Low Back Pain
What is low back pain, and what causes it?
The lower back is an elegant construction of bone, muscle, and ligament. Because the lower back is the hinge between the upper and lower body, it is especially vulnerable to injury when you are lifting, reaching, or twisting. When low back pain strikes, we become acutely aware of just how much we rely on a flexible, strong back. Ironically, most of us don't think of the importance of keeping our back and stomach muscles strong until we have back trouble.
Up to 85% of all people have low back pain at one time or another. Each year, about 2% of American workers are compensated for disability caused by back pain. Low back pain is often triggered by some combination of overuse, muscle strain, or injury to the muscles and ligaments that support the spine. Less commonly, low back pain is caused by illness or spinal deformity.
Back pain can be:
- Acute, lasting less than 3 months. Most people gain relief after 4 to 6 weeks of home treatment.
- Recurrent, a repeat episode of acute symptoms. Most people have at least one episode of recurrent low back pain.
- Chronic, lasting longer than 3 months.
Neck Pain (including whiplash)
What is neck pain?
Neck pain is pain that occurs anywhere from the bottom of your head to the top of your shoulders. It may spread to the upper back or arms and may cause limited neck and head movement.
Neck pain is a common problem, especially in older adults. About 50% of people older than 50 have neck pain at some time.
What causes neck pain?
Most neck pain is caused by activities that result in repeated or prolonged movements of the neck's muscles, ligaments, tendons, bones, or joints. This can result in a strain (an overstretched or overused muscle), sprain (injury to a ligament), spasm of the neck muscles, or inflammation of the neck joints. For example, painting a ceiling, sleeping with your neck twisted, slouching, or staying in one position for a long period of time can all cause neck pain.
Less frequently, neck pain is caused by injury, such as whiplash that occurs in a motor vehicle accident or a fall from a ladder, or by another medical condition, such as infection in the neck area, a narrowing of the spinal canal in the neck (cervical spinal stenosis), or rheumatoid arthritis.
understanding How Hips Work
A joint is formed by the ends of 2 or more bones that are connected by thick bands of tissue called ligaments. The hip -- which, like the knee joint, must bear the full force of your weight -- consists of two main parts:
- A ball (femoral head) at the top of your thigh bone (femur).
- A rounded socket (acetabulum) in your pelvis.
What Causes Hip Joint Pain?
One of the most common causes of joint pain is arthritis. The most common types of arthritis are:
- Osteoarthritis (OA) - sometimes called degenerative arthritis because it is a "wearing out" condition involving the breakdown of cartilage in the joints. When cartilage wears away, the bones rub against each other, causing pain and stiffness. OA usually occurs in people aged 50 years and older, and frequently in individuals with a family history of osteoarthritis.
- Rheumatoid Arthritis (RA) - produces chemical changes in the joint space that cause it to become thickened and inflamed. In turn, the synovial fluid destroys cartilage. The end result is cartilage loss, pain, and stiffness. RA affects women about 3 times more often than men, and may affect other organs of the body.
- Post-traumatic Arthritis - may develop after an injury to the joint in which the bone and cartilage do not heal properly. The joint is no longer smooth, and these irregularities lead to more wear on the joint surfaces.
- Other causes of joint pain include avascular necrosis, which can result when bone is deprived of its normal blood supply (for example, after organ transplantation or long-term cortisone treatment), and deformity or direct injury to the joint. In some cases, joint pain is made worse by the fact that a person will avoid using a painful joint, weakening the muscles and making the joint even more difficult to move.
What's a herniated disc?
There are many different terms used to describe spinal disc pathology and associated pain, such as “herniated disc”, “pinched nerve”, and “bulging disc”, and all are used differently by individual healthcare practitioners. Unfortunately, there is no agreement in the healthcare field as to the precise definition of any of these terms. Often the patient hears his or her diagnosis referred to in different terms by different practitioners and is left wondering if there is any consensus on what is wrong.
