Is It Arthritis…Or Something Else?
by Jan Revella, RN
  Pain? Think it's arthritis? Maybe it is, or...maybe it's not!
 Not everything that is related to joints, muscles, and bones is arthritis. In fact, there are types of problems that are clearly not related to arthritis. Why is this important to know?
 There are problems that can mimic symptoms of arthritis but indeed are not arthritis. Or, you have a type of arthritis for which the treatment being offered isn't effective because treatment differs based on the form of arthritis you have. Additionally, some medical providers may say without intentional harm that your pain is "just arthritis...You have to learn to live with it". Never believe that pain is to be expected and “put up with” because you are simply getting older. If your doctor tells you that you have "arthritis" and does not give you options to reduce pain and improve functionality, it may be because you seem to be getting along “well enough” or he doesn’t have the answers. Remember, you are the head of your treatment team and it’s important that you are able to communicate how you feel and the life you live with the problem.
 Some helpful things to consider:
  • Symptoms of numbness in the fingertips, particularly the thumb, pointer and long fingers may be carpal tunnel syndrome. Other symptoms can be pain or tingling in the palm in the hand, numbness or tingling that wakes you up and you shake or move your hand to improve the feeling. If you have trouble with dexterity such as picking up coins from a table, it may be a sign as well. This condition requires an accurate diagnosis and follow-up treatment. If this condition is severe, nerve damage can be irreversible. It is best to not mask these symptoms with medications; instead, see your doctor and get an accurate diagnosis. It is the best way to resolve the problem either conservatively or surgically depending on its severity and the findings of the history, physical examination and diagnostic testing.
  • When you flex or bend your finger, if it gets "stuck" and is difficult or painful to extend straighten it to its original position can be a condition called tenosynovitis or "trigger finger". It is not arthritis and will not respond to arthritis treatments. If you can live with it, no treatment is required, but if it’s painful and is not getting better, treatment is easy and usually permanent. A cortisone injection or minor surgery can correct this problem. The problem stems from inflammation around one of the "fasteners" that holds your tendon at the base of your finger near the palm of your hand. It's a condition one can live with or easily treat.
  • "I just can't walk" is a common statement. This can be due to many things including arthritis, a neurological problem, progressive weakness or even a medical problem. Often we attribute this complaint because we believe these difficulties are part of aging. They are not. Something is causing the problem. Look into it and ask your doctor why. Once you know, ask specifically what can be done to help improve your walking.
  • When one has arthritis of the knee(s), we hear, "I don't have any pain, I just can't walk". This may be knee osteoarthritis. Many times with this problem, you stop walking, weaken and don't even realize that you are in the process of limiting your independence. If you walked further, the pain would come which is common with knee arthritis. See your doctor. You can consider medication and physical therapy. If this isn’t enough, you can consider viscosupplementation which is a series of one to five injections into the knee. The number of injections depends on the type of viscosupplementation chosen. Viscosupplementation can help to protect your knee and buy you time. This treatment can improve your ability to walk because the pain lessens. Along with correct strengthening exercises, you can return to walking more and feeling better. If you let this problem take its own course, you will gradually lose your ability to get up from a chair and perform even the simplest of activities.
  • Do you suffer from cramping in your thigh or calf muscles? This could be a number of things but specifically consider getting an evaluation as to the cause. Cramping can be a symptom of spinal stenosis or simply a mineral deficiency. It can even be something as simple as a tight muscle that would benefit from a daily stretch. Not only is it important to know the options based on the right diagnosis, there are options to minimize the symptoms. Stretching exercises is one of the easiest remedies along with proper treatment from your doctor.
  • Do you have pain on the side of your hip when you get up and down from a chair, when you walk too much, or when you lie on your side at night? It may be bursitis, not arthritis. However, bursitis is always secondary to something else so it is helpful to know the underlying problem. It can be hip arthritis without arthritis symptoms which is common. It can be muscle weakness specifically in the abductor muscle. It can even be a leg length discrepancy and more. If bursitis is treated with a cortisone injection, always request a course in rehabilitation so you unload the area which can help to keep symptoms away for the long term instead for the short term.
  • Do you have pain in the heel of your foot, particularly when you first take your first steps when getting out of bed or up from a chair? This is not arthritis nor is it a bone spur. It can be a condition called plantar fasciitis. This is an inflammation at the heel where the soft tissue spans from the front of your foot. Usually this is due to a foot imbalance we get as we grow older and our feet weaken and spread. The bone spur is a secondary response to this inflammation. The goal is to treat the inflammation, although the heel spur remains. Try stretching the bottom of your foot with your hand pulling on the toes upward. Also perform calf stretches. Do these five times before bedtime and each morning. Usually in a week or two, the pain will be reduced or gone. Second, buy a good pair of shoes with good support. Most people will not need any further treatment that this, but if you do, be conservative and careful. You might benefit from a shoe orthotic that balances your foot if pronation or a flat foot is part of your problem.
  • Have you broken a bone lately and excuse it to aging? This is not an aging problem, it’s often osteoporosis. If you take a minor or major fall that resulted in a fracture, there is a good chance you have osteoporosis. To know, ask your doctor for a DXA bone density scan. The DXA will test your hip, spine and/or wrist which are common areas for a fracture. The result, called a T-score, determines the need for treatment. A score less than -2.5 means osteoporosis and requires treatment to reverse the process. Fractures do not occur because you are older, it’s because your bone has lost bone strength due to osteoporosis or another medical condition.
These are just a few conditions that come to mind which people often misunderstand.

 What else can you do to understand your problem? Learn to describe your problem and its symptoms in less than 2 minutes. Describe the type of pain, level of immobility and loss of specific activities. Instead of complaining how the doctor may not spend enough time with you, focus on how to make the most of the time you do have. Learn to sum it up, listen to what your doctor says and ask for the options to treat the problem. Additionally, forget the niceties about how he is or what family is with you or asking about your doctor's grandkids. You get the idea. Know that how you spend the time talking with your doctor is going to result in how much you learn so you can help yourself. Don’t be afraid to speak up, ask the pointed questions and ask for clarification for answers you don’t fully understand. You can help your doctor be specific. You can obtain copies of your reports and learn all you can so you know the options, even those he failed to fully discuss.

© 2010 Arthritis Education by Professionals, Inc.


Taking Control of Osteoarthritis
by Jan Revella, R.N.

  Pain in the neck? A crick in the old hip? You may be one of the 20 to 40 million Americans who have osteoarthritis, one of the most common forms of arthritis. Also known as "degenerative" or "wear and tear" arthritis, it is a breakdown of protective joint cartilage, leaving the ends of bone to rub painfully against each other.

  Osteoarthritis is most common after age 45, but can affect people in their 30s and 40s as well. Most often it affects the weight-bearing joints (hip, knee, spine) and the fingers, including the base of the thumb. Involvement of the hip is more common in men, and involvement of the fingers is more common in women.

  Primary osteoarthritis occurs independently; secondary osteoarthritis develops after a traumatic injury to a joint, as a result of a congenital defect, from increased stress on joints due to obesity, or from a metabolic disorder such as gout.

Symptoms and Diagnosis

   The symptoms of osteoarthritis vary greatly from person to person; it can be mild, moderate or quite severe. Most of the time, however, osteoarthritis can be very successfully managed.

  The primary symptoms are pain, stiffness and restricted movement caused by joint degeneration. Unlike rheumatoid arthritis, which is a systemic immune disorder, osteoarthritis does not usually exhibit inflammation (redness, tenderness and swelling), although it is possible. If inflammation is present, it's a result of the joint damage and not due to the same underlying process as rheumatoid arthritis.

The following symptoms are characteristic of osteoarthritis:

  • Joint pain, particularly after overuse
  • Pain that eases after a period of rest
  • Stiffness and (sometimes) swelling
  • Loss of joint motion
  • Achiness when weather changes
  • Pain on standing or walking
  • Crepitus, or the sound of "snap, crackle and pop" when moving the joint

  Bony bumps in the finger joints, at the base of the thumb and in the joints of the spine are also part of the degenerative process of osteoarthritis. When the cartilage in the joint breaks down, the body attempts to repair the damage. Because there is no blood supply in cartilage, cartilage can not heal itself. As a result, extra bone grows, forming osteophytes ("spurs," or calcium deposits) around the joint, restricting its motion and causing pain. Sometimes, these spurs will impinge on or interfere with nerves. When this occurs in the spine, it's called spinal stenosis, resulting in leg pain. When the sciatic nerve is affected, the symptom is called sciatica.

  Particularly characteristic of osteoarthritis are bony changes that increase the size or width of the finger joints. In the mid-finger joints they're called Bouchard's nodes, and the ones at the ends of the fingers are called Heberden's nodes.

  To diagnose osteoarthritis, your physician will conduct a physical exam, take your medical history, and possibly order x-rays and other tests. X-rays will reveal narrowing of the joint space and bone spur formation. Blood tests may be done to rule out other types of arthritis, such as rheumatoid arthritis, or to obtain baseline information prior to treating you with medications. Generally, inflammation that is commonly identified in the blood of people with rheumatoid arthritis will not be present in osteoarthritis.

Treatment Options

   Once the diagnosis of osteoarthritis is certain, the goal is to decrease pain and increase activity and strength. With your doctor, possibly a rheumatologist, you will need to develop an effective treatment plan that will manage pain, prevent disability and keep you as independent as possible in your daily activities. The plan will be different for everyone, because it depends on the severity of the disease, the joint damage that has already occurred, and which joints are affected. A typical treatment plan will combine short- and long-term approaches and can include medication, joint protection, exercise, massage, heat and cold, weight control, surgery and more.

Passive vs. Active Approaches

   Passive approaches like analgesic or NSAID therapy, massage, heat, cold, ultrasound and neoprene sleeves can be useful in relieving the pain of OA. Since these approaches can ease pain, they are many times a first step to becoming more active.

  However, none of these therapies, including medications, will control the disease process or improve the damage that is already done. It's important to realize that both passive and active approaches must be part of your treatment plan to get the most from what you can do to help yourself.

  Passive Approaches. Over-the-counter pain relievers such as acetaminophen (i.e. Tylenol) may be used to relieve mild osteoarthritis pain. If there is some inflammation, a non-steroidal anti-inflammatory drug (NSAID) may be the better choice. Over-the-counter NSAIDs include aspirin, ibuprofen (Advil, Nuprin) and naproxen (Aleve). If necessary, your doctor can select the appropriate medication from a whole array of prescription NSAIDs. Always make sure your medication, whether prescription or over-the-counter, is supervised by your physician. NSAIDs can cause stomach problems, such as ulcers and bleeding, when used over long periods.

  As a result of the problem many people have experienced with NSAID therapy, a new class of NSAIDs called COX-2 inhibitors has recently been FDA approved, designed to provide relief of osteoarthritis symptoms with much less risk of stomach problems. Additionally, COX-2 inhibitor NSAIDs can be taken with blood thinners, something not available before this new class of NSAIDs became available. Celebrex, Mobic and Vioxx are the most frequently prescribed. If medication is needed, work with your doctor to determine the smallest dose that is effective for you.

  Injecting steroid preparations (cortisone) into the joint can ease pain and inflammation. Cortisone preparations are kept at a minimum due to side effects. If a cortisone injection is ineffective in relieving pain, it may be due to the joint losing all its cartilage surface. Cortisone will rarely help a joint that is already severely degenerated. Another injectable preparation is now available to treat osteoarthritis of the knee. It mimics hyaluronic acid, the natural "lubricating oil" of the joint, and goes by the brand names Hyalgan and Synvisc. Again, although proven to be very helpful, these injectables work best when there is some cartilage remaining in the knee joint.

  Active Approaches. These include joint protection and other modalities that help you to become more functional and active--something that passive approaches won't do in the long run. Through appropriate exercise, assistive devices, activity modification and, sometimes, surgery, one will be able to achieve much more in controlling pain and loss of independence.

