It is natural for the spine to curve forward and backward to a certain degree. This is what gives the side-view of the spine its "S"-like shape. But sometimes the spine twists and develops curves in the wrong direction — sideways. When the spine twists and develops an "S"-shaped curve that goes from side to side, the condition is known as scoliosis (sko-lee-oh-sis).
What Causes Scoliosis
Scoliosis is divided into categories based on the age you are when it is diagnosed:
Infantile scoliosis is diagnosed before age three.
Juvenile scoliosis is diagnosed from age three to puberty.
Adolescent scoliosis is diagnosed during puberty, usually between the ages of 10 and 15.
Adult scoliosis is diagnosed in adulthood after the spine has stopped growing.
Scoliosis is most commonly seen in adolescents and adults. Adults can also develop scoliosis as a result of bone degeneration.
Adolescent Idiopathic Scoliosis
The word "idiopathic" (id-e-oh-path-ic) means that the cause of this form of scoliosis is unknown. Adolescent idiopathic scoliosis can affect a child who is healthy and not having nerve, muscle, or other spine problems. It is the most common form of spinal deformity doctors see, affecting about three percent of the general population.
Adolescent idiopathic scoliosis affects children between 10 and 18 years old and affects girls more often than boys. In fact, girls are treated 10 times more often than boys. There are many theories as to why this type of scoliosis develops, but the root of the condition has yet to be discovered. Some of the theories include:
Genetics — Scoliosis appears to run in certain families, so it may be hereditary. Significant research is ongoing in the field of genetics.
Growth — Curves progress rapidly during growth spurts, which may mean there is a link between scoliosis and hormones.
Structural and Biomechanical Changes — Some studies have shown that muscle activity increases around the spinal curves. Differences in leg lengths have also been noted in adolescents with idiopathic scoliosis. But there is no clear evidence that this type of change causes scoliosis. It may simply be a secondary result.
Central Nervous System Changes — Because some forms of scoliosis are associated with central nervous system disorders, a lot of research has been focused on this topic. But so far such disorders have not been proven as the root of idiopathic scoliosis.
Equilibrium and Postural Mechanisms — Idiopathic scoliosis could be related to factors that affect how the body is aligned. If a child has problems with posture, balance, and body symmetry, it could affect the way the spine is positioned. If the problems are chronic, it may disrupt the way the spine and muscles develop.
A concern when scoliosis is diagnosed in children is that the curves will continue to grow bigger. There is no absolute way to tell, but this much is known:
Curves in the thoracic spine are more likely to progress than lumbar curves.
The likelihood of progression is linked to the size of the curve — larger curves are more likely to get bigger.
If the curves start at a young age or before a girl begins her period, they are more likely to progress.
The higher the child's Risser sign at diagnosis, the less chance there is of progression. (The Risser sign is a measure of skeletal maturity. It is based on a 0 to 5 scale, with 5 being full skeletal maturity.)
Scoliosis that occurs (or is discovered) after puberty is called adult scoliosis. Adult scoliosis can be the result of untreated or unrecognized childhood scoliosis, or it can arise during adulthood. The causes of adult scoliosis are usually different from the childhood types.
Most cases of adult scoliosis are idiopathic because the cause is not known. Sometimes adult scoliosis is the result of changes in the spine due to aging and degeneration. The causes of adult scoliosis are further categorized into several types:
Idiopathic Curve — Usually there is no clear-cut reason why the spine is curved.
Congenital (con-gen-it-al) Curve — You were born with a curved spine that may not have been recognized or may not have been severe enough to require treatment during childhood. Although it is rare, the scoliosis can get worse later in life due to wear and tear around the abnormal area of the spine.
Paralytic (par-a lit-ick) Curve — It is often caused by paralysis from injury to the spinal cord. Paralytic means "the muscles do not work." When the muscles around the spine are not working, the spine may be thrown out of balance, which can cause an abnormal curvature in the spine.
Myopathic (my-oh-path-ic) Deformity — Like a paralytic curve, "myopathic" also means that the muscles do not work. In this case, the muscles do not work because of a muscular or neuromuscular disease such as muscular dystrophy, cerebral palsy, or polio.
Secondary Scoliosis — Developed in adulthood as a result of other spinal conditions that affect the vertebrae, such as degeneration, osteoporosis, or osteomalacia (ost-eyo-mal-ace-ia) (softening of the bones), scoliosis can also appear following spinal surgery for other conditions if the surgery causes an imbalance in the spine.
Degenerative adult scoliosis occurs because of a combination of age and deterioration of the spine. It usually starts after age 40. In older patients, particularly women, it is also often related to osteoporosis. Osteoporosis weakens the bone, making it more likely to deteriorate. The combination of these changes causes the spine to lose its ability to maintain a normal shape. The spine begins to "sag" and as the condition progresses, a scoliotic curve can gradually develop.
Symptoms of Scoliosis
Scoliosis is often painless. People with scoliosis commonly see a spine specialist because they notice a problem with the way their back looks. If you have scoliosis, you may notice some of the following things about your body.
One shoulder or hip may be higher than the other.
One shoulder blade may be higher and stick out farther than the other.
These deformities are more noticeable when bending over.
A "rib hump" may occur, which is a hump on your back that sticks up when you bend forward. This occurs because the ribs on one side angle more than on the other side.
One arm hangs longer than the other because of a tilt in the upper body.
The waist may appear asymmetrical.
Back pain can eventually develop as the condition progresses. The deformity may cause pressure on your nerves and possibly even on your spinal cord. This can lead to weakness, numbness, and pain in your lower extremities. In severe cases, pressure on the spinal cord may cause loss of coordination in the muscles of your legs, making it difficult to walk normally. If your chest is deformed due to the scoliosis, your lungs and heart may be affected. This can cause breathing problems, fatigue, and even heart failure. Fortunately these severe symptoms are rare.