Some examples of terms used to describe spinal disc abnormalities include:
- Pinched nerve
- Herniated disc (or herniated disk)
- Bulging disc
- Ruptured disc
- Torn disc (or disc tear)
- Slipped disc
- Collapsed disc
- Disc protrusion
- Disc degeneration
- Degenerative disc disease
- Disc disease
- Black disc
Practical point Individuals’ symptoms of disc degeneration, and their relief from treatments, can vary tremendously, so patients should provide as complete and accurate account of their symptoms as possible to their practitioner so treatment can be customized for them. Rather than try to reconcile the terminology used to refer to spinal anatomy or conditions, it's generally more useful for patients to gain a clear understanding of the precise medical diagnosis, which identifies the actual source of the patient’s low back pain, leg pain, or other symptoms.
What is spinal stenosis?
The vertebral column in the spine and sacrum (at the bottom of the spine) is like a stack of blocks that serve to support the structures of the body. Each of these bony structures has additional bony attachments that serve to help stabilize the spine and to protect the spinal cord or nerves passing downward from the brain to organs, muscles and sensory structures of the body. Each vertebral body and its attachments and the disc between the adjacent vertebrae are known as a spinal segment. The entire length of the spinal column has a large central canal or passage through which the spinal cord descends, and holes to each side of the canal to allow emergence of spinal nerves at each level. The spinal cord stops at the upper part of the low back, and below that the tiny contained nerve rootlets descend loosely splayed out - like a horse’s tail – and are protectively enclosed in a long sack. All central nerve structures are protected further by membranes, with a tough outer membrane called the dura (tough) mater (mother).
Major types of stenosis include:
- Foraminal stenosis. As the nerve root is about to leave the canal through a side hole (lateral foramen), a bone spur (osteophyte) that has already developed from a degenerating disc can press on that nerve root. This type of stenosis is also called lateral spinal stenosis. This is by far the most common form of spinal stenosis. 72% of cases of foraminal stenosis occur at the lowest lumbar level, trapping the emerging nerve root (which comprises a major part of the sciatic nerve).
- Central stenosis. A choking of the central canal, called central spinal stenosis in the lumbar (low back) area can compress the sack containing the horse’s tail (cauda equina, or cauda equine) bundle of loose nerve filaments. Central spinal stenosis is more common at the second from the lowest lumbar spinal level and higher and is largely caused by a bulging of the disc margin plus a major overgrowth or redundancy of a ligament (ligamentum flavum) which is there to help protect the dura. This overgrowth is caused by segmental instability usually from a degenerating disc between adjacent vertebrae. The ligament arises from under the flat laminas of the vertebrae and the inside part of the facet joints (stabilizing joints located on each side at the back of the spine segments).
- Far lateral stenosis. After the nerve has left the spinal canal it can also be compressed beyond the foramen byeither a bony spur protrusion or a bulging or herniated disc. When this happens, it is called far lateral stenosis.
These differences in anatomy may result in similar symptoms, which is why all forms of stenosis are typically referred to as simply ‘spinal stenosis’. However, if surgery is to be performed, the differences are very important in guiding the surgeon. That is, the bad spot(s) must be exactly known in advance to guide the approach for its proper treatment or removal.
Peripheral Nerve Pain
What is Peripheral Neuropathy?
The name of the condition tells you a bit about what it is:
- Peripheral: Beyond (in this case, beyond the brain and the spinal cord.)
- Neuro-: Related to the nerves
- -pathy: Disease
Put these concepts together and you'll find peripheral neuropathy refers to the variety of conditions that result when the nerves from the rest of the body that connect to the brain and spinal cord are damaged or diseased.
