SLIPPED DISK - HERNIATED DISK:

GENERAL INFORMATION

SYMPTOMS

Intravertebral disks are located between the bones (vertebrae) of the spine.
The disks are composed of solid, elastic tissue, held in place by fibrous
rings, and serve to absorb shocks upon the spine. Weakening of a ring may
permit the disk to move out of position (usually backward). The resulting
condition is called a slipped, ruptured or herniated disk.

Herniated disks occur most frequently among active adults between the ages of
thirty and sixty, and are most often located in the lumbar region between
the fifth lumbar vertebra and sacrum, and between the fourth and fifth or
the third and fourth vertebrae.

The resulting pain in the leg, caused by pressure upon the sciatic nerve, is
called sciatica. Among the symptoms of herniation:

   1. Pain in the lower back. Pain along the sciatic nerve (buttock, thigh
      and leg). The pain is generally unilateral, along one side of the hip
      and leg. There may be similar pain (crossover pain) upon bending or
      raising the opposite leg.
   2. Increasing pain upon lifting, bending forward with the knees straight,
      or lifting the straight leg on the injured side .
   3. In cases of severe herniation, possibly numbness and impaired
      sensation, loss of reflexes, or slight weakness of the foot and leg.
   4. In cases of herniated disks of the neck: Severe neck pain, pain in
      the shoulder and arm, and numbness and weakness of one or both hands.
      This condition must be distinguished from spur formation on the
      cervical vertebrae (cervical spondylosis) and from so-called bursitis
      and arthritis of the shoulder joint.

CAUSES

Natural erosion of supporting tissues with the passage of years, complicated
by injury or strain, may cause a disk to rupture its encircling ring, usually
protruding in a backward direction since this is the direction in which the
fibrous rim is at its weakest.

SPECIAL DANGERS AND PRECAUTIONS

Back pain together with radiation of pain down the leg may be caused by
conditions other than herniation of an intravertebral disk. It should be
brought to the attention of a physician.

TREATMENT

The majority of patients with a protruding disk recover without treatment.
Many recover after a prolonged period of bed rest. Acute pain may be treated
with:

   1. Aspirin, codeine or other analgesic drug.
   2. Muscle relaxants.
   3. Bed rest on a firm mattress.

After the pain has lessened or disappeared, the wearing of a back brace may
also be helpful. Traction may be used, but probably does no more than to
restrict the patient's activity. If it is successful, the patient remains in
traction for approximately 8-10 days.

Full recovery may take as long as several weeks to several months. And in
approximately 10-20 percent of severe cases, the conservative treatment will
prove unsuccessful. Repeated acute attacks of pain, unrelieved by measures
such as bed rest, stretch exercises or muscle relaxant medication may then
be treated by surgical removal of the herniated disk.

There is generally little risk in delaying surgery. Prompt surgery becomes
mandatory, however, in cases of progressive weakness of the muscles of the
foot or ankle (dropped foot), as well as in the extremely rare cases in
which signs appear of impairment of bladder or sphincter control. At its
best, surgery will relieve the sciatica. Such relief will occur in 80-90
percent of cases. In many cases with predominantly lower back, buttock and
thigh pain, however, surgery is not always successful.

SLIPPED DISK - HERNIATED DISK

SURGERY

PRE-OPERATIVE INFORMATION

A definitive diagnosis must be reached before surgery is attempted. Two
tests, both performed in a hospital, can serve this purpose:

   1. Myelogram: An opaque substance is injected into the spinal canal and
      viewed by means of x-rays. This permits visualization of the interior
      of the spinal column.
   2. CAT Scan: These are employed to an increasing degree in the diagnosis
      of disk protrusions, and may eventually replace myelography.

OPERATION

Surgery is usually performed under general anesthesia, and requires one to
three hours to perform. It is usually performed either by a neurosurgeon or
an orthopedic surgeon, or by the two acting as a team. The removal of a disk
is usually possible without the removal of any portion of the vertebrae, the
bones of the spinal column.

In some cases, however, portions of bone must be removed to give adequate
access to the disk (laminectomy). This procedure may entail the risk of some
spinal instability following the operation, in which case spinal fusion may
be performed to assure that spinal strength and stability are maintained.
Such fusion will generally not result in noticeable restriction of back
motion.