Degenerative adult scoliosis usually begins as low back pain. While there may also be a deformity that causes the back to look abnormal, usually pain is what motivates people to see their doctor. The pain is probably not coming from the curve, but rather from the degeneration occurring in the spine.
A combination of the degeneration of the spine and scoliosis deformity may cause pressure on nerves and possibly even the spinal cord. This can lead to weakness, numbness, tingling and pain in the lower extremities. In severe cases, pressure on the spinal cord may cause loss of coordination in the muscles of the legs, making it difficult to walk normally. The degeneration and the scoliosis may lead to a condition called spinal stenosis (sten-oh-sis), which is a narrowing of the spinal canal.
A herniated disc occurs when the annulus (an-oo-lus) or outer fibers of the disk are damaged and the soft material inside the disc ruptures out of its normal space. If the annulus tears near the spinal canal, the soft material inside the disc can push into the spinal canal.
A herniated disc in the thoracic spine can be very serious. There is very little extra space around the spinal cord in the thoracic area. So when a herniated disc occurs in the mid back, the pressure on the spinal cord can cause paralysis below the waist. Fortunately, herniated discs are much more common in the lumbar spine where they are not as serious.
What Causes a Herniated Disc
Herniated discs can occur in children, although it is rare. A true herniated disc is most common in young and middle-aged adults, and generally occurs in the low back. Disc herniations in the thoracic spine mostly affect people between age 40 and 60. In older people, the degenerative changes that occur in the spine with aging make it less likely for them to suffer a true herniated disc.
A disc can rupture suddenly when too much pressure is applied to it all at once. For example, falling from a ladder and landing in a sitting position can cause a great amount of force on the spine. If the force is strong enough, either a vertebra can break or a disc can rupture. Bending puts a large amount of stress on the discs between each vertebra. If you bend and try to lift something that is too heavy, the force can cause a disc to rupture.
A disc can also rupture from a small amount of force, usually due to weakening of the annulus from repeated injuries that add up over time. As the annulus becomes weaker, at some point, lifting or bending causes too much pressure across the disc. The weakened disc ruptures while doing something that five years earlier would not have caused a problem. This is due to the effects of aging on the spine, which is the most common cause of disc herniation in the thoracic spine.
The material that has ruptured into the spinal canal from the disc can cause pressure on the nerves in the spinal canal. There is also some evidence that the material from inside the disk causes a chemical irritation of the nerve roots. Both the pressure on the nerve root and the chemical irritation can lead to problems with how the nerve root functions. The combination of the two can cause pain, weakness, and numbness in the area of the body to which the nerve supplies sensation (feeling).
Symptoms of Herniated Disc
The first symptom of a herniated disc is usually pain. The pain is most often felt in the back, directly over the sore disc. If the herniated disc is in the thoracic spine, the pain may also radiate around to the front of the chest. Pressure or irritation on the nerves in the thoracic area can also cause other symptoms. Depending on which nerves are affected, a thoracic disc herniation can include pain that feels like it is coming from the heart, abdomen, or kidneys.
Herniated thoracic discs sometimes press against the spinal cord. When this happens, symptoms may include:
Muscle weakness, numbness, or tingling in one or both legs
Increased reflexes in one or both legs that can cause exaggerated movement
Everything you do during the day while being upright tests the spine's ability to support your body weight. Minor injuries to a disc may occur and not cause pain at the time of the injury. These repeated daily stresses and minor injuries can add up over time and begin to affect the discs in your spine. The disc eventually begins to suffer from the wear and tear and it begins to degenerate. Degeneration of the discs in the spine can cause many painful problems.
What Causes Degenerative Disc Disease
A healthy intervertebral disc has a great deal of water in its center. The water content gives the disc a spongy quality, which enables it to absorb stresses put on the spine. Too much pressure or injury to the disc can damage the ligament that holds the vertebrae immediately above and below the disc together. This is generally the first portion of the disc to be injured. Small tears show up in the ligament material. These tears heal and form scar tissue, which is not as strong as normal ligament tissue. The ligament becomes weaker over time as more scar tissue forms. In time, the disc begins to lose its water content and dry up.
Loss of water causes the disc to lose some of its ability to act as a cushion. This can lead to even more stress on the ligament and still more tears as the cycle repeats itself. As the disc loses its water content, it collapses, allowing the vertebrae above and below it to move closer together. This causes the space between the bones to narrow, changing the way the facet joint works.
Bone spurs, sometimes called osteophytes (os-tee-oh-fights), may begin to form around the disc space. These can also form around the facet joints, which may be your body's way of trying to stop the excess motion at the spinal segment. The bone spurs can become a problem if they start to grow into the spinal canal and press into the spinal cord and spinal nerves. This condition is called spinal stenosis (sten-o-sis).
Symptoms of Degenerative Disk Disease
The most common early symptom of degenerative disc disease is back pain that spreads to the buttocks and upper thighs. When doctors refer to degenerative disc disease, they are usually referring to a combination of problems in the spine that start with damage to the disc, but eventually affect all parts of the spine. Problems thought to arise from the degenerating disc itself include discogenic pain, and bulging discs.
Discogenic pain refers to pain caused by a damaged intervertebral disc. A degenerating disc may cause mechanical (or structural) pain. As the disc begins to degenerate, there is some evidence that the disc itself becomes painful. Movements that place stress on the disc can result in back pain that appears to come from the disc. This is similar to any other body part that is injured such as a broken bone or a cut in the skin. When these types of injuries are held still, there is no pain, but if you move them, they hurt.
Discogenic pain is usually felt in your lower back. The pain may also feel like it is coming from your buttocks and even down into your upper thighs. The experience of feeling pain in an area away from the real cause is common in many parts of the body, not just the spine. For example, a person with gallstones may feel pain in his shoulder, and a person having a heart attack may feel pain in his left arm. This is referred to as radiation of the pain because the pain radiates, or spreads out, to other parts of the body. It is very common for pain produced by spine problems to be felt in different areas of the body — including the back.