The peripheral nerves make up an intricate network that connects the brain and spinal cord to the muscles, skin and internal organs. Peripheral nerves come out of the spinal cord and are arranged along lines in the body called dermatomes. Typically, damage to a nerve will affect one or more dermatomes, which can be tracked to specific areas of the body. Damage to these nerves interrupts communication between the brain and other parts of the body and can impair muscle movement, prevent normal sensation in the extremities, and cause pain.
What is sciatica?
Sciatica is pain, tingling, or numbness produced by an irritation of the sciatic nerve. The sciatic nerve is formed by the nerve roots coming out of the spinal cord into the lower back. Branches of the sciatic nerve extend through the buttocks and down the back of each leg to the ankle and foot.
What causes sciatica?
The most common cause of sciatica is a bulging or ruptured disc (herniated disc) in the spine pressing against the sciatic nerve. However, sciatica also can be a symptom of other conditions that affect the spine, such as narrowing of the spinal canal (spinal stenosis), bone spurs (small, bony growths that form along joints) caused by arthritis, or nerve root compression (pinched nerve) caused by injury. In rare cases, sciatica can also be caused by conditions that do not involve the spine, such as tumors or pregnancy.
An estimated 45 million Americans experience chronic headaches. For at least half of these people, the problem is severe and sometimes disabling. It can also be costly: headache sufferers make over 8 million visits a year to doctor's offices. Migraine victims alone lose over 157 million workdays because of headache pain.
What hurts when you have a headache?
Several areas of the head can hurt, including a network of nerves which extends over the scalp and certain nerves in the face, mouth, and throat. Also sensitive to pain, because they contain delicate nerve fibers, are the muscles of the head and blood vessels found along the surface and at the base of the brain.
Myofascial Pain Syndrome
What is Myofascial Pain Syndrome?
Myofascial pain is a chronic condition that affects the fascia (connective tissue that covers the muscles). Myofascial pain syndrome may involve either a single muscle or a muscle group. In some cases, the area where a person experiences the pain may not be where the myofascial pain generator is located. Experts believe that the actual site of the injury or the strain prompts the development of a trigger point that, in turn, causes pain in other areas. This situation is known as referred pain.
What Causes Myofascial Pain?
Myofascial pain may develop from a muscle injury or from excessive strain on a particular muscle or muscle group, ligament or tendon. Other causes include:
- Injury to intervertebral disc
- General fatigue
- Repetetive motions
- Medical conditions (including heart attack, stomach irritation)
- Lack of activity (such as a broken arm in a sling)
Complex Regional Pain Syndrome/RSD
Complex regional pain syndrome (CRPS), also called reflex sympathetic dystrophy syndrome, is a chronic pain condition in which high levels of nerve impulses are sent to an affected site. Experts believe that CRPS occurs as a result of dysfunction in the central or peripheral nervous systems.
CRPS is most common in people aged 20-35. The syndrome also can occur in children; it affects women more often than men.
What Causes Complex Regional Pain Syndrome?
CRPS most likely does not have a single cause but rather results from multiple causes that produce similar symptoms. Some theories suggest that pain receptors in the affected part of the body become responsive to catecholamines, a group of nervous system messengers. In cases of injury-related CRPS, the syndrome may be caused by a triggering of the immune response which may lead to the inflammatory symptoms of redness, warmth, and swelling in the affected area. For this reason, it is believed that CRPS may represent a disruption of the healing process.
Degenerative Disc Disease/Discongenic Pain
What is degenerative disc disease?
Degenerative disc disease is not really a disease but a term used to describe the normal changes in your spinal discs as you age. Spinal discs are soft, compressible discs that separate the interlocking bones (vertebrae) that make up the spine. The discs act as shock absorbers for the spine, allowing it to flex, bend, and twist. Degenerative disc disease can take place throughout the spine; however, it most often occurs in the discs in the lower back (lumbar region) and the lower part of the neck (cervical region).
The changes in the discs can result in back or neck pain, as well as:
- Osteoarthritis, the breakdown of the tissue (cartilage) that protects and cushions joints.
