the spine. As a result, someone who sits at a desk all day risks suffering the consequences of both cervical and lumbar osteochondrosis. And these conditions can occur within only five years of beginning a career that consists of mainly sedentary work.  

What about extreme sports? Skateboarders, roller skaters performing wild and crazy stunts and even reckless bicycle riders are at increased risk for spinal fractures and early development of osteochondrosis.

I can’t help mentioning excess weight. This too is a factor in spinal and leg joint overload. If you make yourself walk around for several hours with a 20 pound bag tied behind your back, your back will feel tired, and by evening, it will really ache. That’s why 40 to60 pounds of excess weight can wear out your spine within several years.

If you are a young woman and have osteochondrosis of the spine you will need to think about pregnancy and childbirth and the affect they will have on the disease. During pregnancy, the connective tissues and ligaments of a woman’s body soften. This phenomenon is necessary to let a child’s head pass through the pelvic ring. But neither pregnancy nor childbirth cause a hernia of an intervertebral disc. This means osteochondrosis itself cannot contraindicate pregnancy.  Another situation is when a woman had a hernia of an intervertebral disc in the past. In this case, she needs to be sure that a nerve root is not squeezed, and that it does not cause a pain syndrome. This is because the advancing pregnancy can create more compression on the nerve root and increased pain.  And there are limited ways to treat pain during pregnancy due to the potential effect of treatments on the fetus. That’s why you should know what condition your spine is in before pregnancy and consider preliminary treatment of any existing conditions.  

A young mother needs help, even if she has never had problems with her back.  Imagine how many times she has to bend over toward her infant. She probably doesn’t always do it in the right position for her spine. That’s why you need to help her if you can, especially during the first months after childbirth when her spine and cartilaginous tissue are returning to their normal state.

This question can be answered without hesitation! A giraffe! All children want to see this animal on a trip to the zoo and it has the longest cervical spine in the world. Its neck can reach 9 feet in length. A giraffe easily reaches leaves from the tree tops, but it has a hard time picking up something from the ground. It has to move legs apart to lower itself. So despite its length, a giraffe’s neck is not very flexible.

Our neck is also very mobile, even though it’s not so long. Many people think they can turn their head due to the cervical vertebrae, but this isn’t true. Basic movement of the head occurs in the joints of the first and second cervical vertebrae. The rest of the cervical vertebrae (there are a total of 7) contribute very little to neck mobility. There are many more problems with the neck than with any other spinal part. This happens because the spinal cord is inside of the spine. You can compare this to the Internet that connects us with each other. Due to our internal “Internet” (the spinal cord) our brain is connected with EVERY cell in our body.

That’s why, if our spinal cord is injured on the level of the cervical vertebrae, then movements and sensitivity in our arms and legs are disrupted. In medical terms, the condition is called “spondylogenic cervical myelopathy.” This means the cervical part of the spinal cord is destroyed because of a spinal condition. A patient with this diagnosis may have no sign of a disease for years. Later, numbness of the arms at night appears. They can become numb even during the day, during rest or during work. The ability to perform fine movements is lost: it becomes difficult to button up buttons, use scissors, and other detailed tasks. It is known that the spinal cord has no pain endings. So if a hernia of a cervical disc pushes on the spinal cord, there may be no pain for years. But several years after the beginning of pressure on the spinal cord, paralysis appears. The arms become thinner, weaker and useless.  Such a person’s hands resemble a monkey’s paw. Their palm is flat and there are no fatty pads on it. The skin can also change in appearance. It becomes thinner and older and the nails become deformed. At this stage of the disease, the legs are not usually affected very much. The patient might feel only mild stretching or spasms. Some patients notice more severe problems with their legs and think the disease is related to the legs muscles. Their gait is affected, the patient cannot run and eventually walks with difficulty. The reason for these changes lies in the destruction of the spinal cord.