Bulging discs are fairly common in both young adults and older people. They are not cause for panic. Bulging discs are frequently seen in people with and without back pain. In some cases, bulging discs are part of both the aging process and the degeneration process of the intervertebral disc. A bulging disc is not necessarily a sign that anything serious is happening to your spine. A bulging disc only becomes serious when it bulges enough to cause narrowing of the spinal canal. If there are bone spurs present on the facet joints behind the bulging disc, the combination may cause narrowing of the spinal canal in that area. This is sometimes referred to as segmental spinal stenosis.
Over many years our necks are subjected to repeated stress and minor injury. These injuries may not hurt at the time, but repeated injuries add up and can eventually result in degeneration of the cervical spine causing neck pain. Most neck pain is due to degenerative changes that occur in the neck. The overall condition of the cervical spine usually determines how fast you recover from an injury, and whether your neck pain will become a chronic problem.
For chronic neck pain, there may not be a quick fix or a complete cure. For this reason, you should see a healthcare professional about neck pain right away to keep it from becoming chronic. Work with your health care team to address the problem causing pain in order to help slow down the degenerative process. The physician's role in the treatment of neck pain is to find the main causes that need treatment right away. He or she will also try to keep your neck pain from becoming a chronic condition by teaching you how to slow down the degenerative process and prevent further injury.
What Causes Neck Pain
Degenerative Disc Disease
To help you understand disc degeneration, compare a spinal segment to two vanilla wafers (the "vertebrae") and a marshmallow (the "disc"). Imagine a fresh marshmallow between the two wafers. When you press the wafers close together, the marshmallow gives or "squishes out." Suppose you leave the marshmallow out for a week and it starts to dry out. When you press it between the wafers, it is not quite as spongy. If you press hard enough, the outside of the marshmallow may even tear or split. Suppose you left the marshmallow out for a month. It would probably be so dried out it would be hard and very thin and would not have any "shock absorbing" ability.
As we age, the disc loses some of its water content and, as a result, some of its shock absorbing ability. Like the marshmallow, the first changes that occur in the disc are tears in the outer ring of the disc, called the annulus. Tears in the annulus may occur without symptoms. Therefore, you may not notice when they occur or what caused them. These tears heal by forming scar tissue. Scar tissue is weaker than normal tissue. Repeated injuries and tears cause more wear and tear to the disc. As the disc wears, it loses more of its water content. It becomes less and less "spongy," eventually no longer able to act as a shock absorber.
As the disc continues to wear, it begins to collapse. The space between each vertebra becomes smaller. The collapse also affects the way that the facet joints in the back of the spine " line up." Like any other joint in the body, the change in the way the bones fit together causes abnormal pressure on the articular (ar-tick-you-lar) cartilage. Articular cartilage is the smooth shiny material that covers the end of the bones in any joint. Over time, this abnormal pressure causes wear and tear arthritis (osteoarthritis) of the facet joints. Bone spurs may form around the disc and facet joints. It is thought that too much motion in a spinal segment causes the bone spurs to form. Eventually, bone spurs can form around the nerves of the spine, causing a condition called spinal stenosis.
Muscle strain of the neck is a common diagnosis given when a person has a stiff neck. In some cases, it may truly be a "muscle strain" or "pulled muscle" involving the muscles around the spine of the neck. However, in some cases, the pain may be due to a muscle spasm which can result when other areas of the neck are injured. Problems that are commonly referred to as a muscle strain may also involve injury of other soft tissues of the neck including the disc, the ligaments around the spinal segment, and the muscles. Injury to any, or all, of these structures may cause similar symptoms.
Mechanical Neck Pain
A chronic neck ache where the pain stays mainly in the neck may be the result of degenerative disc disease and arthritis of the facet joints of the cervical spine. Doctors sometimes refer to this type of pain as mechanical pain. This term is used because it gets worse when we use our neck more and seems to be coming from the parts of the cervical spine — the mechanical parts that allow us to move our head around and up and down.
Mechanical neck pain does not come from pinched or irritated nerves. The pain seems to come from the inflamed facet joints and from the degenerated disc. The disc and facet joints become more inflamed when we use our neck to move our head, and the muscles around the cervical spine begin to spasm. A muscle spasm is like a muscle cramp. Muscles that are cramping eventually cause pain. The spasm is your body's way of trying to stop the movement in the cervical spine.
Pinched Nerve (cervical radiculopathy)
When a nerve root leaves the spinal cord and the cervical spine, it travels down into the arm. Along the way, each nerve supplies sensation (feeling) to a part of the skin of the shoulder and arm and sends electrical signals to certain muscles to move part of the arm or hand. When a nerve is irritated or pinched — by either a bone spur or part of the intervertebral disc — it causes the nerve not to work properly. This shows up as weakness in the muscles the nerve goes to, numbness in the skin where the nerve goes, or pain in the area where the nerve travels. This condition is called cervical radiculopathy. There are two causes of cervical radiculopathy: herniated disc, and degeneration and bone spurs.
Pinched Nerve from a Herniated Disc
Bending the neck forward and backward, and twisting left and right, puts pressure on the vertebrae and disc. The disc responds to the pressure by acting as a shock absorber. Bending the neck forward compresses the disc between the vertebrae. This increased pressure on the disc may cause the disc to bulge toward the spinal canal and the nerve roots. Remember the vanilla wafers and marshmallow? Pressing the wafers together on one side would cause the marshmallow to bulge out on the opposite side.
Injury to the disc may occur when neck motion puts too much pressure on the disc. One of the most painful injuries that can occur is a herniated disc. In this injury, the tear in the surface of the disk is so bad that part of the inside of the disk squeezes out. A tear or rupture can occur anywhere around the disc. If it tears on the side next to the spinal canal, then when the inside squeezes out, it can press against the spinal nerves. Pressure on the nerve root from a herniated disc can cause pain, numbness, and weakness along the nerve. Chemicals released from the ruptured disc may also irritate the nerve root, leading to some of the symptoms of a herniated disc — especially pain.