- Herniated disc, an abnormal bulge or breaking open of a spinal disc.
- Spinal stenosis, the narrowing of the spinal canal, the open space in the spine that holds the spinal cord.
Although pelvic pain often refers to pain in the region of women's internal reproductive organs, pelvic pain can be present in either sex and can stem from multiple causes. Pelvic pain may be a symptom of infection or may arise from pain in the pelvic bone or in non-reproductive internal organs. In women, however, pelvic pain can very well be an indication that there may be a problem with one of the reproductive organs in the pelvic area (uterus, ovaries, fallopian tubes, cervix, or vagina).
What Causes Pelvic Pain?
Possible causes of pelvic pain in both men and women may include:
- Bladder disorders
- Sexually transmitted diseases
- Kidney infection or kidney stones
- Intestinal disorders
- Nerve conditions
- Pelvis disorder
- Broken pelvis
- Psychogenic pain
Possible causes of pelvic pain in women may include:
- Ectopic pregnancy
- Pelvic inflammatory disease
- Menstrual cramps
- Ovarian cysts or other ovarian disorders
- Uterine cancer
- Cervical cancer
What is osteoarthritis?
Arthritis is a general term that describes many different diseases causing tenderness, pain, swelling, and stiffness of joints as well as abnormalities of various soft tissues of the body. Of the combined term, "arthros" means a joint and its attachments, and "-itis" means inflammation. Various forms of arthritis affect nearly 50 million Americans and contribute to the majority of all physical disabilities. Although arthritis is ultimately associated with a wearing out of joints, nearly a half million children are also affected.
Of the several varieties of arthritis, the most common, the most frequently disabling, and often the most painful is osteo- (meaning bone) arthritis, mostly affecting the weight bearing joints (hips and knees) plus the hands, feet and spine. Normal joints are hinges at the ends of bones usually covered by cartilage and lubricated inside a closed sack by synovial fluid. Normally, joints have remarkably little friction and move easily. With degeneration of the joint, the cartilage becomes rough and worn out, causing the joint halves to rub against each other, creating inflammation with pain and the formation of bone spurs. The fluid lubricant may become thin and the joint lining swollen and inflamed.
Osteoarthritis is also known as degenerative joint disease and affects up to 30 million Americans, mostly women and usually those over 45 or 50 years of age. All races in the U.S. appear to be equally affected. This article focuses on osteoarthritis of the spine, particularly on facet joint arthritis.
Where does osteoarthritis occurs?
Cartilage is a form of usually slick, slightly elastic, connective tissue that covers the ends of the bone joints. In part, cartilage serves as a protective shock absorber to minimize the impact of bouncing, jumping and other types of daily activities on the joints - and is thus subjected to considerable wear and tear during life. Indeed, heavy work, sports, repeated injuries and obesity take a heavy toll on the joints of the limbs and spine. To be healthy, all joints should be exercised, but if this is excessive, joint damage may accumulate slowly. In addition to the hips, knees and lower back, arthritis commonly occurs in the neck, small finger joints, the base of the thumb, and the big toe. In the fingers, nodes (masses of bone and cartilage) can form on either side of the nail bed or the margins of joints to become reddened, tender and swollen. Cartilage breakdown in the hips and knees can be severe enough to require joint replacement. Osteoarthritis found in other joints, such as the hinge of the jaw, is often due to injury or stress.
Osteoarthritis of the spine
Spinal arthritis is one of the common causes of back pain. Spinal arthritis is the mechanical breakdown of the cartilage between the aligning facet joints in the back portion (posterior) of the spine that quite often leads to mechanically induced pain. The facet joints (also called vertebral joints or zygophyseal joints) become inflamed and progressive joint degeneration creates more frictional pain. Back motion and flexibility decrease in proportion to the progression of back pain induced while standing, sitting and even walking. Over time, bone spurs (small irregular growths on the bone also called osteophytes) typically form on the facet joints and even around the spinal vertebrae. These bone spurs are a response to joint instability and are nature's attempt to help return stability to the joint. The enlargement of the normal bony structure indicates degeneration of the spine. Bone spurs are also seen as a normal part of aging and do not directly cause pain, but may become so large as to cause irritation or entrapment of nerves passing through spinal structures, and may result in diminished room for the nerves to pass (spinal stenosis).