  It's very important to remain active with osteoarthritis. That's hard, because when our joints hurt we tend not to use them. After years of extra stress caused by a joint that has degenerated and doesn't move the way it was meant to, your muscles can weaken. As a result, they won't be able to support your joint as well, which increases pain and leads to even more joint damage.

  Exercise and a program for strengthening muscles help break this cycle. Remember, the goal is to reduce pain and increase strength. Strength is obtained through exercise. Strength added to your joints diminishes pain and reduces actual stress to the joint. If you do not consciously do something to increase strength, chances are you will lose ground over the years simply because we weaken with age. Arthritis pain worsens with weakness.

  Whether it's a series of range-of-motion exercises provided by a physical therapist, or swimming, walking or bike riding, always be gentle on your joints when exercising. Start slowly, and build repetitions gradually. Don't use weights unless you know it won't cause further damage to your joints. Proper instruction is important. Swimming or water aerobics are excellent for people with osteoarthritis, because the water supports your body weight. Once you get going, you'll find exercise helps you feel better and function better overall.

  Inasmuch as we may not want to undergo surgery, surgery can play an important role in the treatment of osteoarthritis. Different joints can benefit differently from the various types of surgery. Total joint replacement is the most popular and generally the most successful in the long term. People with knee problems caused by torn or damaged cartilage may find that arthroscopic procedures can provide some relief. If osteoarthritis has caused severe joint damage, the only way to regain that lost function and put an end to the pain may be joint replacement surgery.

  Total joint replacement, especially of the hip and knee, has an excellent track record. It has relieved pain and restored joint function in 95 percent of patients for 15, 20, 25 years--and even longer.

  Always remember that you are the most important member of your treatment team, working with your primary care physician, rheumatologist, orthopaedic surgeon, physical therapist and others. To enjoy the best quality of life possible with osteoarthritis, you must take an active role from the beginning--don't let it control you! The more you know, the more successful your arthritis management will be.

Managing Osteoarthritis: Short-Term and Long-Term Approaches

  Effective management of osteoarthritis--or any type of arthritis, for that matter--requires a treatment plan that balances both "short-term" and "long-term" approaches. A short-term approach helps make today better, such as using an ice pack on a sore joint or taking some medication for pain or inflammation. A long-term approach works to ensure your continued independence down the road, such as learning about joint protection, exercise and strengthening, and assistive devices.

Short-Term Approaches

  • Medication (NSAIDs, analgesics, analgesic creams/rubs, injectable medications)
  • Heat and cold
  • Massage/ultrasound
  • Rest

Long-Term Approaches

  • Exercise (water and land aerobics, flexibility, strengthening)
  • Weight loss
  • Assistive devices
  • Surgery

About the author:
Jan Revella, R.N., Arthritis Nurse Specialist, is founder and director of Arthritis Education by Professionals, Inc., based in Phoenix, Arizona. She is among the most prominent speakers and educators on the subject of arthritis in the United States. Her mission is to empower people with arthritis to use knowledge as power when making decisions about their personal healthcare. Arthritis Education by Professionals, Inc. provides educational programs and services to people with arthritis.

© Copyright 2005. Arthritis Education by Professionals, Inc.



Pain: It's Many Faces
The More You Know, The Less It Hurts
by Jan Revella, R.N.

  Pain?! If we have arthritis, or think we have it, we are inclined to think that the sole cause of our pain is "inflammation." Sometimes, this belief is further reinforced when the only treatment offered by our doctor is an "anti-inflammatory" medication. This assumption is not always a correct one.

  In the beginning, pain can be a friend because it signals something is wrong. But as time passes, the chronic nature and unpredictability of pain symptoms can make life miserable and seem out of control. The optimistic attitude we once had turns into frustration and hopelessness, so medication can seem like the answer. If we take over-the-counter pain medication or anti-inflammatories without understanding the reasons for the pain, we are only masking symptoms and not addressing the progressive nature of the disease. To make matters worse, anti-inflammatory medications do not alter the actual disease progression of arthritis.

  So, let's start at the beginning.

Causes of Arthritis Pain

   Pain caused by arthritis really comes from several sources. Understanding these sources can help us make informed day-to-day decisions, so we can live more comfortably and more actively and have more control over arthritis. In short, it can make us better arthritis "managers."

  The first source of arthritis pain, of which we are all painfully aware, is a result of the disease process or joint damage. In each major form of arthritis, however, a different joint tissue is involved.

  In rheumatoid arthritis, for example, the problem is chiefly "synovitis," or the inflammation of the synovial lining in the joint. Left unchecked, this inflammation can lead to further damage, mainly to precious cartilage, tendons and other soft-tissue structures. This inflammation must be reduced with medication. To preserve joint function, a treatment program should include joint protection, appropriate exercise, rest, heat and cold applications, and management of stress and depression.

  In ankylosing spondylitis, inflammation results where ligaments and tendons attach to the bone of the spine and to adjacent joints. This inflammation needs to be suppressed with medication, along with a regular and vigorous stretching program.

  On the other hand, osteoarthritis, also called "degenerative arthritis," is a problem of breakdown of the cartilage within the joint. Little, if any, inflammation exists. Osteoarthritis is helped by proper exercise and use of joints, and by making many of the lifestyle alterations recommended for the management of rheumatoid arthritis.

  Gout, another form of arthritis, can be controlled through changes in diet and with medication that corrects uric acid levels in the blood. As we see, each form of arthritis is different; pain management techniques and disease treatments differ depending on the kind and severity of the arthritis.

  But the different forms of arthritis aren't the only pain culprits. Another type of pain can be caused by weak or tense muscles. Although it is a natural response for the body to "favor" an injured or arthritic joint in an effort to protect it, this causes our muscles to become smaller and weaker. This weakness leads to further joint instability, and pain. To make matters worse, favoring a joint forces other joints to take on the extra load, thus increasing the stress on those joints, too.

  Other factors can cause pain in the arthritis patient as well. Increased pain can result when we believe we can "beat" or "ignore" arthritis. Many times, we do too much or we don't care for ourselves and our joints as well as we should, causing increased swelling, more joint damage and, therefore, more pain.

  Finally, fear and depression can increase arthritis pain. When we are afraid and depressed, everything seems worse.
Now that we understand that there are many causes of arthritis pain, the question becomes: How do we deal with it?

Pain Management Techniques

   In order to effectively manage arthritis pain, first you have to know what to do, and then you have to know when to do it.
Many times this means going to the doctor and being prepared to discuss the problem, ask questions and be involved with planning your treatment program. Professionals who focus on the management of arthritis usually will offer several techniques simultaneously to achieve the best possible results for short-term pain relief and long-term benefit.

  In addition to seeking medical attention, there are many other things we can do on our own to outsmart arthritis. In fact, your full participation is imperative if you want to live with arthritis successfully.

  Most of us realize that exercise is good for us, but people with arthritis are often unsure as to exactly what kind of exercise will help, how many repetitions to do, and how to exercise to reduce pain.

  Although aerobic exercises like walking, bicycling and swimming are important for good health, joints need full stretching movements to keep them flexible and strong. Range-of-motion exercises help maintain joint movement, relieve stiffness and restore flexibility. Done daily, they also help make muscles stronger which is critical to unloading the stress on a joint.

  The key to success is gentle and regular exercise. It is possible to start your own exercise program, but it can be very helpful to begin by visiting with a physical therapist or an exercise trainer to ensure that the type and amount of exercise done is right for you. The best time to exercise is when you have the least pain and stiffness, and when you are not tired. Stiffness and fatigue go hand in hand with pain. It is our job to keep stiffness and fatigue in check. However, left unmanaged, they result in a vicious cycle, which can lead to more pain. For that reason, how you perform daily living activities is important as well. If done improperly, any activity can lead to joint abuse and destruction.

  There are times, however, when the quality of a person's life is so affected by the pain of arthritis that no amount of planning and rearranging of their lifestyle will relieve pain and immobility. That's when it's time to consider surgical correction. Surgical options for arthritis patients offer them the independence to perform again--to dance, to golf, to do what they did before, many times completely without pain.

  Successful management of arthritis is a multifaceted challenge and requires a well-rounded understanding in many areas to implement effective solutions. Management can be simplified through learning as much as possible and becoming a skillful communicator about our feelings and needs. It's our commitment to ourselves that leads us to workable answers and lifelong independence.


7 Pain Management Tips

  1. Respect pain.
  2. Become aware of body position. Good posture makes a difference.
  3. Control your weight.
  4. Avoid remaining in one position for long periods; move frequently.
  5. Find balance between rest and activity. It's OK to take a break.
  6. Simplify daily chores by using assistive devices, and ease the strain through proper planning.
  7. Ask for help when you need it.

Assistive Devices Lend a Helping Hand

  Assistive devices are products that make everyday tasks easier for people with arthritis and help protect your joints. Whether it's opening a tight jar or reaching a can on the top shelf, there is a handy device to help. For example:

Doorknob turner
Electric scissors
Electric can opener
Fat-handled silverware
Jar opener
Playing card holder
Automatic card shuffler

Lamp switch adapter
Car door opener
Pop-top opener for soda cans
Key turner

   Cleaning brush
Dressing stick
Portable cushions
Sock aid
Shoe remover
Elastic shoelaces
Leg lifter
Bedcover pull-up

Lumbar roll
Elevated TV stand
Prism glasses to read or watch TV while lying flat
Adjustable writing board
Cervical pillow
Back and seat support for car
Swivel cushion for car seat
Foot rest

© Copyright 2010. Arthritis Education by Professionals, Inc.



Rheumatoid Arthritis
Breakthroughs in Medical Management
by Jan Revella, R.N.

  Many people tend to think of arthritis as a disease that affects older people. While it's true that most Americans living with arthritis are over age 50, arthritis is an equal-opportunity disease. Anybody can have arthritis. One of the most common types of arthritis is rheumatoid arthritis (RA). Like some other forms of arthritis, RA occurs more frequently in women than men. It often begins in middle age, with increased frequency in older people. Children and young adults also develop it.

  Unlike osteoarthritis, the "wear and tear" arthritis that results from the mechanical breakdown of joint cartilage, rheumatoid arthritis is an inflammatory disease that causes pain, swelling, stiffness and loss of joint function. It has several special features that separate it from other forms of arthritis. First, RA generally occurs in a symmetrical pattern (both knees, both hands, etc.). It affects the finger joints closest to the hand and the wrist rather than the ends of the fingers. People with RA can experience fatigue, occasional fever and general sense of not feeling well. Joints affected are tender, warm and swollen.

  RA affects different people in different ways. In one person it may last a few months or a year or two and go away without causing noticeable damage. Other people can experience mild or moderate disease with flares and remissions. Still others have severe disease that is active most of the time, which can lead to serious joint damage and disability.

  A normal joint is surrounded by a joint capsule that protects and supports it. Cartilage covers and cushions the ends of the two bones. The joint capsule is lined with a type of tissue called synovium, which produces synovial fluid. This clear fluid lubricates and nourishes the cartilage and bones inside the joint capsule. Since cartilage has no blood supply, if the cartilage becomes damaged it cannot heal itself.

Understanding the Inflammatory Process
  In progressive RA, destruction to the cartilage accelerates when the fluid and inflammatory cells accumulate in the synovium to produce a pannus -- the growth of thickened synovial tissue. The pannus produces more enzymes that destroy nearby cartilage, aggravating the area and attracting more inflammatory white cells, thereby perpetuating the process. This inflammatory process not only affects cartilage and bones but can also harm organs in other parts of the body.

  The inflammatory process is a byproduct of the body's immune system, which normally fights infection and heals wounds and injuries. When an injury or infection occurs, white blood cells are mobilized to rid the body of any foreign proteins, such as a virus. The masses of blood cells that gather at the injured or infected site cause the area to become inflamed. Under normal conditions, the inflammatory process is controlled and self-limited, but in people with chronic rheumatoid arthritis, this process keeps going.

