1. Drive responsibly, use seatbelts, don’t drink and drive. You are not from Krypton…really!
2. Don’t smoke…two chances in three it will kill you. If you are lucky enough to avoid death, smoking will destroy your discs…really!
3. Work to stay fit by exercising regularly including weight training, aerobics and stretching.
4. Stretch and warm up before performing sport or heavy lifting.
5. If you are injured on the job, ask questions, learn your rights and responsibilities. Your best course is to use the resources available to get better. Focus on this and you will maximize your chances for recovery.
6. If your employee is injured, support them through the process, but keep them accountable. Set expectations and demand that they are fulfilled. When they are able, welcome them back. If they like you they will continue to try to perform for you, even while ill.

Back injuries are the most common cause of lost work days in employees under 45 years of age. Two percent of the U.S. workforce suffers an on the job work injury each year accounting for 175 million lost work days per year, costing 23.5 billion dollars annually. It’s no wonder that employers are scratching their collective heads looking for ways to decrease these expenses. Ironically, the worker’s compensation system was designed to be a “no fault” system in which dollars were spent directly on patient care rather than in expensive court battles to determine whether employer or worker was at fault in any particular injury. In many injured employees the system has worked well, however in most studies it has been established that average outcomes for worker’s compensation patients are inferior to those for patients in a non worker’s compensation environment. The current worker’s compensation system unfortunately creates a negative incentive for patients to get back to work or to get well.

Some patients anxious about re-injury upon returning to work, may delay their treatment or recovery, yet continue to be paid two thirds of their normal wage while avoiding work return, reinforcing their undesirable behavior. A patient, who magnifies his disability successfully, stands to increase his final monetary settlement. Such behavior has lead to insurance adjusters hiring nurse case managers to move cases along. Employers and employees all too often become adversaries in the process as employers see the costs mount day after day as loss work days add up, while patients feel they are being pushed back to work with very little concern for their personal well being.  Patients sometimes focus on their disability rating and cash settlement losing focus on getting well. The final financial settlement seldom reimburses an injured worker for the loss of earning capacity, independence, and self esteem that nearly always occurs in this situation.

As a result, all parties lose. Physicians must deal with patients that are often evasive and not focused on recovery, while being forced to complete volumes of paperwork documenting treatment progress. Employers feel they pay too much for employees that may never be productive again, uncertain when and if an employee will return to work. Employees often squander their best chance to get well striving for a cash settlement that is uniformly disappointing. They come out of the system alienated from their employers, and marked as a worker with a bad back that no employer will hire, all for the sake of a cash settlement that often won’t even support the patient a single year.

The bottom line? If you are unfortunate enough to have an on the job neck or back injury, realize that resources provided for your care will not last forever. Your greatest asset is your friend, the back, and your focus should be on doing anything and everything you can to get it as healthy as possible. When all is said and done, a healthy back is worth more than any settlement you will ever receive. Bad things can happen to good people, and once you have recovered as much as possible, it is time to move on, and use whatever settlement you may receive to maximize your long term earning potential. If you are an employer realize that the best predictor of a successful worker’s compensation claim is an employee’s satisfaction with his employer. Offer limited duty to facilitate your employee’s return and welcome them back into the fold. Be supportive, honest and consistent by setting expectations with your employee right from the start of an injury. Let them know that just as it was prior to their injury, if they are responsible, keep their medical appointments, show up on time, and work hard, you will support them with your resources throughout the process.

Cervical and lumbar sprains/strains are some of the most common injuries for which patients will see a physician. A strain is defined as a tearing of the muscles about the spine, while a sprain refers to the tearing of ligaments that hold the spine segments together. Unless associated with major traumatic injuries such as falls from great heights or motor vehicle accidents, these injuries will heal over a period of several weeks. In 1987 a very large interdisciplinary group published the “Quebec Study” in the journal SPINE which evaluated the scientific evidence supporting the various treatments used on patients with acute back pain. This study, which was very well accepted by the medical community, recommended mainly over the counter analgesics, mobilization, and no more than two days of rest as the only treatments that were well supported in the literature. Traction, narcotics, and prolonged bed rest were not effective in treating acute back pain.