Herniated discs are more common in younger, middle-aged adults. This condition may occur when too much force is put on an otherwise healthy disc: for example, in a car accident where your head snaps forward. The force on the neck may be too much for even a healthy disc to absorb, and injury is the result. A herniated disc may also occur in a disc that has been weakened by degeneration. Once weakened, less force is needed to cause the disc to tear or rupture. However, not everyone with a ruptured disc has degenerative disc disease. Likewise, not everyone with degenerative disc disease will suffer a ruptured disc.
Pinched Nerve from Degeneration and Bone Spurs
In middle-aged and older people, degenerative disc disease can cause bone spurs to form around the nerve roots. A bone spur is abnormal growth of bone, and usually occurs inside the neural foramen (nor-al for-a-min) — the opening in the cervical spine between two vertebrae where the nerve root leaves the spine to travel into the arm. If these bone spurs get large enough, they may begin to rub on the nerve root and irritate it. This causes the same symptoms as a herniated disc: pain to run down the arm, numbness to occur in the areas the nerve serves, and weakness in the muscles that the nerve supplies.
Perhaps the most serious of the problems caused by degeneration of the spinal segment in the cervical spine is the condition called spinal stenosis. Spinal stenosis is caused by bone spurs in the late stages of spinal degeneration. As the bone spurs form, the size of the spinal canal becomes smaller. The bone spurs begin to press on the spinal cord or the nerve roots. This pressure can cause numbness, tingling, or pain in the arms, hands, and legs.
Spinal stenosis is sometimes called cervical myelopathy and is different from the simpler problem where only one nerve root is being pinched by a herniated disc or a bone spur. When there is narrowing of the spinal canal (the bony tube where the spinal cord runs), the whole spinal cord may be affected. This is different than when the bone spurs only narrow one of the neural foramen. The symptoms are also much different. A pinched nerve from either a herniated disc or a bone spur rarely affects the legs. Cervical myelopathy can affect both the arms and the legs.
Spinal stenosis (sten-oh-sis) is when the spinal canal — the area where the spinal cord travels through the spine — narrows. It may occur because of aging or degeneration of the bones in the spine, and can cause back and leg pain that comes and goes with activities such as walking. Stenosis can occur in all areas of the spine, but it is most common in the lumbar spine. Spinal stenosis usually affects people over 60 years of age. However, it can also occur in younger people who have abnormally small spinal canals from birth.
Below you can learn about:
What Causes Spinal Stenosis
Symptoms of Spinal Stenosis
What Causes Spinal Stenosis
Anything that narrows the spinal canal places the spinal cord and spinal nerves at risk. The lack of space puts pressure on them, causing irritation and inflammation. Conditions that can narrow the spinal canal include:
Thickening of ligaments
Spinal stenosis usually occurs in older people due to years of wear and tear (degeneration) of the spine. The changes that happen from this process include thickened ligaments, bone spurs, facet joint enlargement (hypertrophy), and bulging discs.
In some cases, simply bending over can relieve the symptoms. Bending makes the spinal canal larger and provides more space so that the blood flow to the spinal nerves increases. Activities that increase the demand for blood flow cause the blood vessels to swell and enlarge. If there is no room for this to occur, the blood flow cannot increase. This causes pain and weakness because the nerves cannot get enough oxygen to meet the demand.
Some people have a narrow spinal canal from birth. This does not mean they automatically feel symptoms of stenosis. But if the spinal canal is too narrow, it can lead to pressure on the spinal nerves. People who have a very narrow canal are at risk for stenosis because even minor crowding inside the spinal canal can lead to symptoms.
Symptoms of Spinal Stenosis
The main symptoms of spinal stenosis are felt in the legs and include:
Pain with walking or standing for a long time
The symptoms of spinal stenosis are caused by the nerve roots getting squeezed, which upsets the normal signals traveling from the brain to the body. Irritation of the nerves becomes worse when you are standing or walking due to pressure and stretching of the nerves. Symptoms often disappear with rest. Sitting down seems to take pressure off the nerve roots.
The spine is made up of strong bones called vertebrae. A vertebra can break just like any other bone in the body. When the vertebral body collapses, it is called a vertebral compression fracture. These fractures happen most commonly in the thoracic spine (the middle portion of the spine), particularly in the lower part. Vertebral fractures are usually caused by a condition such as osteoporosis, a very hard fall, or another type of injury.
What Causes a Compression Fracture
Compression fractures of the spine generally occur from too much pressure on the vertebral body. The fracture occurs when the vertebral body collapses, causing the front part of the vertebral body to become wedge-shaped. The bone tissue on the inside of the vertebral body is crushed or compressed.
A compression fracture can happen when the spine bends forward at the same time downward pressure builds on the spine. For example, falling to the floor in a sitting position causes the spine to bend and the head to be thrust forward. This position, combined with pressure on the buttocks, concentrates stress on the front part of the spine, the vertebral bodies.
There are several causes of compression fractures:
If the vertebra is too weak to withstand normal stress, it may take very little pressure to cause it to collapse. Most healthy bones can withstand stress, and the spine is able to absorb the shock. However, if the forces are too high, one or more vertebrae may fracture.
Osteoporosis is a common cause of compression fractures in the spine. This disease thins bones, often to the point where they become too weak to bear normal pressure. They can eventually collapse during normal activity, leading to a spinal compression fracture. Spinal compression fracture is the most common type of fracture from osteoporosis. Forty percent of all women will have at least one spinal compression fracture by the time they turn 80 years old.
In severe cases of osteoporosis, actions as simple as bending forward can be enough to cause a "crush fracture," which can lead to loss of body height and a humped back (kyphosis [kye-fo-sis]), especially in elderly women.
Compression fractures due to trauma can come from a fall, a forceful jump, a car accident, or any event that stresses the spine past its breaking point.