  The primary infection-fighting units are two types of white blood cells - lymphocytes and leukocytes. Lymphocytes include two subtypes known as T-cells and B-cells. Normally, when a foreign agent infects the body, helper T-cells recognize that the invader, known as an antigen, is an alien and trigger a series of immune responses to destroy it. In RA, however, a process called autoimmunity occurs. The T-cells mistake the body's own collagen cells as foreign antigens and set off a series of events to rid the body of the perceived threat. Initial events include stimulation of lymphocyte B cells to produce antibodies -- molecules designed for attack on a specific antigen. When these antibodies attack the body's own tissue, they are called auto-antibodies.

  The leukocytes are the other major white blood cells that are spurred into action by the overactive T-cells. Leukocytes stimulate the production of two key players in the inflammatory process: leukotrienes, which attract even more white blood cells to the area, and prostaglandins, which open blood vessels and increase blood flow. As part of their activity, leukocytes also produce cytokines -- small proteins that many researchers believe are critical in the process that leads to joint damage and may even be responsible for inflammation that occurs in parts of the body beyond the joints. In small amounts, these powerful chemicals are important for healing. If overproduced, cytokines can cause serious damage, including fever, shock, and even damage to organs, such as the liver. Important cytokines in the process of rheumatoid arthritis are those known as tumor necrosis factor (TNF) and interleukins. Some cytokines play a role in releasing specific enzymes. One of the most important cytokines currently targeted in rheumatoid arthritis research is tumor necrosis factor. Levels of this cytokine soar in the synovial fluid during arthritic flare-ups.

  If this process continues, the abnormal synovial cells begin to destroy the cartilage and bone within the joint. The surrounding muscles, ligaments and tendons that support and stabilize the joint become weak and unable to work normally. This leads to the pain and deformity often seen with RA.

  Scientists who study RA now believe this damage begins during the first year or two that a person has the disease. That's why early diagnosis and aggressive treatment is so very important in the effective management of RA.

Diagnosing Rheumatoid Arthritis
  Diagnosing and treating rheumatoid arthritis is a team effort involving the patient and a variety of healthcare professionals. Patients can begin seeking help through your family doctor or a rheumatologist. A rheumatologist is a doctor who specializes in arthritis and other diseases of the joints, bones and muscles.

  Rheumatoid arthritis can be difficult to diagnose in its early stages for several reasons. First, there is no single test for the disease. Second, symptoms differ in different people. Symptoms can mock other conditions. Finally, the full range of symptoms develops over time. As a result, doctors use a variety of tools to diagnose the disease and to rule out other conditions.

  You can help by describing your symptoms, when and how they began. Describe the pain, swelling and joint changes you are experiencing. The doctor will want to perform a physical examination of your joints, skin, reflexes and muscle strength. Your blood may be tested for rheumatoid factor (RF), an antibody that is eventually present in the blood of most RA patients. Not all people with RA test positive for RF, especially in the early stages of the disease.

  Other common blood tests done include two that indicate the presence of inflammation in the body, called erythrocyte sedimentation rate (sed rate or ESR) and C-reactive protein; a white blood cell count; and a blood test for anemia and others. X-rays or MRI can be used to determine the degree of joint destruction and monitor the disease on an ongoing basis.

Treatment Options
  Doctors use a variety of approaches to treat rheumatoid arthritis. These are used in different combinations and at different times during the course of the disease and are chosen according to the patient's individual situation. While it is important to control the pain and associated symptoms, it is critical that the disease itself be monitored and managed so long-term damage is kept to a minimum

  No matter what treatment plan the doctor and patient choose, the goals are the same: relieve pain, reduce inflammation, slow down or stop joint damage and improve the person's sense of well-being and ability to function.

Elements of a successful RA treatment plan

General Guidelines
  The treatment of rheumatoid arthritis involves medications and lifestyle changes. Many drugs are used for managing the pain and slowing the progression of rheumatoid arthritis, but no medical program has been found to cure the disease. The object of most drug therapies is to reduce inflammation, prevent damage to the bones and ligaments of the joint, preserve movement, and as free from side effects as possible over the long term.

  Years ago, physicians had recommended a "pyramidal approach" for treating people diagnosed with rheumatoid arthritis, using the least powerful drugs first to avoid toxic effects, then building up to stronger and stronger drugs until the disease was under control. The first drugs used against rheumatoid arthritis were usually nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDS have not been shown to slow or halt the course of the disease. These drugs relieve pain by reducing inflammation, but do not contain steroids. In the past, if NSAIDs were still not effective after about four to six weeks, more potent drugs, disease modifying anti-rheumatic drugs (DMARDs) were added to the regimen. Such drugs are more effective than NSAIDs and may even improve long-term function. Some DMARDS have been shown to slow and halt the progression of the disease.

  However, the problem with this pyramidal approach is its failure to prevent the progression of joint destruction in the majority of people with RA. Working through the pyramid, drug by drug, generally takes 5 to 8 years. Much of the damage in rheumatoid arthritis occurs in the first two years when only the drugs used are those that control symptoms or no drugs are used at all.

  Many experts are now recommending that patients with moderate to severe RA should start out immediately with DMARDs, with or without NSAIDs, or start DMARDs after three months if NSAIDs have not relieved symptoms. Indicators for prompt and aggressive treatment with DMARDs include slow progression, involvement in parts of the body other than joints, high levels of rheumatoid factor, and genetic markers. Additionally with the advent of biologic modifying drugs, there are now ways to effective stop the damage of RA and restore active lifestyles before the damage is done. All of these drugs have potentially toxic side effects. Certain factors are always considered when it comes to the various treatments recommended. Gender, age, genetic markers and the accuity of the disease are just some of what is considered when these decisions are made by you and your doctor.

  Now, let's look at medications and specific areas of lifestyle change-

  Medications-As already stated, the use of medication is aimed at reducing pain and slowing or halting the disease process.

  Non-steroidal anti-inflammatories. More than two-thirds of people with RA seek professional help for pain. The most common pain relievers are non-steroidal anti-inflammatory medications. There are dozens of NSAIDS and some are safer than others. NSAIDS do not alter the course of the disease but are designed to reduce inflammation and pain. These drugs block prostaglandins, the substances that dilate blood vessels resulting in inflammation and pain. Pain and stiffness from RA increase gradually during the night, reach their greatest severity at the time of awakening. It's important to take your dose, if singular, in the evening or, if twice daily, morning and evening. All NSAIDS are capable of damaging the mucous layer and causing ulcers and gastrointestinal (GI) bleeding when taken for long periods. Other side effects include dizziness, ringing in the ears, headache and skin rash. If you experience new swelling and rapid gain when using an NSAID, report it immediately to your doctor. People with hypertension, severe vascular disease, kidney or liver problems and those taking diuretics must be closely monitored if they need to take NSAIDS.

  The only Cox-2 inhibitor medication available is celecoxib (Celebrex) which is generally safer and easier on the stomach. However, celecoxib is no more effective than other NSAIDS.

  Disease-Modifying Anti-Rheumatic Drugs (DMARDs) are designed to slow down the progression of rheumatoid arthritis. Studies show that these drugs significantly delay the long-term damage and joint deformities associated with RA. Methotrexate has the best record for long-term use.

  Biologic Response Modifiers are drugs that interfere with the autoimmune response in RA. These drugs are genetically engineered to target the immune factors, particularly tumor necrosis factor (TNF) and certain interleukins, which play a major role in the destructive RA process. There are several biologic type drugs available today.

  Although some people with RA would prefer to stay off these types of medications, it is critical to understand that sometimes these drugs are the mainstay of a long-term quality lifestyle.    
                                                                                                   Rest and Exercise-Both are important. Rest more when the disease is active, and exercise more when you are feeling well. Rest helps reduce active joint inflammation and pain, and fights fatigue. The need for rest varies from person to person, but in general shorter rest breaks every now and then are more helpful than long periods of best rest.

  The goal of exercise is to maintain a wide range of motion, increase strength, endurance, and mobility, improve general health, and promote well-being. A patient should begin with the easiest exercises -- stretching and tensing of the joints without movement -- and then slowly progress to more difficult types. The patient can next attempt mild strength training. Aerobic exercises (walking, dancing or swimming-particularly in heated pools). T'ai chi, which uses graceful slow sweeping movements, is an excellent method for combining stretching and range-of-motion exercises with relaxation techniques. People with RA should avoid heavy impact exercises such as running, downhill skiing, and jumping. Common sense is your guide; if exercise is causing sharp pain, stop immediately. If lesser aches and pains continue for more than a hour or two, then a lighter exercise program should be tried for awhile.

  Exercise is important for maintaining healthy and strong muscles, preserving joint mobility and maintaining flexibility. To simply reduce pain will not return function.

  Joint Protection-You can reduce stress to joints by discovering new ways of doing old tasks. Zipper pullers, long-handled shoe horns, thick-handled brushes, and devices to help with getting on and off chairs, toilet seats and beds are examples of things that help protect joints. Sometimes people find that using a splint for a short time for a painful joint reduces pain and swelling as well.

  Healthful Diet-A nutritious diet with the proper amount of calories, protein and calcium is important.

  Surgery-Several surgical procedures are available to people who have severely damaged joint(s). They can reduce or eliminate pain, improve joint function and appearance, and improve lifestyle. Joint replacement surgery is the most frequently performed for RA. Tendon reconstruction is done when RA causes damage to tendons. This procedure is most often done on the hands. Synovectomy is another procedure sometimes done when its necessary to reduce inflamed synovial tissue around a joint. Synovectomy is commonly performed as part of a reconstructive procedure, especially tendon reconstruction. Total joint replacement is performed when a particular joint is damaged so severely that the joint needs to be reconstructed with artificial parts to restore normal joint movement without pain.

Keeping a Positive Attitude
  People with RA often have a hard time coming to grips with the fact that their lifestyle must be rearranged to accommodate their disease, that they can't always do the things they used to. It can be a difficult adjustment, particularly for people in the prime of life, with children and jobs to manage. Lifting your child or tying your shoes suddenly becomes difficult or impossible.

  Fear, anger and frustration combined with pain and physical limitations can increase stress, and make living with RA more difficult. Regular rest, relaxation and visualization exercises do help. Exercise, warm baths, music, support groups, taking time for yourself and good communication with your healthcare team will also reduce stress. Learn to let little things go, and don't feel you have to do everything.

  Studies continue to show that people who learn about living with RA and participate actively in their own care experience less pain and make fewer visits to the doctors than do other people with RA. People who are actively involved understand more about the disease process, utilize many methods to reduce pain, learn coping skills and have a greater sense of control over their disease.

  While there is no cure for rheumatoid arthritis, we do know that people with a certain gene are susceptible to the disease, and researchers are honing in on what triggers it. For now, we can take charge of RA and take comfort in the knowledge that medicine has made great strides in its ability to effectively treat RA before it causes serious damage.

© Copyright 2010. Arthritis Education by Professionals, Inc.



Thumb-Base Arthritis
Get a Grip on This Common Condition
by Jan Revella, R.N.

  If you're experiencing pain while turning a key, holding a coffee cup, opening the car door, golfing, crocheting, holding a hand of cards, pinching, grasping and performing other fine motor activities using the thumb, you may have what is called "thumb-base arthritis."

  Arthritis at the base of the thumb is extremely common, with women affected four times as often as men. For the most part, the causes are unknown. We do know that this condition is not always related to generalized arthritis of the hip, knee or even finger joints.

Symptoms of Thumb-Base Arthritis

  Frequently, thumb-base arthritis is an isolated case and affects only the unique "saddle" joint of the thumb. The saddle joint is the joint that allows humans to turn and oppose their thumbs in cooperation with the fingers. Arthritis of this joint results in painful pinching, gripping and grasping actions between the thumb and hand. Thumb-base arthritis is painful to varying degrees and can be progressive. The pain is usually located directly over the base of the thumb where it meets the wrist.

 Thumb-base arthritis, particularly in women, frequently begins with a loose joint. Such a person may be "double jointed" at the thumb and is able to pull his or her thumb down to the wrist.

This x-ray shows degenerative arthritis at the base of the thumb, a common problem that causes pain and dysfunction. Both conservative measures, such as therapy and joint protection, and corrective surgery can provide relief.