Osteoarthritis in the spine is anatomically divided into:
- Lower back (lumbar spine) osteoarthritis, sometimes called lumbosacral arthritis, which produces stiffness and pain in the lower spine and sacroiliac joint (between the spine and pelvis).
- Neck (cervical spine) osteoarthritis, sometimes called cervical spondylosis (spondy- implies the spine, and -osis is an abnormal condition), which can cause stiffness and pain in the upper spine, neck, shoulders, arms and head.
What causes of osteoarthritis and spinal arthritis?
There are a number of reasons why some people are particularly disposed to osteoarthritis. However, as with nearly all abnormal conditions affecting the body, it is likely that a combination of risk factors work together to cause osteoarthritis. As indicated above, repetitive trauma to the spine from repetitive strains caused by accidents, surgery, sports injuries, poor posture, or work-related activities are common causes of spinal arthritis. Therefore, athletes and people with jobs that require repetitive, and particularly heavy, motion have been found to be at greater risk. Other known risk factors for developing spinal arthritis include:
- Aging: steady and advanced aging of spinal structures, beginning in the 30's, often work-related
- Gender: osteoarthritis being more common in post-menopausal women (although below age 45, it is more common in males)
- Excess weight: causing more stress on weight-bearing joints and the spine, particularly during the middle age years
- Genetics: having a family history of osteoarthritis or congenital defects of joints, spine, or leg abnormalities
- Associated diseases: the presence of other associated diseases, infections, diabetes, and various other forms of circulating arthritis, such as rheumatoid arthritis or gout
When a specific cause of the osteoarthritis is unknown, as it is in most cases, it is referred to as primary osteoarthritis, which appears to be mostly due to aging. Aging leads to changes in cartilage and synovial fluid - the tissue water content increases as the protein content decreases. Long term repetitive joint use has been shown to lead to joint inflammation with associated joint pain and swelling, eventually leading to the loss of cartilage.
When the cause of the osteoarthritis is known, it is referred to as secondary osteoarthritis, caused by a particular disease or condition, such as obesity, trauma or surgery to the joints, or abnormal joints at birth.
Patients with osteoarthritis who take an active role in their own treatment can prevent additional joint damage and usually will be able to continue with most of their normal activities. The key to managing the condition is to get an accurate diagnosis and start early, proactive treatment. Most osteoarthritis treatments are focused on reducing the pain and inflammation associated with osteoarthritis and maintaining the joint mobility and flexibility needed to continue with necessary and desired activities. It is clear that a combination of proper exercise, joint mobility, weight control, nutrition and use of appropriate medication is required to control osteoarthritis.
What is Osteoporosis?
First the good news-osteoporosis is a condition that is both preventable and treatable if caught in time. However, the bad news is that there is not enough awareness of the opportunities for prevention and treatment of osteoporosis, and too many people-mostly women over the age of 50-suffer significant illness, deformity and sometimes death from this condition.
Osteoporosis itself does not cause back pain. However, osteoporosis can weaken the vertebral body (spine) so that it can no longer withstand normal stress or a minor trauma (e.g. a fall), resulting in a fracture. In fact, a fracture is typically the first outward sign of the disease, and advanced osteoporosis is potentially very painful and disabling.
It is a fairly well known fact that osteoporosis is one of the most common conditions in the US. Approximately 8 million women and 2 million men suffer from this syndrome. Another 34 million have low bone mass and are thus at increased risk for osteoporosis. Some key statistics includes:
- Approximately 1.5 million people suffer from an osteoporotic (caused by osteoporosis) fracture each year. An estimated 700,000 of them experience vertebral compression fractures (spinal fractures).