POST-OPERATIVE INFORMATION

The patient may usually leave his bed within a few days following surgery. A
body cast is usually not required, but the patient will generally be placed
in a body brace, to be worn for several weeks. The patient will generally be
able to leave the hospital within 5-12 days unless a fusion operation has
been performed.

CONVALESCENT INFORMATION

Most patients will be able to drive an automobile, and to return to work,
within four weeks following surgery. They will usually be able to resume
sexual relations when comfortable in assuming the position. This is often a
matter of perhaps one month or some what longer.

Spinal fusion requires a longer period of convalescence. The patient will be
able to engage in restricted activities during the period of up to 6 months
required for complete healing.

LONG-TERM RESULTS

Strenuous physical activity may usually be resumed following disk excision
and fusion, once the convalescent period has been concluded. Cure is
obtained in approximately 80 percent of cases. Surgery will leave a 6 inch
scar above the vertebrae involved.

SLIPPED DISK: ENZYME INJECTION

NATURE

The enzyme injection treatment for a severe and chronic herniated disk
consists of the injection of a protein-digesting enzyme (chymopapain) into
the protruding disk, under x-ray guidance. The enzyme selectively destroys a
portion of the spinal disk, thus relieving the painful and possibly
crippling pressure exerted by the disk protrusion. Such treatment appears to
be most effective among patients who:

   1. Have sciatic pains (sciatica) rather than other, less specific lower
      back pains.
   2. Have attempted non-surgical treatment of their condition (bed rest on
      a firm mattress, special back exercises, muscle-relaxant drugs) but
      have found no relief with these measures.

The enzyme injection treatment is not recommended for:

   1. Treatment of a disk that has previously received enzyme or surgical
      treatment.
   2. Children. Pregnant women.
   3. Patients with severe arthritic or neurological disease of the spine.
   4. Patients who in the past have exhibited anaphylactic shock (see the
      section titled: Serum Sickness-Anaphylactic Shock--the term describes
      a condition of shock that results from an allergic reaction to a
      foreign substance introduced into the body by eg. an injection, a bee
      or hornet sting, or an enzyme injection).

PRE-OPERATIVE INFORMATION

A CAT scan may be performed to locate the disk protrusion (see the section
titled: CAT Scan). Alternatively or in conjunction with the scan, a
myelogram may be prescribed, in which an opaque substance is injected into
the spinal canal and viewed by means of x-ray, thus permitting a
visualization of the interior of the spinal column. The protruding disk must
be located precisely for the planned enzyme injection.

OPERATION

The patient is given local or general anesthetic. A needle is inserted into
the protruding disk, under x-ray guidance. The enzyme (chymopapain) is
injected through the needle, and selectively destroys a portion of the disk.

POST-OPERATIVE INFORMATION

The patient will spend 2-5 days in the hospital. In approximately half of
cases, severe back pains may occur during this period. The pains may be
expected to disappear within one week.

A small number of patients develop a severe allergic reaction to the
injected enzyme. Hospitals are prepared for this eventuality. Immediate
treatment is available and recovery is almost invariable, with no lasting
after effects.

CONVALESCENT INFORMATION

A 1-2 months period will be devoted to a program of gradually increasing
special exercises, to strengthen the patient's back and to restore him to
the point at which normal physical activities can be resumed. The patient
must continue to recognize the importance of proper measures of care of the
back. Particularly in view of the fact that one fewer disk is now available
to absorb normal shocks to the spine.

LONG-TERM RESULTS

Up to 70 percent of suitable patients may be expected to experience lasting
relief of pain and significant improvement in mobility, while another 10
percent may be expected to experience lesser but nonetheless noticeable
improvement in their condition. The treatment, however, is relatively new,
so that these statistics are the products of quite limited experience with
its results.

LAMINECTOMY

Operations on the spinal cord require the removal of sections of the
overlying vertebrae; this operation is called a laminectomy. The removal of
this bone does not weaken the remaining spinal column, even when several
laminae must be removed, provided the joints are kept intact.
A laminectomy must usually be performed when a spinal tumor is to be
removed, or an epidural infection drained.