  This looseness or instability (it's actually a partial dislocation) of the joint can progress to the point where cartilage wears away (arthritis) and pain worsens. Pain will occur from both the partial dislocation and the arthritis.

Treatment of Thumb-Base Arthritis

   Treatment usually begins with a cortisone injection and splint immobilization of the thumb and wrist. This may be followed by hand therapy. For cortisone to be effective in this case, it must be injected accurately into the joint, not just somewhere near it. Cortisone can help the painful symptoms of thumb-base arthritis; however, it will not correct the problem or change the ongoing deterioration. Repeated cortisone injections can accelerate the damage and make the problem worse.

  Immobilization of the thumb in a "thumb spica" splint is also an effective treatment for thumb-base arthritis. The splint immobilizes both the thumb and the thumb side of the wrist. Wearing such a support at night can rest the painful joint and improve comfort in the daytime after the rest in the splint. Additionally, a rubber-like neoprene splint often can be temporarily used and is quite helpful during stressful activities. Learning about joint protection techniques is also a very important part of conservative management for this condition.

  Since the thumb is used every time you perform pinching or grasping activities, it gets plenty of exercise. Specific exercise for the thumb is not necessary. In fact, joint protection and learning how to use the thumb less can help relieve pain and protect the joint at the same time. For example, you should use two hands instead of one when picking up an object, such as a coffee cup, dinner plate or magazine; this prevents one hand from bearing all of the stress between the thumb and fingers. Or, lighten the load when you can, such as when lifting wet clothes from the washer to place into the dryer.

  If conservative treatment fails to relieve pain, and correct use of the thumb and hand continues to be a problem, surgery can be an appropriate next step. Early in the condition's course, surgical tightening of the ligament in this area can be the best treatment to prevent further deterioration of the joint.

  Another option includes a surgical arthroscopic evaluation and cleaning out the joint. Fusion--making the joint stiff so it cannot move, and therefore there is no pain--can be performed through either a traditional open incision or less invasively through arthroscopy. Fusion can be an excellent way to limit the pain and provide more function, but you will experience some loss of motion in the joint. Fusion can be the treatment of choice in men and women who perform repetitive hand tasks, for example on a production line or at a checkout counter at the grocery store.

  For people who would not place a high demand on their thumb base, reconstruction with ligament rebuilding and tendon transfer, both with or without artificial joints, can be used with good results. This type of reconstruction is excellent for pain relief and will increase mobility and function of the thumb for relatively normal use. After this surgery, most people can once again enjoy golf, tennis, needlepoint and other hobbies.

  Postoperative recovery includes splinting for six weeks, with six to eight weeks of hand therapy. All surgeries can be done in about one hour as an outpatient. You'll be able to use the splinted hand within 48 hours of surgery.

  If you have thumb pain, there are many options for help to relieve the pain and dysfunction. You don't have to live with the pain of thumb-base arthritis. Also, it's important to remember that not all pain is arthritis. Some thumb pain can be tendinitis, which is easily treated with a proper program of cortisone and therapy. For more information, consult with an orthopaedic hand surgeon.

About the author:
Jan Revella, R.N., arthritis nurse specialist, is founder and director of Arthritis Education by Professionals, Inc., based in Phoenix, Arizona. She is among the most prominent speakers and educators on the subject of arthritis in the United States. Her mission is to empower people with arthritis to use knowledge as power when making decisions about their personal healthcare. Arthritis Education by Professionals, Inc. provides educational programs and services to people with arthritis.

© Copyright 2010. Arthritis Education by Professionals, Inc.


Winning Over Arthritis
by Jan Revella, R.N.

   For many arthritis patients, the greatest fear as they grow older is a loss of independence. But the good news is that you have control over your condition and your future, as long as you take an active role in the management of your disease.

First, Get an Accurate Diagnosis

   For the arthritis patient, achieving independence for a lifetime begins with an accurate diagnosis, because you need an accurate diagnosis to have accurate treatment. Did you know that there are more than 100 different kinds of arthritis? Also, you can have several different types of arthritis at the same time, for example osteoarthritis and rheumatoid arthritis. While not every musculoskeletal problem is arthritis, most any kind of joint degeneration is some form of arthritis.

   Doctors may try to protect patients from the word "arthritis" because of its negative impact, so they might say that a patient has "degeneration" or "a bone spur." The problem with this is that the patient believes he or she does not have arthritis, and minimizes what could become a very problematic condition later on. Also, the treatment ends up taking a different path than what it should, and patients have no way to find the resources they need to teach them how to manage their condition and remain independent.

  A misdiagnosis or "keeping your head in the sand" can cause you and your doctor to mismanage the situation, prolonging the time it would have taken for your treatment to be effective or--even worse--endangering yourself. That's why it's very important to get an expert opinion, from someone who has enough education and experience to identify the real problem.

Try Active vs. Passive Approaches

   I find that people with aches and pains of arthritis tend to go to their primary care physician or family doctor, and the usual result is a prescription for an NSAID (non-steroidal anti-inflammatory drug) pain reliever such as Naprosyn or Celebrex. If the medication helps, the patient simply continues to renew the prescription on an ongoing basis. But this is a passive approach to arthritis management. Even though a prescription may help inflammation and control symptoms, relief is short-lived because pills don't often significantly alter the course of the disease. They may help today, but five years down the road, depending on the course the disease has taken in that time, they may no longer be effective. While masking symptoms, you may not be aware of the underlying changes going on in your joints as a result of your disease.

   Analgesic creams, NSAIDs, massage, heat and cold packs--all of these things are good to use in the short term to get you through a bad day, but when it comes to looking at where you're going to be later in life, you have to take an active approach to make sure your disease process is really under control. If you're going to outline a course that aims for the long-term goal of independence later on, rather than just the short-term goal of symptomatic control today, you have to manage your arthritis with both passive and active approaches. You have to understand that function is the ultimate goal, rather than only pain control.

  What constitutes an "active" approach? Get educated. Look for legitimate and reputable educational sources. Ask questions of your doctor and find out how other people with your particular type of arthritis take care of themselves.

  Take advantage of joint protection techniques. Joint protection involves many things, including dealing with the mechanical changes arthritis causes in your joints, and keeping these to a minimum. When cartilage diminishes in a joint as a result of the arthritic process, the ligaments and tendons become more unstable, muscles weaken due to inactivity, and bone spurs and other processes secondary to the arthritis crop up and start to limit your motion. This is a progressive problem. Arthritis never goes away; you must be able to understand the pathology, or course of the disease, and decide how you're going to manage that pathology for the rest of your life.

   Also falling under the umbrella term of "joint protection" are nutrition and exercise. Nutrition plays a role on two levels: first, eating right helps in weight control, and that reduces stress on the joints. In addition, good nutrition contributes to your overall health and energy level, which in turn inspires you to be more active. Exercise, combined with periods of rest, is important for building muscle strength; the stronger your muscles, the more work they do and the less stress is placed on your joints. Overall, good nutrition and exercise appropriate for people with arthritis will build and strengthen your muscles, increase your metabolism and make your body more fuel efficient.

  Another active approach to arthritis management, and one that directly contributes to independence, is taking advantage of assistive devices such as those you find in catalogs. Combs and brushes with longer or built-up handles, larger ignition key holders for your car, easy-to-grip pens--not only do these devices make life a little easier, they also can protect your joints from unnecessary damage.

  Finally, the ultimate active approach is surgical intervention. Whether it's a joint replacement, a fusion or any orthopaedic surgical procedure, if it will help you stay as independent as you can be later in life, it should be considered. Learning about the surgery, undergoing the procedure and recovering might take several months, but in the overall span of your life isn't it worth taking that time out to ensure your optimum function later? Especially when you realize that joint replacement not only permanently relieves pain and improves mobility, but it also boosts general health--if your hips or knees don't hurt, you're going to be able to walk and get enough exercise, helping maintain your cardiovascular health as well. If you wait until your health otherwise is risky, the option of surgery might no longer be available to you, and then your health will ultimately fail. To be a joint replacement candidate has nothing to do with age but everything to do with your medical condition and potential ability to recover from surgery. The oldest hip replacement patient I remember was 99 years old. Her main goal was pain relief, and that mission was accomplished. She came through it very well and lived five more years--pain-free years. The youngest hip replacement patient I've worked with was just 14.

   The two most important questions you should ask your surgeon regarding joint replacement are "How many surgeries do you do in a year?" and "What are your personal statistics of success?" It's important to choose an experienced orthopaedic surgeon who can tell you how patients are doing 15, 20 and 25 years after their joint replacement surgery.

  So don't just be passive, act! You are the head of your treatment team. A pill by itself is not the solution. While yes, you must treat the pain, you must also take an active role in order to achieve independence for a lifetime.

About the author:
Jan Revella, R.N., Arthritis Nurse Specialist, is founder and director of Arthritis Education by Professionals, Inc., based in Phoenix, Arizona. She is among the most prominent speakers and educators on the subject of arthritis in the United States. Her mission is to empower people with arthritis to use knowledge as power when making decisions about their personal healthcare. Arthritis Education by Professionals, Inc. provides educational programs and services to people with arthritis.

© Copyright 2010. Arthritis Education by Professionals, Inc.




Advances in Joint Replacement Surgery
by Dennis Armstrong, M.D.

   Undergoing joint replacement surgery can make the difference between living in pain or doing the activities you enjoy. The goal of the surgery is to reduce or eliminate pain in the diseased joint and give you a new joint that allows you essentially pain free movement for many years.

Due to new advancements in joint replacement technology, many people are opting for this surgery at a younger age. With this in mind and for the benefit of anyone who has a joint replacement, it is important that we continually evaluate the success and risks associated with joint replacement surgery, short and long term.

    For years, improvements have focused on specific areas of the surgery. Experts have evaluated fixation of the artificial joints components in the host bone, the refinement of cement and cementing techniques, biological fixation of titanium and similar materials, the effect of beads or surface roughness on the implant interface with bone, ingrowth techniques and the design of many artificial joints. Having achieved a high degree of success through new innovations and upgrades, the current focus centers on the design of the implant and how it wears long term.

    Historically, loosening of the replaced joint from the host bone had been the primary reason for revision surgery. With total joint replacements lasting longer, the issue of wear is now the number one reason joints may require re-operation. Our goal now is to reduce the degree of wear between the moving surfaces of the artificial joint components so they last even longer.

   Over many years, different materials including precious metals, glass, ivory, Teflon and other synthetic materials have been tried and/or evaluated. Now, three materials are routinely used for bearing surfaces: 1) high-density polyethylene (with and without radiation treatment), 2) metal, commonly a stainless steel alloy which is harder than stainless steel, and 3) ceramics.

    Because the need for hip and knee replacement surgery is greater than shoulder replacement, research has more focused on hip and knee joints. Due to the differences of stresses and movements of different joints, artificial joint materials wear differently. Because of these significant differences, I feel each joint should be addressed separately.

The Hip

   Total joint replacement of the hip has been performed at least ten years longer than that of the knee. Since the hip is a ball-and-socket joint, the greatest stresses result from rotation, these stresses are directly related to weight and muscle strength. Early hip replacements performed usually included a small metal ball being placed into a thick polyethylene (plastic) socket. Many of these surgeries have lasted more than 20 years. We now know that the wear of polyethylene in the joint frequently results in a significant amount of debris formation. Over time, this reaction can loosen the bond between the metal components and the bone around them. This long-term process of loosening can sometimes cause local bone loss necessitating a revision to exchange the components. Bone grafting is sometimes necessary depending on the amount of bone loss. Occasionally, these changes are severe in nature, requiring extensive bone grafting with major revisional surgery. This is the primary reason why routine follow-up, including undergoing new x-rays, is recommended annually once youve undergone joint replacement surgery.