50% of these injuries will resolve in four weeks. 90% will resolve by 3 months, and the remainder may continue to have non specific complaints indefinitely. Pain and disability that continues longer than two to three months should be evaluated for additional problems. Although these injuries will resolve in 95% of cases with only supportive care, they often occur due to risk factors that can be identified and minimized. If these risk factors are not addressed, recurrence is very likely. Patients in very poor physical condition have a significantly greater chance of back injury. Lifting with poor technique, using you back instead of your legs, lifting bulky items without help, or performing heavy lifting or sports without stretching and warming up, can also increase your chances of injury. Ligaments and muscles that are worked regularly and warmed up before activity are stronger more flexible, enabling them to stretch instead of tear. The bottom line? Warm up and stretch before you perform activities which stress you back. Keep fit with a combination of aerobic, stretching and strengthening activities.

These injuries occur when the outer ring of the disc (annulus) weakens and tears, allowing the soft inner material within the disc (nucleus) to pass out of the confines of the disc and into the spinal canal. Most commonly this injury occurs in a disc which has begun to have some degree of degeneration, yet have relatively young fluid nuclear material that is still mobile. Disc herniations most commonly occur during the 30s and 40s, but can occur at any age. Although some disc herniations can probably be avoided through proper warm up and lifting technique, they occur in many patients without any manageable risk factors identified.

The nuclear material compresses nerve roots or spinal cord, and incites an inflammatory response that can further cause pain. The pain experienced most commonly is a combination of leg or arm pain, tingling and numbness with about half of patients suffering pain in the back, neck or between the shoulder blades as well. The treatment of disc herniations should always be conservative at first, unless there are clear signs of progressive weakness, numbness or loss of bowel and bladder function. Nearly 70% of these injuries will gradually subside with non surgical treatment. This treatment should include a short period of rest, anti-inflammatory medications, gentle stretching to maintain range of motion, and if possible increase the space available for the compressed nerve root. Avoiding activities that aggravate the arm or leg is also important. Nearly 50% will improve over four weeks with this treatment alone. Those that do not are usually offered a targeted epidural steroid injection, done under direct fluoroscopic vision. If pain persists outpatient microscopic discectomy in the low back, or discectomy with anterior fusion in the neck is the treatment of choice. It is important to point out that any surgical treatment is never an endpoint in and of itself. The success of any procedure depends upon the quality of the post surgical rehabilitation one receives and how closely one follows his or her surgeon’s post surgical plan.

It has been estimated that two thirds of those who smoke will die from complications associated with cigarette smoking. Although the popularity of smoking as a habit dropped through the last decade of the twentieth century, it is again on the rise. It is risk taking young adults that are largely responsible for this rise. Besides causing profound increases in most forms of cancer, chronic obstructive pulmonary disease and heart disease, cigarette smoke also affects your friend the back.

Twenty three very unusual and specialized structures within each of our spines, extending from the base of your skull to your pelvis are the intervertebral discs. These structures are specialized joints made of cartilage and fibrous tissue. One of the ways they are unusual is that they are the largest structures in the body without a specific blood supply. Each disc is surrounded by small blood vessels, but few if any penetrate into the disc itself. For cells inside the disc to receive nourishment and oxygen, these nutrients must diffuse out of the blood vessels around the periphery of the disc and into the disc itself. This passage of nutrients is aided by a gradual squeezing of fluid out of the disc during the day with weight bearing, and a gradual rehydration at night that occurs while you are asleep. This process is inhibited by nicotine. Nicotine in cigarette smoke is a very powerful vasoconstricting agent. In other words, it makes blood vessels spasm, and the amount of blood flow drop off or stop all together. The cells within the disc then, one by one begin to starve to death, and the disc gradually looses volume, and strength, leading to premature degenerative disc disease. Once the damage is done it cannot be reversed. This may not seem like a problem to you, as a young adult, but it makes your friend the back very unhappy, and over time the arthritis that develops in each disc can become so widespread that even surgical fusion procedures cannot effectively control the disabling pain. The bottom line?  Smoke at your own risk…and that of your friend your back.

Motor vehicle accidents are the number one cause of death in young adults. According to the CDC more than one in three accidents are associated with alcohol consumption. In addition, the use of seatbelts has been shown to dramatically diminish the rate of injury and death associated with motor vehicle accidents. The NHTSA (National Highway Traffic Safety Administration) has documented a 45% drop in MVA fatalities in autos, and 60% drop in MVA fatalities in light trucks. Despite this only approximately 75% of front seat occupants typically wear seatbelts in states where it is not mandated by law. In 2002 over 42,000 people were killed on the nation’s highways and 3 million suffered serious injuries making this the most common cause of death in the 2 – 33 year age group. By far and away the most common demographic to leave their seatbelt unbuckled is the young adult male. In 2002, 6,000 young men died on the nation’s highways that would have survived had they been wearing seatbelts. As of 2004, there are still only 21 states and the District of Columbia that have mandatory seatbelt laws, making seatbelts still largely a matter of choice. Tennessee has a seatbelt law, making it unlawful to drive and not buckle up.