SPINAL FUSION

NATURE

Spinal fusion is most often performed to fuse two or three adjoining
vertebrae, Care must be taken whenever the patients  shifted or turned in
any manner. No harm however can occur to the fusion if the patient is moved
within pain tolerance.

CONVALESCENT INFORMATION

The wound will heal in approximately two weeks. A hospital stay of
approximately 10 days may be expected. Sexual activities and a normal social
life (including the driving of an automobile) may usually be resumed within
6 weeks following the operation. Return to normal work becomes possible one
month later. Strenuous physical activity can usually be resumed within 9
months to one year.

LONG-TERM RESULTS

The operation leaves no particularly disfiguring scars, nor is the pelvic
area from which bone grafts were taken weakened in any fashion.
Spinal fusion is usually successful in relieving pain and curing the
condition that instigated it. A small number of fusion operations, however,
does not achieve successful fusion of the vertebrae, and a second fusion
operation may then be required to stabilize the spine.

SLIPPED EPIPHYSIS OF THE UPPER FEMUR

SYMPTOMS

A slipped epiphysis of the upper femur occurs when the upper growth plate
(epiphysis) of the thighbone is displaced.  Among its symptoms are:

   1. Mild pain in the groin, especially after activity.
   2. Stiffness, and then tenderness, in the region of the hip.
   3. A tendency of the thigh to turn inward, and the foot outward. The
      patient will be unable to reverse these positions without pain.
   4. A limp.

The ailment most frequently occurs among children during the years when they
grow most rapidly. Tall or heavy children seem to be more vulnerable, and
far more boys are affected than girls. In between one-quarter and one-half
of cases, the ailment will eventually affect both sides.

CAUSES

The cause of the condition is unknown. Attempts have been made to implicate
endocrine factors. The direct cause may sometimes be a fall or injury.

SPECIAL DANGERS AND PRECAUTIONS

In case of symptoms, a child should be kept off his feet. A physician should
be consulted. If the condition is severe, it can lead to permanent
shortening of the affected leg. If the condition is left untreated, and
weight is not taken off the hip, it is likely to lead to a painful condition
of osteoarthritis later in life.

TREATMENT

The treatment for a slipped epiphysis of the hip is surgery. In mild cases,
the operation may involve placing metal pins across the displaced area in
order to prevent any further slippage. In more severe cases, the upper end
of the femur bone may have to be surgically reshaped.

CURVATURE OF THE SPINE

SCOLIOSIS - KYPHOSIS

SYMPTOMS

Curvature of the spine is described by the variation of the spine from the
vertical direction, as follows: Scoliosis--Curvature of the spine from side
to side. Kyphosis--Curvature of the spine from front to back, and back to
front. Lateral curvature of the spine may also be accompanied by spinal
rotation.
Spinal curvature usually appears between the ages of 10 and 12, four times
as frequently among girls as among boys. Maximum curvature is then attained
at approximately the age of 1, when the child has reached a maximum height.
Among the symptoms:

   1. If the condition is mild, there may be no symptoms at all, and the
      patient may remain unaware of its presence.
   2. The condition itself is not painful.
   3. The child may have one shoulder blade that protrudes more prominently
      than the other, or one hip that is noticeably higher than the other.
      His chest may have an unsymmetrical appearance.
   4. Later in life there may be visibly poor posture, as well as back pain
      that results from the cumulative effect of the abnormal spinal
      configuration.
   5. In more severe cases, the child may suffer from shortness of breath
      and difficulty in breathing.

CAUSES

Most spinal curvature is of unknown cause (ideopathic). There appears to be
a tendency for the condition to run in families. Some factors, however, are
known not to be responsible for scoliosis-kyphosis:

   1. Poor posture does not cause curvature of the spine.
   2. diet and vitamin supplements can neither cause nor prevent curvature
      of the spine.