    The materials used in joint replacement surgery and the relationship between these materials including the wear factors are continuously scrutinized. As a result, weve updated the ball size from a 22 mm size up to a 44 mm ball diameter because it reduces the risk of dislocation. Weve upgraded the plastic component to a higher-density with radiation to make the plastic polymers link together more strongly; thus, decreasing wear over time. To minimize wear and debris formation, metal on metal and ceramic implants have been developed as well as the ball being altered in size. The development of new materials has significantly reduced wear and debris formation in the hip joint. I feel these material changes will further improve the longevity of the joint implants used in hip replacement.

The Knee

The knee has a different wear pattern. In addition to weight and rotation, the knee joint glides as a hinge.
Because of the differences between the hip and knee, surface materials cannot always be exchanged with the materials used in the hip. Some of the polyethylene changes are being used in the artificial knee joints, but more changes are still expected. Like the hip, ceramic material has been developed as an alternative to the metal component in the knee but the fixation method requires cementing. More changes are likely in this particular design. Metal-on-metal alternatives are not yet available in knee replacement. Continued analysis of the knee component designs has already extended the lifespan of the knee replacement. We now know that moveable parts of the artificial knee does reduce the individual wear in each of the components used, thereby enhancing the lifespan of these components. These components appear to be very successful. Continuing studies, which examine outcomes of current surgery, helps us predict the results of the future.

The Shoulder

    Because the shoulder joint is not a weight-bearing joint, it is not subjected to as much weight and is more of a ball on a socket versus a hall in a socket. The shoulder provides much more sliding motion than the hip.
Due to the shoulders non-weight bearing status, the shoulder components are more affected by activity than by weight factors. The Gold standard of the shoulder replacement continues to be the use of the metal-on-plastic principle. I feel confident that the improved quality of the polyethylene will help increase this joints longevity. This improvement as well as new designs will help decrease bone loss at the time of surgery, increase shoulder stability and extend wear of the components.

In Summary

   Early results in joint replacement surgery have helped direct efforts of total joint replacement surgery improvements. Today, joint replacement has been consistently successful 90-95% of the time and is now lasting between 1220 and more years. The weak link continues to be the wear factor. With continued improvement of the materials we aim at doubling the expected lifespan of these new joints. Major factors of wear continue to be body weight and activity. These concerns must be addressed prior to surgery with understanding and education for the best chance at long term success. Gliding activities such as walking, bicycling, golfing and bowling are better in the long run for the patient and his/her joint replacement then high-impact loading exampled by running, jogging and jumping.

New Horizons

   New approaches and procedures continue to come our way. In some cases, to minimize soft-tissue trauma during surgery, we are turning to minimally invasive surgery resulting in a smaller incision. Future enhancements include the use of three-dimensional enhancement whereby the surgeon utilizes computerized guidance during surgery. We continue to research and develop ways of further preventing blood clot formation, blood loss and other complications. In all probability, the future of joint replacement surgery will include computer-guided surgery with synthetic materials. The benefits will be minimal blood loss and complications.

   Most of our discussion has been focused on osteoarthritis in major joints. Other significant factors involved in the long-term success of total joint replacement including inflammatory arthritis (i.e. rheumatoid, psoriatic), metabolic diseases (gout, pseudogout) have not been addressed in this article. They should be considered on an individual basis. Once your joint has been replaced, individual care is a very important factor in keeping your joint in good condition and furthers the research, which evaluates the long-term success of the surgery.

About Dennis Armstrong, M.D.
Dennis Armstrong, M.D. graduated from Wayne State School of Medicine and completed his orthopaedic residency at Henry Ford Hospital in Detroit, Michigan. Dr. Armstrong is board certified in orthopaedic surgery and specializes in arthritis reconstructive surgery. Dr. Armstrong has been involved in several clinical investigative studies researching and caring of those undergoing total joint replacement. He has presented numerous papers and provided multiple presentations on his clinical research. Dr. Armstrong has been in practice for more than 20 years in the East Valley of the Phoenix Metro area in Arizona.

© Copyright 2007. Arthritis Education by Professionals, Inc.



Differentiating Between Hip and Back Pain
by Jan Revella, R.N. 

   Often people go to the doctor seeking help for hip pain. Sometimes, people try to treat it themselves. They are convinced there is something wrong with their hip and the treatments begin. However, one thing is for sure, hip pain is not always as it appears. Hip pain can be a result of a problem in the hip joint itself. However, it can also be a result of a back problem or a soft tissue problem around the hip region.

   Obtaining an accurate diagnosis is the first step to resuming activities and living an active lifestyle. Let's discuss the reasons for confusion and see if we can realize the causes and treatments for both hip and back pain. Some of a patient's misunderstanding about the origin of the pain is due to not understanding hip and back anatomy. Sounds odd but it's true. The hip joint lies just behind the groin area on each side of the body. At the same time, the spine runs from the base of the skull to the tip of the tailbone. The lumbar spine contains specific nerves that can influence the feelings in the region around the hip area.

Pain Originating in the Hip

   If the problem originates in the hip joint itself, common symptoms include groin pain on the affected side, and sometimes down the inner aspect of the thigh in the front of the leg. This pain can move to the knee and sometimes feels like a knee problem instead of a hip problem. Walking worsens the pain and with continued activity, the pain increases. Rest relieves it; however, when hip arthritis becomes severe, you may have pain most of the time. Minimal activity such as slight movements while in bed can worsen the pain. Other conditions such as advanced congenital hip dysplasia or avascular necrosis of the hip can cause these symptoms as well.

   When the pain originates in the hip from arthritis, motion of the hip is often limited. This limitation is often realized when attempting to get out of a chair or bed and standing up. Contrary to hip pain, pain coming from the back may worsen when sitting or lying down, depending on the origin of the back pain itself.

   Sometimes pain on the side of the hip is a result of bursitis. A weak abductor muscle, a leg length discrepancy, overuse, and an underlying early degenerating hip joint can cause bursitis. At times, the origin cannot be determined. Symptoms include pain on the side of the hip with prolonged walking, side lying in bed or when rising from a chair or similar types of movement.

Pain Originating in the Back

   Low back pain commonly is experienced in the back itself. However, due to the complexity of the spinal cord and associated nerves being an intricate part of the low back, pain may and frequently can radiate or travel further down the course of the nerves. This is similar to striking your "funny bone" in the elbow and feeling the sensation in the hand below the elbow.

   Although some of us are familiar with a "pinched nerve" which is associated with sciatic-like pain in the leg, irritation or inflammation of nerves in the low back region can also cause a sensation in the upper leg or hip region. It is important to realize there are many things that can go wrong in the spine. Remember, sciatica is not a diagnosis but, instead, a symptom of an underlying problem. It is possible to feel back-related pain in the hip region and upper leg as well. It depends on the nerves involved and ultimately the actual diagnosis. "Back pain" or "hip pain" is not a diagnosis but simply an explanation of the area of pain. Symptoms are correlated with physical examination and confirmed through x-rays and similar tests. Some back pain is caused from a "ruptured disc". This pain is often experienced in the gluteal region of the body. Many people call this the "hip" region although it is not usually indicative of a hip joint problem. This is actually behind the hip, an important anatomic thought when considering hip pain, rather than in the hip itself.

   A condition related to degeneration of the lower back creating narrowing of the spinal canal or adjacent areas is called "spinal stenosis" and frequently causes pain in the hip region. (For more on spinal stenosis, refer to p.1 of this newsletter). The history of stenosis has to be compared with hip joint pain. Spinal stenosis can cause leg pain while walking as well as fatigue in the legs even when rising from a chair. Stenosis pain is relieved with sitting and will re-occur when walking is resumed.

   There are differences in symptoms between spinal stenosis pain and herniated or ruptured disc pain. A herniated disc often is more painful when sitting and relieved by standing or walking (opposite of stenosis). A herniated disc can cause sciatica (so can stenosis) and can be a result of degenerative changes in the disc. Sciatica will commonly radiate or travel down the backside of the thigh, into the calf and sometimes the foot itself.

Getting an Accurate Diagnosis

   A thorough history and physical examination is a good start when sorting out symptoms. X-rays will attest to specific bony/cartilage changes but x-rays don't always correlate with the pain. It is possible to have little pain and much damage on the x-rays or visa versa. It is important to treat the patient, not the x-rays alone. Secondly, x-rays of the back can reveal degeneration of the discs or small joints in the spine but the person does well. Contrary, the back may look degenerative and because of the subsequent bone spurring and subsequent symptoms as arthritis progresses, it's important to obtain an MRI to confirm nerve impingements that are suspected. X-rays alone will not show nerve impingement. As you can see, it's important to undergo the history and physical examination and tests that can confirm your diagnosis before treatment begin.


   Both types of problems are frequently helped by anti-inflammatory medications particularly in mild to moderate situations. Some types of analgesics can be used intermittently as well. It's important to realize that both problems can be helped significantly by weight loss, proper forms of exercise and conditioning. In fact, back pain can become chronic without a commitment to the appropriate exercises necessary to stabilize and strengthen the spine. Epidural blocks (corticosteroids are injected into the canal of the low back to reduce inflammation and pain) can help several types of back disorders. Using a cane when walking can help both hip and back pain.

   Surgery, whether a hip replacement for hip arthritis or back surgery due to a ruptured disc, vertebral disorders or spinal stenosis, is a last resort for the treatment of the pain. Both surgery of the hip and the back are quite successful. Full evaluation is necessary and conservative measures are always tried first.

   The question of pain in the hip region is not always a simple one and frequently involves specialized evaluation. Once the diagnosis is determined, options are many and should be discussed with you prior to instituting a treatment plan. The purpose of this article is to help to better assess pain, whether it's coming from the back or the hip itself. Remember, there are many options for treatment. Diagnosis is the first step to successful treatment.

© Copyright 2010. Arthritis Education by Professionals, Inc.




Hip Pain
Is It Your Hip, Your Back or Your Bursa?
by Dennis Armstrong, M.D.

   "What's causing my hip pain?" This is one of the most common questions patients ask their doctors. Unfortunately, it's not always easy to answer. Many conditions can cause hip pain, including some you'd suspect--arthritis or a fracture--and some you wouldn't--spinal stenosis, or a previously undiagnosed congenital hip condition. Whatever the cause, chronic hip pain can force you to cut down on your activities, and leave you stiff and unable to get around as well as you once did.

Location of Pain: Side of hip
Symptoms: Pain when sitting or lying on side
Treatment: Rest, heat, anti-inflammatory medication, cortisone injections, physical therapy
Hip Arthritis
Location of Pain: Front of hip
Symptoms: Pain when walking; groin pain radiating into front of thigh
Treatment: Anti-inflammatory medication, cane, behavior modification, joint replacement
Spinal Stenosis
Location of Pain: Low back, buttocks
Symptoms: Pain on sitting/walking; pain radiating down to knee/ankle
Treatment: Rest, anti-inflammatory medication, spinal injections, physical therapy, surgery
Where's Your Pain?

Pain in the hip, a ball-and-socket joint, can emanate from the hip itself or from unrelated causes, including bursitis and spinal stenosis.

  The hip joint unites the femur, or thigh bone, and the pelvis. The bone ends are covered by glistening blue-white caps of "gristle" called articular cartilage. Articular cartilage is a unique material--it is more slippery than ice on ice. It is an excellent shock absorber, and contracts and expands with pressure. Articular cartilage has no nerve endings or blood supply, so it has little or no ability to reproduce itself (although researchers are currently working on changing that). The joint is held in place by a tough, flexible material called the joint capsule. On the inner capsule is the synovial lining, which produces the fluid that lubricates and nourishes the joint. Movement of the joint is dependent upon the muscles that attach around the joint.

  The hip itself is a ball-and-socket joint. Within its capsule is a very stable joint that can move in any direction. Many muscles attach around the hip, particularly around the trochanter, which is the bony protrusion you can feel at the widest part of the hip area. Around the hip there are two important nerves, the sciatic nerve and the femoral nerve. The sciatic nerve originates in the lower back and supplies sensation to almost all the major muscle groups in the lower leg. The femoral nerve supplies the muscles in the front of the thigh (quadriceps) and down to the level of the knee.