 A hernia of a cervical intervertebral disc can squeeze a nerve root of the spinal cord. Pain then becomes severe. Patients usually complain of neck pain that can be felt in the arms. Numbness of the fingers or weakness of certain arm muscles (biceps or triceps) sometimes appear. It is usually easy for a doctor to see the hernia on an MRT of the cervical spine and diagnose the condition.

It often happens that a hernia of a cervical intervertebral disc is small and does not lead to any serious pinching or compression of the spinal cord or of a nerve root. But the patient complains that he suffers from unbearable pain in a shoulder or the shoulder-blade. He complains he cannot brush his hair, raise his arm or put it behind his back because of pain. The reason for these complaints lies in the injury of a cervical disc or discs. Every spinal disc is connected with a certain part of the body. That’s how every person was formed during prenatal development. If a certain disc is injured, then pain occurs in the part of the body connected with that particular disc. For example, lower cervical discs cause pain in the neck, shoulder-blades and shoulder joints. Upper cervical discs are connected with pain in the nape or the upper part of the neck.

Another extremely important part of the cervical spine is the vertebral artery. It is called this because it is located in the vertebral column. The spine has a special bone “tunnel” containing two spinal arteries. One is on the left side and one is on the right. These blood vessels carry nourishing blood not only to the spine, but also to the spinal cord and, to what is of crucial importance, the section of the brain in which the centers of equilibrium, hearing and sight are located. That’s why not only headache, but also dizziness, noise in the ears, weakness, instability or even fear of death appear when there are disturbances in blood circulation.

 Blood pressure can also be very unstable. It can increase sharply or decrease below normal limits. The combination of these symptoms is called vertebro-basilar insufficiency or vertebral artery syndrome. Most often this condition is called cervical osteochondrosis. A small split in a cervical intervertebral disc is usually enough for neck pain to appear and a vertebral artery to spasm, or become more narrow at the same time. Blood flow is diminished, and all the symptoms that were just described develop. If this situation repeats itself frequently, over the course of several years the nerve cells in the brain are affected. A hernia of a cervical disc can disappear or become numb, but if nerve cells are destroyed, noise in the ears or dizziness becomes your constant companion.

I’m sure you can understand that the problems of cervical osteochondrosis are very serious. A small hernia of a cervical intervertebral disc can cause big problems with the arms, legs, and even the brain. That’s why you have to be especially attentive to treating and healing this part of the spine and not neglect it. The special methods and treatments for healing the cervical spine will be discussed in the next chapter.

This story isn’t true, but there is a little truth in it if you look closely.  Not only a turnip can be pulled, a neck can be pulled as well. This method is used for manual and osteopathic treatment quite frequently. The practice of stretching the spine was used in ancient times. We have engravings of images of ancient devices that were used for pulling the spines of sufferers. Nowadays various collars and belts for stretching spines are sold. Stretching the spine is usually explained as being therapeutic due to the fact that intervertebral discs are flexible and if you stretch them, a hernia of the disc will “draw back in to place.” Unfortunately, this does not happen in reality.  I always tell my patients that the spine is not a rubber toy. Spinal diseases, osteochondrosis in particular, develop over years. Changing of both the disc and a hernia happens during this time. The body very often tries to hide a hernia in order to keep it from growing and getting worse. That’s why calcium deposits appear in the area of the hernia. The shell gradually hardens and the hernia turns into a bone spur or osteophyte. Ligaments of the diseased spine thicken as well; their flexibility and stretchability decreases. As a result of these changes, the spine becomes more rigid.  That’s why, if a spine like this is stretched, the disease becomes even worse. Pain increases and the treatment only makes things worse.  I tell my patients, especially if they’re elderly, they must be very careful with stretching their spine.