TREATMENT

Most cases of curvature of the spine are mild, often without symptoms of any
kind. The progress of spinal curvature may be sporadic, however, with
dormant intervals followed by sudden increases of curvature. A young patient
should therefore undergo frequent orthopedic examinations and measurements
during the last few years of adolescent growth.
Special exercises may be of value when no bone changes have taken place
(functional spinal curvature). Braces have been effective in cases of mild
curvature. These can in most cases be worn underneath normal clothing, and
permit the child to participate in almost all normal activities, including
sports. They must generally be worn for one year or longer, but can be
removed periodically for brief periods of time.
Patients with severe curvature of the spine may consider surgical spinal
fusion, an operation that results in significant straightening of the spine
but that will limit spinal mobility and flexibility.
The fusion operation proceeds in the following way. The spine is
straightened by metal rods, and fused in this position by bone that is
attached to adjoining vertebrae. The metal rods can be left in place to
maintain the correct position of the spine, until a time when they are no
longer needed and can be removed in a second operation. The fusion will
solidify over a period of several months, and a cast must usually be worn
during this time. In most cases the cast will not greatly impair mobility,
so that the patient will be able to leave his bed within a few days
following surgery, and the hospital within a few weeks.
A year or more of convalescence will then be required, during which special
care must be taken to protect the patient from respiratory infections, and
to provide him with an adequate diet.
Bending of the fused portion of spine will no longer be possible. The back,
however, will have been straightened by the operation. Occasionally a second
fusion operation will be required to strengthen weak portions of the fused
spine.

SPINAL CANCER - SPINAL TUMOR

SYMPTOMS

The spinal canal is formed by the hollow centers of the bones that comprise
the spinal column. Interior to this canal is the spinal cord, protected by a
series of covering membranes, the outermost of which is the dura mater. The
spinal cord is a delicate, vulnerable, primary component of the central
nervous system.
Approximately half of all tumors of the spine are extradural tumors, and
occur on the bone of the spinal column or in the extradural space inside it.
Somewhat less than half of all tumors of the spine are intradural
extramedullary tumors, and lie between the dura mater and the spinal cord.
Approximately ten percent of all tumors of the spine are intramedullary
tumors, and arise upon the spinal cord itself. Among their diverse
symptoms:

Extradural Tumors: At first there is a constant, localized dull pain that is
                   made worse by movement of the spine, by pressure upon it,
                   or by bed rest (this will often distinguish the pain from
                   that of a herniated disk, for which bed rest provides
                   significant relief). After some weeks or months, signs of
                   spinal cord dysfunction appear and lead rapidly to total
                   paralysis unless treated at once.

Intradural Extramedullary Tumors: These are the meningiomas and
                   neurofibromas, single and relatively small tumors within
                   the spinal canal. Meningiomas occur most often among
                   women in their middle years, and in the thoracic region
                   of the spine. Neurofibromas appear equally among men and
                   women, at all ages, and in any portion of the spine.

                   1. The symptoms of meningiomas are often slow to appear,
                      and include pain in only half of all patients. With the
                      passage of time there may occur loss of muscle control,
                      and nystagmus (the rapid, rhythmic movement of the
                      eyeballs from side to side).
                   2. The symptoms of neurofibromas consist of pain of long
                      duration near the location of the tumor, and
                      occasionally of growth sufficiently large to be felt
                      externally.

Intramedullary Tumors: Ependymomas are the most common of these tumors,
                   which also include lipomas and hemangiomas that occur in
                   this region of the spine. The tumors can occur at any
                   point along the spine, and may extend to large portions
                   along the length of the spine. Among their symptoms are
                   sudden, dull, localized pain, and eventually muscle
                   weakness, disturbance of sphincter control, and (in males)
                   impotence.

CAUSES

Extradural tumors are most often the result of metastasis of cancer from the
lung, breast, prostate or kidney.

TREATMENT

Myelography provides the definitive diagnosis and precise location of any
cancer of the spine. This is followed by treatment determined by the nature
and extent of the tumor:

Extradural Tumors: These are usually treated with hormone therapy,
                   radiation, or chemotherapy, or combinations of these.
                   Surgical relief of compression may be attempted when
                   necessary. Treatment must be undertaken immediately upon
                   identification of the condition, while neurological damage
                   is still minimal.

Intradural Extramedullary Tumors: Surgical removal of a meningioma or
                   neurofibroma at an early stage usually results in
                   complete cure.

Intramedullary Tumors: Surgical removal of such tumors is sometimes
                   feasible, particularly if they are not extensive. There
                   is a tendency, however, for such tumors to recur after
                   several years

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