Congenital Defects of the Hip

   Congenital (present at birth) defects can affect the hip, and if not properly diagnosed and treated in childhood can lead to problems later in life.

  Congenital dislocation of the hip (CDH) involves an abnormal formation of the hip joint. The ball at the end of the femur does not fit within the socket, making the joint unstable and prone to dislocation. This condition is not always evident at birth; sometimes symptoms do not show up until the child is older. Splints are used on newborns to coax hips back into their proper position. If this does not work, open surgery may be necessary. If CDH isn't diagnosed until adulthood, it may require surgery to place the hip in its socket or to move the bone into a better position.

  A less treatable but more frequent hip condition is congenital hip dysplasia. In this case, the hip appears to be in position, but the ball is not really deeply seated in the socket. There is typically a very shallow socket, and the ball will tend to ride at the very edge of the socket.

  Left untreated, these conditions can lead to pain, abnormal gait, unequal leg length and, eventually, degenerative or arthritic changes in the hip (osteoarthritis) that may require further treatment.

Avascular Necrosis

   Another condition that affects the hip is avascular necrosis (AVN). Bone requires a constant blood supply to remain healthy; without it, bone begins to die and collapse. This is called avascular necrosis, literally bone death due to lack of blood vessels. In the hip, the head of the femur (the acetabulum, or "ball") is primarily affected. If not treated, the joint surface breaks down, leading to arthritis, pain and disability.

  The most common reason why the femoral blood supply is compromised is a hip fracture that tears the vessels supplying blood to the head of the femur. Another cause is taking steroid medications, such as prednisone and other immunosuppressant drugs. AVN is often seen in patients with chronic asthma, rheumatoid arthritis, lupus and organ transplants.

  Avascular necrosis can be diagnosed with x-rays, bone scans and other imaging methods. To prevent further bone destruction and ensure the survival of the affected hip joint, there are a variety of treatment options. Less invasive ones include reduced weight-bearing, medications and electrical stimulation to increase the growth of new bone and blood vessels. Several surgical procedures are also available. Core decompression, best used in patients with early-stage disease, removes the inner layer of bone, reducing pressure and increasing blood flow. An osteotomy can be done to reshape the bone, alleviating stress on the affected area. (This comes with a very long recovery period, however.) Bone grafts can help support the bone after core decompression by transplanting some of the patient's healthy bone into the diseased area. And when the architecture of the hip joint is completely destroyed due to avascular necrosis, total joint replacement is the treatment of choice.

Arthritis and the Hip

   Of the more than 100 forms of arthritis, two are most common in the hip: osteoarthritis (OA) and rheumatoid arthritis (RA).

  OA is the most common arthritic condition affecting the hip. It is characterized by loss of cartilage space and pain in the groin or buttocks, sometimes radiating down the front of the thigh to the knee. There is limited motion and increased pain when walking. Later in the disease process, motion is even more limited and there is pain at rest. Osteoarthritis of the hip can usually be handled with exercise, less-strenuous activity, anti-inflammatory medication and support from a cane or walker. Adult arthritic hips that do not respond to treatment require total hip replacement.

  Rheumatoid arthritis (RA) affects multiple systems in the body and is associated with acute inflammation and severe pain, frequently resting pain at night. Often there is an acute episode of pain, swelling and limitation of motion involving many joints, followed by cyclic flare-ups. The disease process damages joint cartilage, resulting in secondary changes later in life. Patients who are unable to successfully manage their disease process working with a rheumatologist and using conservative means such as medication may also need joint replacement surgery.

   With RA, initial treatment is the key to long-term success. Rest, directed exercise, proper diet and medication can be used to suppress the disease process before damage occurs to the hip and other joint surfaces. However, most patients will experience continued deterioration and need surgery at some point later in life.

Hip Fractures

   Through the teen and young adult years, hip trauma, whether from an accident or sports injury, can result in a fracture. Later in life, osteoporosis is also a common cause of hip fracture. If the fracture is repaired and put in perfect anatomical position, the hip can heal without problem. But if there is any damage to the joint surface itself, patients will later develop arthritic changes.

   Proper treatment for a hip fracture usually is an open reduction and pinning of the hip, unless the joint is so unstable or the fracture is so displaced that a total hip replacement may be the better alternative. Fractures can lead to later arthritic changes in the hip that may require further reconstructive surgery, even though the fracture itself healed properly.

Other Causes of Hip Pain

   Two non-arthritis-related conditions are also major causes of hip pain. Certainly the most common disorder around the hip joint is bursitis. Numerous large muscles that control the motion of the entire leg attach to the bone around the outside of the hip joint. The muscles attach to the crest or top of the pelvis, travel down the side of the leg and form a tendon; this tendon then attaches the muscle to the hip joint. As the muscle contracts, it will pull on the tendon, and thus move the hip joint. If this were to occur without some protection for the tendon, the tendon would rub directly on bone and over a period of time would fray and rupture. The body protects the tendon with a bursa, a sac filled with a gel-like, fluid material that lies between the tendon and the bone and acts as a buffer for the tendon to work across. Unfortunately, the bursa may become inflamed and swell, causing even more pressure and pain. Most forms of hip bursitis can be treated effectively with behavior modification and anti-inflammatory medications. Sometimes directed exercise or an injection of steroids is recommended. Rarely, the bursa must be removed.

  The second most common non-arthritis hip condition is actually a spine disorder. In adult patients, this may be a ruptured disk in the spine or degenerative arthritis of the spine. Older adults will often have spinal stenosis. In these patients the cartilage disks, or spacers between the vertebrae, will lose a large portion of their water content and begin to degenerate and flatten. The bone will form spurs, causing pressure on the nerves that exit at each disk level and then exit out of the pelvis into the buttock. Patients will experience chronic back pain, muscle spasms in the lower back and pain in the buttocks. In more advanced stages, the pain will travel down the back of the leg to the knee, ankle or foot, either in front or in back of the calf (sciatica). Because the sciatic and femoral nerves may be affected, pain from spinal stenosis may sometimes feel like hip pain.

  A comprehensive treatment plan includes strengthening and flexibility exercises, use of heat and cold, joint protection including weight control, anti-inflammatory medication, analgesics and muscle relaxants. If symptoms persist, a series of epidural blocks can decrease the amount of swelling in the nerves and relieve pain. Occasionally, surgery will be necessary. Spinal surgery has improved markedly over the past decade and gives significant relief of nerve compression.

   The bottom line is that you don't have to live with hip pain that drives you crazy and limits your activities. It can be successfully treated and you can regain better long-term function once the correct diagnosis is obtained.

About the author:
Dennis Armstrong, M.D. graduated from the Wayne State School of Medicine and completed his orthopaedic residency at Henry Ford Hospital in Detroit, Michigan. Dr. Armstrong is board certified in orthopaedic surgery and specializes in arthritis reconstructive surgery. He has been involved in several clinical investigative studies researching the surgery and care of those undergoing total joint replacement, and has authored numerous papers and provided multiple presentations on his clinical research.

© Copyright 2007. Arthritis Education by Professionals, Inc.



Get a Leg Up on Knee Pain
by Dennis Armstrong, M.D.

  An incredible feat of engineering, the knee is one of the most complicated and moveable joints in the body. Not only does it bend and straighten like a simple hinge joint, it can also rotate; in fact, the knee has one of the widest ranges of motion of any joint.

  The knee is where the femur (thigh bone) and tibia (shin bone) come together. A third bone, the triangular-shaped patella (kneecap), lies across the front of the joint to protect it. As in our other joints, a layer of protective cartilage covers the ends of the bones to allow for smooth movement. Additionally there are the medial meniscus and the lateral meniscus, which add more protection. The entire joint is encased in a capsule lined with a membrane called the synovium that produces fluid to lubricate the joint. Various ligaments support the knee and prevent excess side-to-side movement. Two ligaments called cruciate ligaments (from the Latin word "crux," meaning cross) cross over each other as they run diagonally between the femur and tibia; they help prevent overbending and overstraightening of the knee.

Causes of Knee Pain

   Considering the complicated way the knee is put together, there are many things that can cause knee pain. The knee is susceptible to damage from repetitive weight-bearing activity, such as running or jogging, and a variety of sports injuries. Movements such as coming to a quick stop, changing directions, pivoting or landing from a jump can injure the knee's ligaments. Athletes often rupture their anterior cruciate ligament, for example. When a cruciate ligament is sprained or ruptured, the knee joint loses some of its stability and may become painful. When the meniscus is torn, small fragments of cartilage can loosen and catch between the surfaces of the femur and tibia, causing pain, limiting knee movement and at times causing instability.

  As a weight-bearing joint, the knee is one of the primary joints affected by arthritis. Both osteoarthritis (OA) and rheumatoid arthritis (RA) can damage the smooth cartilage and decrease the space between the femur and tibia. Eventually, so much cartilage may be eroded that bone rubs on bone, causing a great deal of pain and limiting your ability to walk, climb stairs and participate in everyday activities.

  Swelling also frequently affects the knee, and can have many causes. Fluid can accumulate in the bursae (a bursa is a sac filled with a gel-like, fluid material that lies between a tendon and a bone and acts as a buffer for the tendon to work across). For example, injury or excessive kneeling can cause the bursa located in front of the kneecap to become inflamed and fill with fluid, resulting in what was once commonly called "water on the knee."

These x-rays show how degenerative arthritis in the knee joint causes bone to rub on bone, resulting in pain and loss of function. (The image at left is a side view; at right is a frontal view.

   In patients with some type of arthritis, particularly rheumatoid arthritis, the synovium (joint lining) may produce excess synovial fluid. This is called an effusion, and it makes the joint red, warm and swollen. Blood can also accumulate in the knee as a result of injury or certain diseases, such as hemophilia.

  Several disorders affect the kneecap. It can be fractured or dislocated due to a direct blow; congenital abnormalities may also cause dislocation. Retropatellar arthritis, an inflammation of the underside of the kneecap, causes a roughening of that surface and causes pain that worsens when you bend your knee or climb stairs.

  There are many other possible causes of knee pain, too many to go into here. By evaluating your symptoms, conducting a physical exam and ordering diagnostic tests such as blood work and x-rays, the doctor will determine the cause of your knee pain.

Managing Knee Pain

   The key to successful treatment of your knee pain is to obtain the correct diagnosis. Once that's accomplished, you and your physician can work on designing the treatment plan that's right for you, starting with conservative measures.
Non-steroidal anti-inflammatory medications (NSAIDs)--aspirin, ibuprofen, Naprosyn, etc.--are the first line of defense against pain and inflammation in the knee joint, whether the cause is a sports injury or arthritis. In the case of rheumatoid arthritis, when both knees are painful and inflamed, a disease-modifying medication may be prescribed to try to slow down further damage to the joint. Physical therapy, heat and cold, rest, exercise and use of assistive devices such as canes are some of the other conservative methods that may be effectively employed.

  Several surgical procedures also can help relieve pain and restore mobility to the knee joint. For a torn ligament or a tear in the meniscus, your doctor may suggest a minimally invasive procedure called arthroscopy. Through small incisions, the surgeon inserts a tubular instrument called an arthroscope, complete with a light and camera, into the joint capsule. An image of the inside of the joint is projected onto a monitor in the room. Once the nature of the problem is determined--a loose cartilage fragment, for example--the surgeon can use another small instrument to cut and remove the fragment. All this can be done without a large incision, or a hospital stay. Recovery is also much faster than with traditional surgery.

  Another procedure is synovectomy, the removal of diseased or damaged tissue from inside the joint. This is often used in patients with rheumatoid arthritis, and can be done traditionally or arthroscopically. A procedure called osteotomy involves trimming and repositioning the leg bones to obtain a better weight distribution across the knee, slowing damage caused by osteoarthritis and relieving pain.

  When more conservative treatments have not provided adequate relief, total joint replacement may be recommended. Total knee replacement is a major surgical procedure that replaces the weight-bearing surfaces of the femur and tibia, as well as the underside of the kneecap, with durable metal and plastic components. Pain relief is often immediate and dramatic, and the success rate for total knee replacement, like total hip replacement, is quite high. On average, 90+ percent of knee replacements are still going strong 15 years after the surgery. Research continues into developing new materials and implant designs that will last even longer. More than 100,000 knee replacements are performed in this country annually.