An effective method of treating the spine is vertebral diaplasis. Manual practitioners usually do this. Their actions actually resemble magic tricks sometimes! They can resolve a spasm or eliminate pain with only one sharp and sudden move of the patient’s head. Not everyone experiences these positive results. Unfortunately, not enough training or experience on the part of the practitioner can lead to tragedy. Unskilled manual manipulations of the spine can “twist” a neck in such a way that a small hernia can become a big one. That’s why you can only trust your spine to an experienced specialist. Never think that any masseur can “set” your spine. Moreover, the word “to set” has figurative meaning here. In reality, short and sharp intervertebral joint movement that exceeds the usual range of movement causes reflectory muscle inhibition. The muscle spasm and pain go away. But the point at which a movement should be stopped is very indefinite, and an osteopath must have intuition and a great deal of experience so as not to do additional harm. You have to consider all the pros and cons before you start this kind of treatment. It may be safer for you to have ten sessions of basic massage. You will get the same effect of muscle relaxation without any risk, especially if you have a diagnosis of a hernia of a cervical intervertebral disc.  

Along with some other traditional methods of conservative treatment of osteochondrosis (massage, physiotherapy, acupuncture and others) a Schanz collar can be used for relieving neck pain. It is usually made of firm foam rubber with a soft cover. It fits around the neck and limits head movements to some extent. I instruct patients to wear it constantly every day for several days up to one week, only in cases of acute pain. In other cases it is useless.  It makes no sense to wear this collar only two hours a day for “prophylaxis” or to prevent pain. 

You already know that when there are problems with the cervical vertebrae and discs, blood flow in the vertebral arteries and the brain is disrupted. That’s why treatment of these patients must include vascular medications that improve blood flow.

The choice of gymnastics for the cervical spine is also important. This is not an easy matter. Imagine that your head weighs 10 pounds and that it places a constant load on the cervical discs and joints. If you decided to “pump up” your neck muscles by attaching a dumbbell to your head it would be the worst decision of your life! Within several months, your cervical discs and joints would be dozens of years older. Yet most of us whose job involves continuous sitting at a desk working on a computer suffer from spasms of the neck muscles and vessels. Every bookkeeper or system administrator is familiar with pain in the back of the neck. So neck exercises must be part of your exercise routine and you must do them every day. Isometric gymnastics is the most appropriate way to exercise the cervical vertebrae and the whole spine. Other names for these exercises are static, positional and postural. All these names describe the principle of this training very precisely. It is straining of muscles without any movement.

 I’ll show you one exercise so you can see an example of how these gymnastics should be done. The name of this exercise is “Bending the head forward.”  This is an exercise for strengthening the muscles that help you bow your head. First, put one hand on your forehead and resist bowing. Staying in this pose, hold your neck muscles strained. The muscles and ligaments on the front of your neck surface are working and training. Hold this tension for 10-30 seconds. After this, you will stretch the muscles that have just worked. Remember, they are your front neck muscles. To do this, tilt back your head and neck carefully and smoothly with the hand that is on your forehead. This way you are stretching the front neck muscles. Stretching lasts for 5-10 seconds. All the movements must be done smoothly and carefully. This principle of training can be applied to any movement and to any muscle group. In my books “The Smart Neck,” “The Smart Back” and “The Smart Loin,” all the exercises of isometric static gymnastics are fully described. The essential exercises for each part of the spine are described in these books. Detailed pictures will help you learn these exercises and an electronic format lets you download these books to any device, smart phone, tablet or electronic book, so you can always have these books with you. I consider isometric gymnastics SAVING. They will save your intervertebral discs and joints, train your spinal muscles and ligaments, improve blood flow, and “clarify” your thoughts. Those who do these exercises daily not only feel better, but also have excellent working abilities.

When talking about surgical treatment of cervical spine degenerative conditions and osteochondrosis, remember non-traumatic, minimally invasive methods of treatment like laser disc reconstruction. A surgeon can irradiate a diseased cervical disc with an infrared laser beam under local anesthesia and with only one puncture with a thin needle. This precise treatment influences the nourishment of the disc cartilage and stimulates growth of new cartilaginous cells where the disc is split. 