Prior to the current lap belt/shoulder belt combination, head on and rollover accidents caused a severe forward bend across the lap belt, rupturing the abdominal organs, and ripping the mid/low back apart. The use of shoulder belts decreased this injury, but did not improve the incidence of neck injuries. In 2002, there were 50,000 major spinal injuries, and the data suggests that many of these were also not wearing seatbelts. 38% of those patients that survived a traumatic injury in the mid/low back suffered permanent neurologic injury, while 40% of those surviving a neck injury suffered permanent spinal cord injury. For those that have never met such a victim, the longevity and quality of life of an otherwise healthy individual is profoundly impacted. This fact was brought home for many of us through the heroic story of Christopher Reeves. For those young readers that remain in denial that seatbelts are too much trouble, or don’t matter, I would refer them to the Christopher Reeves website and foundation for spinal cord injuries. The bottom line? Wear them…if not for you, then for all those you care about that will suffer from your poor choices, gradual painful decline and inevitable, demise.

1. Parents perform the forward bending test on both sons and daughters from eight to fourteen, and seek medical opinion for any suspected abnormalities.
2. When kids complain of pain, access the situation, look for signs of overuse, and implement rest and activity modification. If the pain persists seek help. Kids usually are not chronic complainers, take them seriously.
3. Teach good habits early including proper diet, regular exercise, good posture, and stretching.

Spondylolysis is thought to represent a small stress fracture that develops in the low back of children after minor trauma. The break occurs in an area of the spine called the “pars intrarticularis” or “part between the joints”. This condition occurs in less than 5% of the population, however in certain football players, cheerleaders and gymnasts the incidence can be as high as 50%. When symptomatic it causes low back pain (which is made worse with back bending), and stiffness in the hamstrings caused by walking in a habitual forward bent, knee flexed posture. Treatment consists of stabilization and stretching exercises while avoiding activities that cause pain. Occasionally, more aggressive techniques including pain blocks or surgical fusion are required, however these are seldom necessary.

When spondylolysis occurs on both sides of the spine it can lead to a slipping of one vertebra on another, a condition known as spondylolisthesis (spine slip). The vertebrae will usually only slip a centimeter or so, but occasionally slippage can be extreme. The best prognosticator for slip progression here seems to be the angle the slipping bone has with the pelvis (slip angle). The more vertical the slip angle, the more likely the slip will get worse over time. The treatment of spondylolisthesis is similar to spondylolysis in milder forms, but can require surgical spine fusion in more severe cases. Spondylolistheses that is progressing on repeated X-ray exams or have slipped more than 50% of the way off of the vertebrae below are candidates for fusion. Spine fusion for spondylolisthesis as with scoliosis is designed to lay down bone graft between the two slipping vertebrae so that they may form a solid sheet of bone between them, thus preventing further slip. As with scoliosis this is occasionally done with rods and screws, but in children it is often done without instrumentation. As we will see later, adult cases are very different. The rates for solid fusion and pain relief are superior when rods and pedicle screws are used as part of the fusion process.

The word scoliosis means curved spine. In truth, the spine has several normal curves, most of which are best seen by looking from the side. The neck has a gentle backward curve called the cervical lordosis, the upper back has a gentle forward curve between the shoulder blades called the thoracic kyphosis, and the lower back has a gentle “swayback” curve called the lumbar lordosis. When there is an obvious side to side curve (greater than 10 degrees) we call this scoliosis. It can occur in the upper (thoracic) spine, the lower (lumbar) spine or combinations of both. Usually, when the spine develops an abnormal curve it will also twist. This is what creates the characteristic rib hump or prominence of the rib cage seen with many curves on the right side of the spine with forward bending. Scoliosis can occur in newborn, (congenital form), in young children, (juvenile form), and in older children, (adolescent form). Scoliosis is much more common in girls, but does occur from time to time in boys. In general the earlier scoliosis develops, the more likely it is to get worse; and because it often progresses, the later it is diagnosed the more severe the curve and the more involved the treatment.

Scoliosis can often be suspected from a simple “forward bending test” that every mother or father ought to do on every child yearly from the age of about eight or nine through the age of thirteen or fourteen. The forward bending test is done by sitting in a chair with your child standing in front of you turned away with his or her back toward you. Have your child gradually bend forward and touch his or her toes while you hold the pelvis stable, then gradually return to a standing position. During this maneuver look closely along the spine. The spine and ribs should be symmetrical, of equal fullness, on the left and right. The spine should be straight without any evidence of curve. A scoliotic curve will be most obvious in this forward bent position, and will usually show as a “rib” hump (actually all of the ribs where the spine is curved) that sticks up on the right side, or a fullness or enlargement of the muscles along the spine on one side or the other. If any of these abnormalities are found or even suspected, an immediate referral to your pediatrician or an orthopaedic spine specialist is in order.