  Patients with severe knee damage who are not candidates for knee replacement may undergo knee fusion; while this greatly reduces your ability to move the joint, at least it allows pain-free weight bearing.

  If you suffer from knee pain and don't know what's causing it, I encourage you to see your doctor for an accurate diagnosis and appropriate treatment plan. Not only can painful knees limit your activities, they can also have a negative effect on your overall health. If your knees hurt, you aren't going to walk or get the cardiovascular exercise your heart needs. So the earlier your knee pain is diagnosed and treated, the better your quality of life will be in the long run.

About the author:
Dennis Armstrong, M.D. graduated from the Wayne State School of Medicine and completed his orthopaedic residency at Henry Ford Hospital in Detroit, Michigan. Dr. Armstrong is board certified in orthopaedic surgery and specializes in arthritis reconstructive surgery. He has been involved in several clinical investigative studies researching the surgery and care of those undergoing total joint replacement, and has authored numerous papers and provided multiple presentations on his clinical research.

© Copyright 2005. Arthritis Education by Professionals, Inc.


Viscosupplementation Can Relieve Pain
and Protect Your Knee
by Jan Revella, R.N.

   We bend our knees a million times in a year. The lubricating fluid, called synovial fluid, helps this process acting like a lubricant and shock absorber to protect your knee. To understand viscosupplemention and its benefits, let's take a look at the normal knee and osteoarthritis (OA).

   The knee joint is where the femur (thigh bone) and tibia (shin bone) come together. A third bone, the triangular-shaped patella (kneecap), lies across the front of the joint to protect it. As in our other joints, a layer of protective cartilage covers the ends of the bones to allow smooth movement. Special to the knee are two pads of protective tissue called menisci. The entire joint is encased is a capsule lined with a membrane called the synovium which generates a fluid that acts as both a lubricant and a shock absorber. This fluid is called synovial fluid. Various ligaments and muscles support, stabilize and power the joint.

   Although there are many problems associated with knee pain, the most prevalent joint disorder is osteoarthritis. Osteoarthritis can be due to a predisposition to its development but also often is a result of repetitive micro traumas over many years, an injury left untreated such as a torn meniscus and being overweight. The end result of osteoarthritis of the knee is often severe cartilage loss resulting in significant pain particularly while weight bearing (walking), getting up from a chair and sometimes at night.

   Through this process of progressive osteoarthritis, the components of the synovial fluid often breakdown, resulting in diminished shock absorbing characteristics. This loss of shock absorption results in less protection of the knee during movement. One such component of the synovial fluid is hyaluronic acid (HA), which is responsible for the synovial fluid's ability to lubricate and act as a shock absorber in the knee. When one has knee OA, the concentration of HA in the synovial fluid is reduced causing a loss of shock absorbing and lubricating properties. This results in increased joint pain, stiffness and possibly an onset or worsening of osteoarthritis.

What is Hyaluronic Acid?
   Hyaluronic acid (HA) is a substance natural in the body and is present not only in the synovial fluid but also in the eyeballs, skin and cartilage. When isolated, it is a thick, viscous solution. Viscosupplements, which are designed to replace osteoarthritic synovial fluid with a more normal prosthetic synovial fluid, use purified HA derived from either rooster combs or genetically engineered cells to add to the natural HA in the knee joint.

The Role of Viscosupplementation
   Viscosupplementation is an option of treatment for those with moderate to moderately severe osteoarthritis of the knee. Through a series of injections, supplemental HA can be added to the knee joint. It is believed that by replacing the osteoarthritic synovial fluid with a product made of HA that is closer to normal synovial fluid, the patient experiences pain relief due to the presence of a new "lubricant" in the knee that is also acting as a shock absorber. The result is increased protection of the knee joint itself and a soothing of the nerve endings exposed by the degraded cartilage of the osteoarthritic knee.

Could You Benefit?
   Viscosupplementation is given to people with knee osteoarthritis who have not responded to traditional therapies, such as oral anti-inflammatory or analgesic medications or exercise. It is also can be considered for those who are trying to delay or simply are not candidates for total knee replacement surgery. This treatment has not been approved for other joints, although there are studies underway for hip and shoulder arthritis.

How Is It Administered?
   Viscosupplementation therapy is only available through injection into the knee. The injection is given directly into the knee from a point on the side and under the kneecap. There are several viscosupplementation products available and they can provide pain relief that can last for months. It is given in several ways including one single injection, three or five injections, one each week. It can take up to 12 weeks to take full effect.

Is There Any Risk?
   If you have had any allergic reaction to any hyaluronate preparations or are allergic to poultry products, you are not a candidate for these injections. You also should not receive these injections if you have an infection or skin disease around the injection area. Sometimes one can experience some swelling, heat, redness or itching around the joint, but this is temporary. Any reaction is usually mild and short-lived.

Does Viscosupplemention Work?
   HA viscosupplemention is a safe and effective treatment for osteoarthritis of the knee. Depending on the severity of the knee arthritis, these injections can be 72-75% effective for six months to a year.

   If you wonder whether you are a candidate or could benefit from viscosupplemention, see your orthopaedic surgeon or rheumatologist for an evaluation of your options.

© Copyright 2010. Arthritis Education by Professionals, Inc.




All About Total Joint Replacement
by Dennis Armstrong, M.D.

   When you have arthritis of the hip or knee and your orthopaedic surgeon introduces the topic of surgery, you probably never want to hear that undergoing surgery may be the right choice to return you to an active lifestyle. Surgery is an alternative to failed conservative measures to control pain and return mobility. Even though surgery is usually avoided if possible, pain and limitation of activity can create such a roadblock to comfort and doing the things you enjoy, it may be worth considering instead living the rest of your life with progressive worsening of pain.

   Most importantly, knowing what to consider when deciding whether to have surgery is powerful information. The more you know about what to expect when considering joint replacement surgery, the more comfortable you will be in your decision to proceed. With that in mind, let's discuss total joint replacement, specifically of the hip or knee.

   In the early to moderate stages of arthritis, it may be possible to simply to alter your activities a bit. Reducing impact activities and increasing non-impact activities is a good start. Adding over-the-counter analgesics and anti-inflammatory medication may be good for a while as well. When it's time to visit with the physician, he/she can prescribe stronger NSAIDS and physical therapy. You can consider receiving a cortisone injection to reduce inflammation. Specifically for osteoarthritis of the knee, you could try viscosupplementation (see article on Viscosupplemention) for a series of injections designed to decrease pain and at the same time provide extra shock absorption for the joint. You can protect the joint by using a cane and keeping your weight down. Joint replacement is introduced when these types of modalities have failed.

   Joint replacement, or arthroplasty, is a surgical procedure in which the diseased parts of the hip or knee joint are removed and replaced with new, artificial parts. These artificial parts are called the prosthesis. Joint replacement of the hip or knee has an excellent track record to eliminate or reduce pain and improve function of the affected joint.

Are You a Candidate for Joint Replacement Surgery?
   The most common reason people undergo joint replacement of the hip or knee is for the pain and immobility that results from the wearing down of the cartilage in the joint from osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN) (loss of bone caused by insufficient blood supply), and less common types of arthritis. Injury can also lead to the breakdown of the joint and the need for TJR.

   In the past, joint replacement was reserved those people over 60 years of age. Typically older people tend to be less active and put less strain on the artificial joint. In recent years, however, younger people can consider this option as well. New technology has improved the artificial parts, allowing them to withstand more stress and strain. Most importantly, overall health and activity level of the person is the best indicator for the success of a joint replacement once you've chosen an experienced surgeon who can provide you with the artificial joint.

   Some people worry they are "too old" to consider joint replacement surgery. Again, it's the health of the patient that determines who is a candidate and who is not. For example, people who suffer from extreme muscle weakness or Parkinson's disease may not be candidates. Those in poor health generally are more likely to be a higher risk for complications or to recover successfully.

What to Expect Before Surgery

   When you see the surgeon in the office for an evaluation, he/she will obtain your medical history and perform a physical examination that will include x-rays and a visual analysis of your gait. Once you and the doctor have agreed that surgery is the next step, your doctor will do the scheduling and help arrange for your pre-operative blood work, electrocardiogram (EKG) and chest x-ray. If needed, you may also donate some of your own blood (autologous blood donation) in case you need it during the procedure.

The Surgery

   During joint replacement surgery, the surgeon removes the diseased bone tissue and cartilage from the joint. The healthy parts of the joint are left intact. In the hip, the ball is removed and socket cleaned out; in the knee, the damaged knee surfaces are removed. Once the joint is prepared, the surgeon replaces the removed parts with the artificial components. The new joint is made from man-made materials that allow a natural, gliding motion of the joint. Surgery time varies with the experience of the surgeon and difficulty of the surgery and can range from 45 minutes to a couple of hours.

   The artificial parts are kept in place through the use of bone cement or inducing bone growth into the prosthesis. The process of natural bone growth can cause thigh pain for several months after surgery. Because each person's condition is unique, the bone strength variable, the decision of which is best for you should be discussed with your doctor.

   The primary disadvantage of an uncemented prosthesis is the extended recovery period. Sometimes, people must limit activity up to three months while the cemented prosthesis allows more mobility much more quickly.

   Research has proven the effectiveness of the prosthesis to reduce pain and increase joint mobility. This mobility is noticeable immediately after surgery. Cemented replacements are much more frequently used for older people and people with weak bones, such as those who have osteoporosis.

In the Hospital

   On average, you can expect four to five days of hospitalization, depending on your personal situation. Everyone is different. It is important to evaluate a patients' abilities and difficulties beforehand to be sure they receive all the help necessary while in the hospital.

   The day after your surgery, you can expect to be out of bed with the assistance of a physical therapist. No excuses will be permitted! The physical therapy is required-your work after surgery is necessary to get you home as soon as possible. There will be some limitations and these will be discussed with you as you go along. Positioning is important; we'll show you all the moves! With practice and a little time, you'll be walking and exercising with minimal or no assistance and can look forward to being discharged from the hospital.

   You will have several discharge options depending on your personal situation. You may be sent home with your family to assist you, or with arrangements for home care; you may be discharged to an extended care rehabilitation center or skilled nursing facility. Family support, your physical strength and motivation are all factors to be considered.

   After surgery, you will spend a few weeks on an assistive device such as a walker or crutches. Daily exercises will strengthen the muscles around the new joint having been weakened from nonuse. Once you return to the doctor in his office for x-rays and an evaluation of your new joint, you will be able to plan your return to activities.

The Future
   Remember, your artificial joint is just that. In the long term, you can do just about any activity that has a "gliding motion," as opposed to a "direct impact." For example, you can walk, dance, bowl, bicycle, golf, swimbut if you have plans to jump, jog, run or ski, this impact loading type of activity can place extra stress on the joint and put it at risk. That's not to say some people with joint replacements don't do these things-they do. But just realize that such activities could cause harm to your joint, ruining all the good work you've done.

   Patient care begins with education and extends into rehabilitation and follow-up. Your role is to educate yourself, understand the purpose of surgery, what to expect before and after surgery, including a discussion of the risks of the surgery and long term outcomes of undergoing total joint replacement. Neither the doctor nor the patient is totally responsible for a successful joint replacement; it is a shared responsibility. Together, you will work for the best possible results. In the long run, you should be able to enjoy many years of comfort and an active lifestyle. Now, that is worth considering.

About the Author:
   Arizona orthopaedic surgeon, Dennis Armstrong, M.D., is board certified in orthopaedic surgery and specializes in arthritis reconstructive surgery. He received his medical degree from the Wayne State School of Medicine and completed his orthopaedic residency at Henry Ford Hospital in Detroit, Michigan. Dr. Armstrong has been involved in several clinical investigative studies researching the surgery and care of those undergoing total joint replacement, and has authored numerous talks/papers on options for knee and hip pain.