Cancer that spreads to the spine weakens its ability to support the body and withstand normal stresses. The bones of the spine are a common place for many types of cancers to spread. The cancer may destroy part of the vertebra, weakening the bone until it collapses.
Symptoms of Compression Fracture
If a spinal fracture is caused by a sudden, forceful injury, you will probably feel severe pain in your back, legs, and arms. You might also feel weakness or numbness if the fracture injures the nerves of the spine.
If the bone collapse is gradual, such as a fracture from osteoporosis, the pain will usually be milder. There might not be any pain at all until the bone actually breaks.
In very severe compression fractures, parts of the back of the vertebral body may actually protrude into the spinal canal and put pressure on the spinal cord. Fortunately, this is not a common occurrence.
When people age — particularly women — there often comes a loss of height and weight, and the development of stooped posture. A bone-thinning disease called osteoporosis (os-tee-oh-pour-osis) often causes these body changes. Osteoporosis causes destruction of bone tissue which leads to loss of bone mass. As a result, bones become brittle and the risk of fracture of the spine, hip, and wrist increases. Spinal fractures are the most common type of fractures due to osteoporosis. Forty percent of all women will have at least one spinal fracture by the time they are 80 years old. These vertebral fractures can permanently alter the shape and strength of the spine.
Most women are likely to feel some effects of osteoporosis in their lifetime, but the good news is that much can be done to reduce and even prevent loss of bone mass and fractures. New treatments for osteoporosis are being discovered each year. You can also actively work to decrease your chances of suffering the effects of osteoporosis. The key is prevention and intervention.
What Causes Osteoporosis
Loss of bone mass begins at around age 30. Although men can be affected by osteoporosis, older women are usually affected — particularly those who are past menopause. Bone loss becomes worse in women after menopause because of the body's lack of estrogen. When bones lose mass they tend to weaken and become fragile. This increases the risk of fracture under stress or because of a fall — particularly in the spine and hip.
Falls in elderly women are often actually the result, rather than the cause, of hip fractures. In other words, a fragile hip bone may simply fracture, causing the person to fall. In severe cases of osteoporosis, the bones can fracture with any kind of slight movement, leaving some people bedridden.
Doctors have identified two types of osteoporosis, primary and secondary. Primary osteoporosis is further divided into "Primary Type I" and "Primary Type II" osteoporosis.
Primary (Type I) Osteoporosis
Most people think of this type when talking about osteoporosis. It is the form that mainly affects women after menopause. Primary Type I osteoporosis is six times more common in women than men. It occurs in women 15 to 20 years after menopause. The loss of bone is linked to an estrogen deficiency in women and a testosterone deficiency in men. Amounts of these hormones tend to become low with age.
Primary Type I Osteoporosis is sometimes called high-turnover osteoporosis because it causes a rapid loss of the spongy inner part of the bones (called trabecular [tra-beck-you-lar] bone). Normally there is a large amount of trabecular bone in the vertebral bodies of the spine and in the end of the long bones, like the wrist. People who lose trabecular bone have a higher risk of spine and wrist fractures.
Primary (Type II) Osteoporosis
Compared to Type I, Type II Osteoporosis is only two times more common in women than men. It typically occurs when people reach their 70s or 80s. It is also thought to be the result of too little calcium in the diet, low Vitamin D levels because of age, or increased activity of the parathyroid (para-thigh-roid) glands.
Primary Type II Osteoporosis causes a loss of both hard outer bone and spongy inner bone. Because the rate of bone turnover is much lower, Primary Type II Osteoporosis is also called Low-turnover Osteoporosis. Hip fractures are the most common result of this type of osteoporosis.
In healthy people, bone is constantly regenerating. New bone is formed while old bone is resorbed by the body. This process is called remodeling. The amount of bone mass you have depends on the balance between bone formation and bone resorption. This is your bone turnover rate. If bone production is less than the amount of bone being resorbed, the risk of developing osteoporosis increases. In secondary osteoporosis, the rate of bone remodeling increases, leading to a loss of bone mass. Secondary osteoporosis can also occur from an imbalance in hormones due to the following diseases:
Hyperparathyroidism (hy-per-para-thigh-roid-ism) — increased activity of the parathyroid glands
Hyperthyroidism (hy-per-thigh-roid-ism) — increased activity of the thyroid glands
Diabetes (dye-a-beet-ees) — high blood sugar due to the body's inability to produce or use insulin correctly
Hypercortisolism (Hy-per-cort-i-sole-ism) — high cortisol levels due to illness or long-term use of steroid medication
Secondary osteoporosis can also occur from disorders where the bone marrow cavity expands at the expense of the trabecular or spongy bone, which causes bones to lose some of their strength.
Other Causes of Secondary Osteoporosis include:
Thalassemia (thal-a-seem-ia) — a genetic form of anemia which causes there to be too few red blood cells
Multiple myeloma (my-a-lome-a) — a type of cancer where there are multiple tumors within the bone and bone marrow
Leukemia (loo-key-me-a) — a serious disease in which white blood cells grow out of control
Metastatic (met-a-stat-ic) bone disease — a condition that occurs when cancer cells spread from one part of the body through the blood stream and into the bones
Symptoms of Osteoporosis
The most common symptoms of osteoporosis are fractures — particularly vertebral compression fractures and hip fractures. Compression fractures in the spine are caused by weakened vertebrae and can lead to pain in the mid back. These fractures often stabilize by themselves and the pain eventually goes away. But the pain may persist if the crushed bone continues to move around and break.
In severe cases of osteoporosis, actions as simple as bending forward can be enough to cause a "crush fracture" in a vertebra. This type of vertebral fracture causes loss of body height and a humped back, especially in elderly women. This disorder (called kyphosis [kye-fo-sis]) is an exaggeration in the curve of the mid back. It causes the shoulders to slump forward and the top of the back to look enlarged and humped.