- From age 50 on, one in every two women and one in four men will sustain some type of osteoporosis-related fracture.
- An average of 24% of hip fracture patients aged 50 and over die in the year following their fracture.
Coccydynia is a medical condition characterized by pain in the coccyx or tailbone area. Coccydynia is often reported following a fall or after childbirth. Since sitting on the affected area may aggravate the condition, proper padding (or a donut cushion) is recommended. For prolonged cases, anti-inflammatory or pain-relieving drugs may be prescribed, and local nerve blocks are often beneficial. In rare cases, surgery to the coccyx may be required.
Cancer and Post-Radiation Pain
The majority of people with cancer will experience pain at some time or another. The pain can result from the cancer itself, or from the cancer's treatment. In addition, some people who have been cured of their cancer can continue to suffer from pain.
Cancer pain, or the discomfort that stems from cancer and its treatment, can be controlled most of the time. There are many different medicines and methods available to control cancer pain. People who have cancer and are feeling pain need to inform their doctor immediately. The earlier pain treatment is started, the more effective it is.
What Causes Cancer Pain?
There are many causes of cancer pain, but most cancer pain occurs when a tumor presses on nerves or body organs or when cancer cells invade bones or body organs. Cancer treatments such as chemotherapy, radiation, or surgery also may cause pain.
Tietze syndrome, also known as costochondral junction syndrome, is a rare, inflammatory disorder characterized by chest pain and swelling of the cartilage of one or more of the upper ribs (costochondral junction). Onset of pain may be gradual or sudden and may spread to affect the arms and/or shoulders. Tietze syndrome is considered a benign syndrome and, in some cases, may resolve itself without treatment. The exact cause of Tietze syndrome is not known.
Temporomandibular disorders (TMD) occur as a result of problems with the jaw, jaw joint and surrounding facial muscles that control chewing and moving the jaw.
The temporomandibular joint (TMJ) is the hinge joint that connects the lower jaw (mandible) to the temporal bone of the skull. This joint is immediately in front of the ear on each side of your head. The joints are flexible, allowing the jaw to move smoothly up and down and side to side and enabling you to talk, chew, and yawn. Muscles attached to and surrounding the jaw joint control its position and movement.
What Causes TMD?
The cause of TMD is not clear, but dentists believe that symptoms arise from problems with the muscles of the jaw or with the parts of the joint itself.
Injury to the jaw, temporomandibular joint, or muscles of the head and neck such as from a heavy blow or whiplash can cause TMD. Other possible causes include:
- Grinding or clenching the teeth, which puts a lot of pressure on the TMJ
- Dislocation of the soft cushion or disc between the ball and socket
- Presence of osteoarthritis or rheumatoid arthritis in the TMJ
- Stress, which can cause a person to tighten facial and jaw muscles or clench the teeth
Spine and Spinal Cord
- Epidural Steroid Injection (ESI) – cervical, thoracic, lumbar
- Discography – cervical, thoracic, lumbar
- Radiofrequency Lesioning (Rhizotomy) – cervical, thoracic, lumbar
- Myelography Injection/Epidurography Injection
- Trigger Point Injections
- Sacroiliac Joint Injection
- Injections – small joint, intermediate joint, major joint, hip, knee, shoulder
- Epidural Venogram
- Injection Tendon Sheath, Ligament Ganglion Cyst
- Selective Nerve Root Block
- Greater Occipital
- Cervical Plexus
- Other Peripheral Nerves
- Facet Block – cervical, thoracic, lumbar
- Transforaminal – cervical, thoracic, lumbar
- Stellate Ganglion (Cervical Sympathetic)
- Thoracic (Paravertebral Sympathetic)
- Lumbar (Paravertebral Sympathetic)
- Celiac Plexus
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