If a hernia of a cervical disc is so big that it causes compression on the spinal cord or nerve roots, it will be impossible to avoid surgery. It is important to know that the spinal cord is one organ of the body which has practically no “extra” cells. For example, there are so many nerve cells in our brain that if we lost one million of them, we wouldn’t notice or feel it because we have several dozens of billions more.   It’s just the opposite when it comes to the spinal cord. Every neuron and every nerve cell works exactly in its own special place and nothing can replace it. The thickness of the spinal cord is comparable to an adult person’s finger. So if the spinal cord is squeezed by a hernia and blood flow to a certain area of the spinal cord is disrupted, then the nerve cells at that spot will die. This process is called apoptosis or programmable cellular death. In addition, these changes set off a chain reaction. Death of one cell causes the death of two neighboring cells, and the process continues in a geometric progression. Destruction of spinal cord cells is called myelopathy. That’s why if a patient suffering from a hernia of a cervical intervertebral disc that squeezes the spinal cord comes to me with an acute form of myelopathy, when the movements of the legs and arms are already affected, as a rule, the chance for a successful surgery has already passed. If a patient comes to me in the initial stage of the disease, improvement is possible not more than one-half of the time. The purpose of surgery in these cases is not recovery, but to at least try to stop the progression of the disease and the destruction of the spinal cord.  In the late stage of the disease, the possibility of post-surgical neurologic complications becomes higher, so surgeons often refuse to perform these operations.  

To remove a hernia of a cervical disc, front surgical access is usually used. When the carotid artery is felt under the front surface of the neck, the surgeon knows the spine lies a bit deeper. Despite the complexity of surgery on the cervical vertebrae, the approach to the cervical spine is not traumatic. A small cosmetic incision is made along the front surface, and at the completion of the operation, an internal glue stitch forms a very thin surgical scar. There is no need to remove stitches; the surgical glue comes off the skin by itself about two weeks after surgery. The incision is already invisible in just a few months. During the removal of a hernia of a cervical disc, the disc is usually totally removed and replaced by a prosthesis at the end of the operation. The prosthesis can be an immovable cage that resembles the disc in form and size. The cage is filled with bone and causes the fusion of neighboring vertebrae. Movable prostheses for cervical intervertebral discs also exist that preserve movement in the operated segment of the spine. The choice of the kind of implant depends on the surgeon’s or patient’s preferences. An implant replaces the disc and prevents the disease from happening again. After the operation patients forget they have ever been bothered by pain in their neck, shoulder or arm. Headaches and other symptoms connected with the interruption of blood flow in the vertebral artery are eliminated.

The most important factor to ensure a successful operation is to not miss the optimal time for surgical intervention and to not neglect the disease. 

As a wise man said: “You can buy a house, but not a home; you can buy a bed, but not sleep; you can pay for a doctor, but not for health.” Osteochondrosis is not just a simple disease. Once it appears, it stays with you for life. It would be so nice to visit a shop of health and happiness; to walk in, choose a healthy intervertebral disc, replace several vertebrae with new ones, and walk away with a healthy back. Unfortunately, such shops do not exist. We can buy a new ointments and drugs, but to enjoy good health we have to EARN it. It’s not enough to inherit good genes from your parents. You have to PRESERVE and build on what you’re born with by working at it EVERYDAY.

 Osteochondrosis is a demanding lord that requires a HEALTHY DIET EVERYDAY for keeping your body weight optimal.  Osteochondrosis of the spine calls for DAILY EXERCISES that maintain spinal MUSCLES AND LIGAMENTS, or the spine will get old too early. If symptoms occur, osteochondrosis demands WELL-TIMED COMPETENT EXAMINATION AND SCIENTIFICLY GROUNDED TREATMENT. Only under such conditions can you make friends with your osteochondrosis and love it.

I HOPE YOU WILL LOVE YOUR OSTEOCHONDROSIS AND EACH OF YOUR 33 VERTEBRAE!

BE HEALTHY!