Consult your doctor if you have symptoms of osteoporosis. Older women should discuss their risks with their doctor, even if they are not currently showing any signs of osteoporosis. All women should be aware of the many preventive steps that can lower their risk of developing osteoporosis.
Who is at Risk for Osteoporosis
Osteoporosis does not affect everyone. There are risk factors that may predict your chances of developing it. Some risk factors are genetic, meaning you inherited them from your biological parents. Some risks are due to medical conditions that you may not be able to avoid, such as use of particular medications. Risk factors that are considered "lifestyle-related" are the ones that you can change.
Biological and Medical Risk Factors
Biological Sex — Women have a greater chance of developing osteoporosis than men.
Race — Caucasians and Asians are at greater risk of having osteoporosis.
Age — Since bone loss begins at around age 30, the risk of osteoporosis increases with age.
Family History — If others in your family have experienced hip or spine fractures or become hunched over as they age, you are at greater risk of experiencing the same symptoms.
Body Frame — A thin body frame and low body weight relative to your height will increase the risk of osteoporosis.
Post-menopause — Women who are past menopause have lower estrogen levels, which increases their chance of losing bone mass.
Low Estrogen — Women who have had low estrogen rates over their lifetime are at higher risk for osteoporosis. Low estrogen may be because of late onset of puberty/getting their period, early menopause (before 40), or an absence or suppression of menstruation.
Medication Use — Some medications increase the risk of osteoporosis because they contribute to loss of bone mass when used long-term. These drugs include steroids, inhaled steroids, anti-epileptic drugs, immunosuppressants, anticoagulants, and thyroid hormone suppressive therapy.
Nutritional Conditions — Conditions such as anorexia nervosa (an-or-ex-iya ner-vo-sa), chronic liver disease, malabsorption syndromes, or malnutrition can increase the risk of osteoporosis.
Endocrine Disease or Metabolic Causes — These include thalassemia, diabetes, and hemochromatosis (heem-oh-krome-a-toe-sis).
Other Medical Disorders — Conditions such as Down's syndrome, mastocytosis (mast-oh-sigh-toe-sis), myeloma (my-a-low-ma) and some cancers, renal tubular acidosis, rheumatologic (room-a-toe-lodge-ic) disorders, and lack of movement add to the risks for osteoporosis.
Lifestyle Risk Factors
Low Calcium Intake — Less than 300 mg per day of calcium (which is equal to one glass of milk) is considered low.
Low (or no) Vitamin D in Your Diet — Vitamin D comes from sunlight and foods such as egg yolks, fortified milk and cereals, and some types of fish.
High Caffeine Intake — More than two or three cups of caffeinated coffee each day is considered high if you have a low calcium intake.
Tobacco Use — This includes current use as well as past use of tobacco.
Alcohol Use — More than 7 oz. of alcohol per week can slightly increase the risk of hip fractures.
Low Activity — Your activity level is considered low if you do not walk or exercise regularly.
How You Can Prevent Osteoporosis
Whether you are at risk or not, below are some things you can do to help keep your bones healthy and prevent osteoporosis.
Increasing your calcium intake is the easiest thing you can do to help prevent osteoporosis. You can increase your calcium intake by eating foods that are high in calcium or by taking a calcium supplement. It is best for people to begin adequate calcium intake at an early age, as bone mass begins to decrease around the age of 30. After age 30, calcium helps decrease bone loss, strengthen bones, and decrease the risk of fractures.
The recommended daily intake of calcium for women 25 to 50 years old and women over 50 who take hormone replacements is 1,000 mg per day. Women over 50 who do not take hormone replacements should take 1,500 mg of calcium per day. Men 25 to 65 years old should take 1,500 mg of calcium per day. Men and women over age 65 should take 1,500 mg of calcium per day.
If you take calcium supplements, make sure they contain Vitamin D, as this helps with absorption. Also, look for calcium citrate because it is absorbed better than calcium carbonate. If you take the carbonate form, make sure you take it with food.
To help prevent bone loss and fracture, adults should take at least 800 mg per day of vitamin D. Many calcium supplements contain vitamin D. You can also get vitamin D through foods such as egg yolks, fish, and fortified milk and cereals. Halibut, mackerel, sardines, shrimp, pink salmon, and cod liver oil are good sources of vitamin D.
Exercising five days a week for at least 30 minutes helps reduce the risk of bone loss. The best exercises for maintaining bone mass are weight-bearing exercises like walking, low-impact aerobics, and safe forms of dancing. Always check with your doctor before starting an exercise program.
Currently there are four medications that are approved by the US Food and Drug Administration (FDA) to help prevent bone loss and osteoporosis.
Hormone Replacement Therapy (HRT)
Hormone (estrogen) replacement therapy (HRT) is used to both prevent and treat osteoporosis. HRT can reduce bone loss, increase bone density in the spine and hips, and reduce the risk of hip and spinal fractures in postmenopausal women.
HRT is usually given as a pill or skin patch. It is effective even when started after age 70. Estrogen taken alone can increase the risk of developing endometrial (en-doh-me-tree-al) cancer (cancer of the uterine lining). For this reason, a second hormone called progestin (pro-jest-in) is usually prescribed in combination with estrogen for women still having their uterus.
Side effects of HRT can include nausea, bloating, breast tenderness, and high blood pressure. Some studies indicate a link between estrogen use and breast cancer, while other studies do not. Make sure to discuss the pros and cons of hormone replacement therapy with your doctor.
Bisphosphonates (bis-foss-foe-nates) inhibit breakdown of bone and slow down bone resorption. They have been shown to increase bone density and decrease the risk of hip and spinal fractures. Alendronate (al-en-dro-nate) is the bisphosphonate that has been approved by the FDA for preventing and treating osteoporosis in postmenopausal women. The strongest side effect of alendronate is gastrointestinal problems. To avoid these problems, alendronate should be taken with a full glass of water and on an empty stomach, and you should remain in an upright position for at least thirty minutes after taking alendronate.