Scoliosis can occur in conjunction with many very serious diseases such as tumors, neurological degenerative diseases, spinal cord trauma, and various birth defects, however by far the most common for of scoliosis is called idiopathic, (not associated with any other problem). The purpose of the initial exam is largely to check for associated diseases, and to measure the severity of the curve.

Scoliosis is treated in different ways depending on the severity of the curvature. Mild curves, those less than 20 degrees, are only observed over time for signs of progression. These kids need not change anything they do day in and day out, and receive X-rays every six months or so. We become more concerned around active growth spurts when these curves most commonly progress. Moderate curves, those between 20 degrees and 45 degrees, must be placed in a scoliosis brace. The brace type and the hours per day a child must wear it will vary based upon the curve configuration and the skeletal maturity of the child. As a rule, bracing is not intended, nor is it successful in decreasing the severity of a curve. Rather, bracing can if successful, prevent progression of a curve in growing children. The vast majority of curves that remain less than 45 degrees by the time a child reaches skeletal maturity will not progress during adulthood, while those that exceed 45 degrees usually do. The role therefore of any bracing program is to slow or stop curve progression such that no curve exceeds 45 degrees before skeletal maturity is reached and the brace is discontinued. Most if not all curves that exceed 45 degrees must be considered for surgical correction and fusion.

Scoliosis fusion is sometimes accomplished through the back, sometimes through the side, and occasionally through both approaches. The best approach is influenced by the age of the child, curve pattern, and the curve severity. There are many additional factors your doctor will need to consider here, and the final decision of the physician is usually made with a great deal of deliberation. The surgery consists of placing two rods in the spine spanning the curve and securing them to the vertebrae with screws or hooks. This construct of rods, hooks and screws is then rotated and extended or compressed to straighten the scoliosis and recreate as closely as possible the normal curves of the spine. The area from the top to the bottom of the rod is then roughened and packed with bone graft, in an effort to convert the once mobile vertebral segments into a solid fused sheet of bone. Once fused solid, the curves usually will not progress or change over a lifetime. Occasionally, 10% of the time, a gap in the fusion can develop (pseudoarthrosis) and further surgery may be required to obtain solid fusion. Other possible complications associated with surgery include blood clots in the legs or lungs, pneumonia, infection, reaction to blood products, neurologic injury, and dislodgement of the hooks and rods. These additional risks are unusual, less than 1-3% taken in total. Youngsters rebound very fast after major surgery, but even so, expect 4 to 6 weeks before energy levels come back to normal. Lastly, although this surgery will effectively correct the majority of a scoliotic curve, it will never correct it all. In addition, the remaining movable segments above and below the fusion often undergo added stresses through life, frequently developing premature arthritis, instability or both.

Overuse syndromes tend to affect kids when they are rapidly growing. As kids grow, their muscles can occasionally mature more quickly than their bones, becoming stronger than the bones they are mounted upon. The resulting over pull and irritation at the point of muscular attachment leads to pain with activities, sports, carrying heavy book bags and so forth. These “enthesopathies” are usually self-limiting, respond to activity modification and mild over-the-counter medications such as ibuprofen. Back pain associated with overuse, many times is related to high intensity sport in a skeletally immature athlete, or recurrent heavy lifting. The classic example is that of the sixth grade girl with the 60 pound book bag. Awareness is half the battle. Getting extra copies of books to leave in class or at home and providing extra time to change out books at a locker can go a long way in limiting the stress. I have also seen children that are pushed by their parents and themselves to achieve great feats in competitive sports. Many sports such as swimming and gymnastics require kids to dedicate themselves to superhuman workout schedules in order to succeed. Extreme physical and emotional duress can develop under these conditions, in a child ill equipped to recognize or deal with it. Occasionally the only way a child has of pleading for help is to develop an injury or painful condition.  Occasionally, the workup will reveal a painful benign tumor (osteoid osteoma), stress fracture, or other even more serious problem that would have gone undiagnosed had an investigation not been performed. It is important to remember however, that just because the physical workup is negative does not mean there is no problem. It is important to remember that most kids will not continually complain unless there is something wrong. Recurrent complaints of pain should be evaluated by a physician.