Calcitonin (kal-si-toe-nin) is recommended for women who cannot or choose not to take estrogen or hormone replacement therapy. For women who are at least five years past menopause, calcitonin can increase spinal bone density and slow bone loss. Calcitonin is a protein, so it cannot be taken by mouth because it would digest before it is able to work. Calcitonin is available as an injection or nasal spray.
Selective Estrogen Receptor Modulators (SERMs)
SERMs are medications that have effects similar to estrogen in some parts of the body, such as the spine and hip. SERMs seem to prevent bone loss of the spine, hip, and total body. Raloxifene (rah-lox-i-feen) is the SERM drug currently approved by the FDA for preventing osteoporosis. Its impact on the spine does not appear to be as powerful as either hormone replacement therapy or alendronate. There are no common side effects with raloxifene. Some women have experienced hot flashes and deep vein thrombosis (throm-boh-sis) (DVT) which is a blood clot in the leg.
Scheuermann's kyphosis is a "developmental" type of kyphosis. This means that it happens while your body is growing. Normal vertebrae are rectangular-shaped and stacked on top of one another like building blocks, with a soft cushion disc between each one. In Scheuermann's Kyphosis, the front of the vertebrae wedge forward and closer together in a triangular shape. This causes the spine to curve forward more than normal. Scheuermann's Kyphosis develops in adolescents while their bones are still growing. It happens to about 1% of people in this age group, and happens in boys as often as in girls.
What Causes Scheuermann's Kyphosis
The cause of Scheuermann's kyphosis is not yet known, but there are many possible theories about how it develops. Scheuermann, a Danish radiologist, proposed that the problem started because cartilage in the spine died from a lack of blood supply. He suggested that this interrupted bone growth during development, leading to wedging of the affected vertebrae.
Most researchers think that some sort of damage to the growth area of the vertebrae starts the process. This damage may be caused by a vertebral disorder during the rapid growth spurts of adolescence. Many spine specialists also believe that a problem with the mechanics of the spine (the way it is put together and functions) plays a part in Scheuermann's kyphosis. Others suggest mild osteoporosis could contribute to the deformity. Muscle abnormalities have also been considered as a possible cause. And there does seem to be a high genetic predisposition to this disease — meaning that it tends to run in families.
Scheuermann originally noticed this spinal deformity in agriculture workers who were frequently hunched or bent over. This led to the question of whether poor posture could lead to extra kyphosis. While this is a logical question, the connection between posture and this deformity has never been confirmed. However, poor posture has been shown to play a role in making the problem worse. Therefore, correcting postural problems can sometimes help improve abnormal kyphosis.
Symptoms of Scheuermann's Kyphosis
Symptoms of Scheuermann's Kyphosis generally develop around puberty, between the ages of 10 and 15 years old. It is difficult to know exactly when the problem begins because X-rays do not show the changes until the child reaches 10 or 11 years old. Scheuermann's Kyphosis is often discovered when parents notice their child has poor posture or is slouching. The child might experience pain and fatigue in the mid back. The pain is rarely disabling or severe at this point, unless the deformity is severe.
Scheuermann's Kyphosis is usually slow to develop. When it progresses to the point the rounded curve becomes noticeable, a concerned parent or teacher will suggest a doctor visit. This is what leads most children to get medical help — not the presence of pain. By comparison, adults who develop Scheuermann's Kyphosis early in life tend to seek help because pain from the deformity becomes unbearable.
A rigid curve in the spine is common with Scheuermann's Kyphosis. The curve gets worse with bending over and only partially corrects when standing up straight. Pain typically increases with time and severity of the deformity. About one-third of people with Scheuermann's Kyphosis also have scoliosis (sko-lee-oh-sis). Scoliosis is another type of spinal deformity that usually occurs in teenagers. Looking at an X-ray from the front, scoliosis curves side to side, like an "S" rather than a straight line.
People who have Scheuermann's Kyphosis usually do not have nerve problems from the spinal deformity. However, a severely rounded spine can squeeze the contents of the chest and abdomen. The disorder may eventually put pressure on the heart, lungs, and abdomen. This can cause chest pain, shortness of breath, and loss of appetite.
The bones of the spine are arranged to give the spinal column stability. Damage or defects within the supporting structures of the lumbar spine can be a source of back pain. A crack in the bony ring of the spinal column is called spondylolysis (spon-dil-low-lie-sis). If a crack occurs on both sides of the bony ring, the spine is free to slip forward. This condition is called spondylolisthesis (spon-dil-low-liss-the-sis). About 5% to 6% of people are affected by these two conditions.
What Causes Spondylolysis and Spondylolisthesis
Spondylolysis mainly affects the lowest lumbar vertebra. The bony ring, formed by the pedicle and lamina bones, protects the spinal cord and spinal nerves. The bone is weakest between the pedicle and lamina, an area called the pars interarticularis—"pars" for short. A pars defect is believed to be a stress fracture. A stress fracture happens from repeated strain on a bone. At first your body is able to heal the damage. If strains repeat and happen faster than your body can respond, the bone eventually fractures. People are not born with spondylolysis. It commonly first appears in childhood. Football linemen and gymnasts are affected the most.
Spondylolisthesis occurs when a spondylosis occurs on both sides of the bony ring. A crack on both sides of the bony ring separates the facet joints from the back of the spinal column. The facet joints can no longer steady the vertebra, and the vertebra on top starts to slide forward, slowly stretching the disc below. In adults, there is usually no danger that the top vertebra will slide completely off the vertebra below. But teenagers sometimes have a unique type of spondylolisthesis in which one vertebra slips forward and slides completely off the vertebra below.
Symptoms of Spondylolysis and Spondylolisthesis
Spondylolysis and spondylolisthesis can be a source of low back pain. Having one of these conditions does not mean you are certain to have back problems, but it does put you at higher risk. These conditions can cause mechanical pain—the kind that comes from within the moving parts of the spine. They can also cause compressive pain, which is from pressure on the nerves of the low back.
Pinched or irritated nerves produce compressive symptoms. This occurs in spondylolysis when a lump of tissue forms around the crack where the body has tried to heal itself. The lump can cause pressure on the spinal nerves where they leave the spinal canal. A pinched nerve can also happen in spondylolisthesis when the vertebra slides forward and squeezes the nerve. The forward slip of the vertebra also makes the spinal canal smaller, leaving less room for the nerve roots. Pressure on the nerve can produce pain that radiates down to the foot. It can also cause numbness in the foot and weakness in the muscles supplied by the nerve.
Spondylosis (spinal osteoarthritis) is a degenerative disorder that may cause loss of normal spinal structure and function. Although aging is the primary cause, the location and rate of degeneration is individual. The degenerative process of spondylosis may affect the cervical (neck), thoracic (mid-back), or lumbar (low back) regions of the spine.
In the first part of the 20th century, sacroiliac (sack-row-ill-e-ack) (SI) joint syndrome was the most common diagnosis for lumbago (lom-bay-go) (low back pain). Any pain in the low back, buttock, or leg was usually referred to as SI joint syndrome. Before 1932, SI joint syndrome was a very popular diagnosis. There was actually a period referred to as the "Era of the SI Joint."
In the late 1980s, many doctors "rediscovered" the SI joints as a possible source of back pain. Yet even today, SI joint pain is often overlooked. Many doctors have not been trained to consider it. Many are still reluctant to believe a joint that has so little movement can cause back pain.
What Causes Sacroiliac Joint Syndrome
Many problems can cause degenerative arthritis of the SI joints. It is often hard to tell exactly what caused the wear and tear to the joints. One of the most common causes is an injury. The injury can come from a direct fall on the buttocks, a motor vehicle accident, or even a blow to the side of your pelvis. The force from these injuries can strain the ligaments around the joint. Ligaments are the tough bands of connective tissue that hold joints together. Tearing of these ligaments can lead to too much motion in the joint. The excess motion can lead to wear and tear of the joint and pain from degenerative arthritis. Injuries can also cause direct injury of the cartilage lining the surfaces of the joint where motion occurs. Over time, this will also lead to degenerative arthritis in the joint.
Pain can also be caused by an abnormality of the sacrum bone. The sacrum bone is actually a very specialized set of vertebrae. When your body is undergoing development in the womb, several vertebrae fuse together to form the sacrum. In some people the bones that make up the sacrum never fuse together. In these cases, two or more of the vertebra that should fuse together remain separated. This creates an odd situation where the SI joint is not formed properly and a false joint occurs (sometimes called a "transitional syndrome"). This abnormality can be seen on X-rays. People who have this syndrome seem to have more problems with their SI joints, as well as back pain that appears to come from that area.
Women are at special risk for developing SI joint problems later in life due to childbirth. Female hormones are released during pregnancy that allow the connective tissues in the body to relax. The relaxation is needed so the pelvis can stretch enough to allow the baby to be born. This stretching causes changes to the SI joints, making them extra or overly mobile. Over a period of years these changes can lead to wear-and-tear arthritis. During pregnancy, the SI joints can cause discomfort both from the effects of the hormones that loosen them and from the stress of the growing baby. The more pregnancies a woman has, the more chance she has of developing SI joint problems.
Symptoms of Sacroiliac Joint Syndrome
Symptoms of SI joint syndrome are often hard to distinguish from other types of low back pain. In most cases, there is a confusing pattern of back and pelvic pain that mimic each other, making diagnosis of SI joint syndrome very difficult. The most common symptoms of SI joint syndrome include:
Low back pain
Difficulty sitting in one place for too long due to pain
Rheumatoid (room-a-toyd) arthritis or RA is a disease that affects all of the synovial (sin-o-vee-al) joints in the body including the spine. For people with RA, the effects of the arthritis on the spine can vary from minimal symptoms to life-threatening pressure on the spinal cord that requires complicated surgery to stabilize the spine and reduce the pressure on the spinal cord.
How Rheumatoid Arthritis Causes Back and Neck Pain
RA destroys synovial joints. As the joints are destroyed, the connection between each vertebra becomes unstable. The damage allows the upper vertebra to slide forward on top of the lower vertebra in the joint. This slippage is called spondylolisthesis (spon-dil-low-liss-the-sis). Spondolisthesis can cause pain due to pressure applied by the slipped vertebra on the nerve roots and the spinal cord. The problem of joint instability is very serious when it occurs between the C1 and C2 vertebrae in the cervical spine.
Symptoms of Rheumatoid Arthritis in the Spine
RA in the spine causes a wide range of symptoms. Pain is the earliest symptom and may be part of the overall joint inflammation that occurs with the arthritis. As the disease progresses, the symptoms that are most worrisome are those that suggest your spinal cord is being affected.
Pain at the base of the skull is common when the cervical spine is affected by RA and can indicate that the nerves that exit the skull and the upper spine are being irritated or compressed. Pressure on the vertebral arteries can lead to blackout spells when the blood flow through these arteries is reduced when you move your head and neck a certain way.
A change in the ability to walk can signal increasing pressure on your spinal cord. Your gait (the way you walk) may become irregular and may be accompanied by weakness and problems keeping your balance. This is an indication that your spinal cord is being compressed. Any change in the ability to walk should be brought to the attention of your doctor. Feelings of tingling, weakness, or a loss of coordination can affect the arms or legs. Changes in bowel or bladder control such as incontinence or inability to urinate can also occur.
Fibromyalgia is a chronic pain disorder that affects millions of Americans each year and can be both physically and emotionally distressing. Fibromyalgia sufferers experience widespread chronic muscle pain, but localized pain in a series of tender points is another classic symptom.
Most of us think of back strains and back sprains as pains of daily living. You lift something wrong, and you pull a back muscle—just an example. These sprains and strains can usually be treated with a combination of over-the-counter medications, rest, ice, and heat.