© Copyright 2007. Arthritis Education by Professionals, Inc.



Total Joint Replacement
A System for Success
by Jan Revella, R.N.

  In my seminars, I outline active approaches to managing your arthritis in order to help control pain and maintain mobility. One of those active approaches that many patients eventually will need to consider is joint replacement.

  First of all let me emphasize that the single concept underlying all of our efforts at Arthritis Education by Professionals, Inc. is education. From the beginning, I have believed that arthritis patients would do better with joint replacements if they were provided with solid patient education. Over the years, I have held pre-operative educational classes for patients and also have provided custom-made informational videos, booklets, brochures and other educational materials to help answer questions. The patient always plays an active role in the decision-making and ultimate success of the procedure. The philosophy is that a patient is not simply a"hip" or a "knee"--a patient is a whole person who also has other needs in terms of managing arthritis and independence.

Making the Decision

   So, once conservative measures such as medication and activity modification have failed, it's time to consider joint replacement. By this time, patients have what we call end-stage arthritis--a significant loss of cartilage in the joint(s), perhaps bone spurs, and the ligament instability and muscle atrophy that occur when a joint is unable to move and function as it was intended. Often there is pain related to these mechanical changes, and it worsens as you put more weight on the joint. There may be limping, deformity (especially in the knees), loss of joint motion and loss of leg length. In addition, the patient's overall physical and mental health may be negatively affected because it's simply too hard to get up and be active.

  The direct benefits of joint replacement are that it reduces or eliminates pain, restores lost range of motion, and, in the case of hips and knees, improves the gait and corrects deformity. The indirect benefits are just as important: by restoring the ability to walk and function, joint replacement gives you the chance to rebuild your cardiovascular and pulmonary conditioning. Even your mental outlook will bloom, as you are once again able to get around, enjoy life and make a contribution to the world and the lives of others. Joint replacement is like a drop of water in a pond--its beneficial effects spread throughout your body and your life like ripples on the water.

  In making the decision to have a joint replacement, patients often will wait until their lifestyle is simply no longer acceptable and they can't stand the pain any longer. However, there is such a thing as waiting too long. Especially for people with osteoporosis or poor bone material due to rheumatoid arthritis, you may be leaving the surgeon less to work with, which means the joint might not turn out as well.

  It's not that you should be pushed into surgery before you're ready; it's just that you need to weigh the risks vs. benefits early on. That way you actively make the decision when the time is right. You should be in control, rather than making the decision from the standpoint of a victim ("I can't stand this anymore") and having the disease control you. When you're empowered, you will work harder to achieve an excellent outcome.

  Fear often keeps people from making the decision to have surgery, but that's where education comes in. If we can give you the proper information and education, the decision may be easier. And sometimes, after weighing all the options, the decision can still be "no." Perhaps now is not the right time, but joint replacement can be an option for the future

A Shared Responsibility

   Neither the doctor nor the patient is totally responsible for a successful joint replacement; it is a shared responsibility.

  It's extremely important that you see an orthopaedic specialist who is skilled in joint replacement and has a great deal of experience with the specific procedure you need. After all, if your carburetor needed fixing, you wouldn't take it to a garage that fixed maybe 10 carburetors a year; you'd take it to a carburetor specialist who works on 200 or more carburetors a year. It's the same with your joints. You need to know that the surgeon and his or her team are not only experienced and knowledgeable in joint replacement, but that they are current, up to speed on the latest innovations and able to react quickly to changing circumstances that might occur during surgery.

  The bottom line is that it's important to select a surgeon who has done a large number of joint replacements, one who does research on his own patients to track success rates, and one who will willingly give you data on patient outcomes. A surgeon simply stating that he or she is "experienced" in joint replacement is not enough of a recommendation; be sure to ask for numbers.

  When you see the surgeon in the office, he or she will do a physical examination that includes a complete medical history, x-rays and a visual analysis of your gait. To prepare for surgery, your doctor will handle all the scheduling, and help you arrange for your pre-operative blood work, electrocardiogram (EKG) and chest x-ray. If you prefer, you may also donate some of your own blood (autologous blood donation) in case you need it during the procedure.

What to Expect in the Hospital

   I've outlined the many benefits of joint replacement, so now let's take a look at the risks. Of course there is risk with any major surgery, and joint replacement is no exception. But it has been proven that the patient will do better if we adopt a preventive mentality, instead of waiting until something crops up and treating it.

  In joint replacement there are two kinds of risks: local and systemic. Local risks happen at the joint itself, and the most often discussed of these is infection. But again, prevention is key. For instance, instead of waiting for an infection to develop, we operate in surgical suites equipped with laminar airflow, a "clean room"-type system that eliminates almost all chance of infection. We also administer preventive antibiotics to the patient before, during and after your surgery. These precautions pay off for patients by resulting in a much lower infection rate.

  The other type of risk with joint replacement is systemic, changes elsewhere in your body that are caused by the days of relative immobility as you recover from surgery. (These risks could crop up with any major surgery, not just joint replacement.) Because the operation is a major trauma to your body, your systems tend to close down slightly. With the cardiovascular system, the risk would be blood clots. However, we dramatically reduce the chance of blood clots forming through the use of carefully regulated blood-thinning medication. Instead of waiting for pneumonia to develop, we schedule several days of breathing treatments to help clear the lungs after surgery. Your skin may be irritated from the pressure of lying in bed; also, you may develop constipation or a urinary tract infection. The point is we tell you in advance about these things so that we can all work together to prevent them.

  On average you can expect two to four days of hospitalization, depending on your personal situation. Everyone is different. Some patients may need to stay in the hospital longer than others, such as patients who not only have arthritis but also have cardiac or pulmonary difficulties. It's important to evaluate patients' abilities and disabilities beforehand to be sure they receive all the help they need while in the hospital.

  The day after your surgery, you are going to get out of bed with a physical therapist and start your rehabilitation. No excuses! The physical therapy is mandatory-you're not allowed to pretend you can't get up, or refuse because you didn't have a good night's sleep. You will get up--because activity is what gives you your life back.

  In terms of discharge options, you may be sent home with your family to assist you, or with arrangements for home care; you may be discharged to an extended care nursing center or skilled nursing facility within the hospital; or those who require more intensive rehabilitation work may be discharged directly to a rehabilitation facility. Family support, your physical strength and motivation are all factors to be considered in the discharge.

  Afterward, you'll spend a few weeks on an assistive device such as crutches or a walker. Daily exercises will strengthen your new joint and the muscles that have weakened from non-use. During this time your mobility will be curtailed, but after six weeks you'll visit your surgeon for a checkup and then life will get pretty quickly back to normal. In the long term, you can do just about any activity that has a "gliding motion," as opposed to a "direct impact." For example, you can walk, dance, bowl, bicycle, golf, swim--but if you have plans to jump out of an airplane anytime soon, better cancel. Things like jumping, running and jogging, bungee jumping and hang gliding are definitely no-nos. That's not to say some people with joint replacements don't do these things--they do. But just realize that such activities increase the risks to your joint, ruining all the good work you've done and putting you back in the hospital.

  Patient care begins with education and extends into rehabilitation and follow-up. Your role is to educate yourself, understand the system and follow through with all the steps the way they are designed in order to ensure the best possible outcome.


Criteria for Selecting a Surgeon for Joint Replacement

  • Education
  • Experience of the Surgeon
  • Experience of the Surgical Team
  • Number of Joint Replacements Done
  • Success Rate
  • Patient Data--15/20/25 Years Out

© Copyright 2010. Arthritis Education by Professionals, Inc.



Osteoporosis: What You Need to Know to Prevent Fractures
by Claire Moore, P.A.-C. and Jan Revella, R.N.

About 32 million Americans, 80 percent of them women, suffer from osteoporosis or low bone mass, which literally means porous bones. Most of these people, unfortunately, remain undiagnosed and untreated. The good news? Over the past ten years, medical research has given us prevention strategies, improved diagnostic techniques and new treatments to help us deal with this often debilitating condition.

 The deterioration of bone structure and bone mass associated with osteoporosis leads to compromised bone strength and susceptibility to fracture (NIH Consensus Conference on Osteoporosis, March 2000).  Simply stated, osteoporosis refers to the thinning of bone which increases a persons risk for fracture or broken bones.  It is called the silent disease because the person experiences no symptoms associated with the bone lossuntil a fracture occurs.  The most common types of osteoporotic fractures are of the vertebrae, hips and wrist.

  A fracture can occur with little or no trauma, leaving a person with debilitating, severe pain. Repeated fractures lead to more pain, loss of height, postural changes that can limit activity, including bending and reaching. It also causes spinal deformity (Dowagers hump), restrictive lung disease and digestive problems, including constipation, abdominal pain, distention, and reduced appetite.  There can be psychological symptoms as well, most notably depression and loss of self-esteem as one grapples with pain, physical limitation and cosmetic changes. Because osteoporosis can affect a person in many ways, it is important to correctly manage the disease, even before symptoms are experienced. 


  Every year, there are 1.5 million new fractures in people who have soft bone secondary to osteoporosis. Of these, 700,000 people annually sustain spine fractures, 300,000 hip fractures, 250,000 wrist fractures and 250,000 fractures of other bones, all as a result of osteoporosis. With 700,000 spine fractures a year, this translates to one compression fracture every 45 seconds. After a patient sustains their first compression fracture, the risk of an additional fracture goes up more than five fold (Annals of Internal Medicine).

  Over half of women aged 70-79 years will have developed osteoporosis.  By age 80, it increases to three out of four women.  Men also develop osteoporosis, but it is usually related to medications or some other health issue.

Are You At Risk?

  Understanding the risks for developing osteoporosis is helpful in prevention and treatment of the disease.  Those at most risk are postmenopausal females (including those who had surgery-induced menopause by hysterectomy) of Caucasian or Asian descent; other factors include being thin or having a small frame, a family history of osteoporosis, a low-calcium diet, smoking, alcohol use and an inactive lifestyle. Some medical conditions such as hyperparathyroidism or anorexia nervosa can also lead to bone density loss. Long-term use of certain medications, specifically oral steroids (not inhaled steroids), anti-convulsants, chemotherapy, heparin and aluminum-containing antacids are also associated with bone loss.

  Women reach peak bone mass around age 30.  After 30, bone loss slowly begins. However, with the loss of estrogen due to menopause, bone loss accelerates to about 2-3% a year for the first five years. Then it slows again to about 1% loss a year. As you can see, over time, bone loss can be significant. As an older adult, its not surprising that osteoporosis can become a problem particularly when one has one or more risk factors.


  Prevention of osteoporosis begins during childhood to early adulthood when bone density is still increasing.  A healthy diet with appropriate amounts of calcium is essential while young.  Depending on your age, it is recommended that you ingest appropriate amounts of calcium daily (along with vitamin D) Adults, aged 19-50 years, 1000 mg; 51-64 years, 1200 mg; 65+ years, 1500 mg. Also note that one can not absorb more than 500 mg of calcium supplement at one time. So, if a supplement is necessary because diet is not sufficient, it should be taken in split doses, not all at once.

  Calcium supplementation is important in anyone at risk of developing osteoporosis and in those who already have the disease.  Several types of calcium supplements are available at your drugstore.  Calcium carbonate is most readily available and least expensive. However, adults over age 70 or adults taking medications that reduce stomach acid production should use calcium citrate, which does not need much stomach acid for absorption.  Calcium citrate is also most easily absorbed by the body with or without food, while Calcium carbonate is absorbed best when taken with food. Check with your doctor on the best type of calcium and dosage for you.    

  Other important preventative steps include weight bearing exercise, smoking cessation, and a periodic check-up including bone density testing.  Walking as little as 20 minutes a day has been shown to increase bone density.  Other weight bearing exercises include jogging, dancing, hiking, and stair climbing.  Swimming and bicycling are not considered weight bearing exercises.  A weight-lifting exercise program can be helpful but always consult your doctor before beginning any exercise program.

  Smoking has been shown to increase a persons risk for osteoporosis.  Smoking cessation is vital not only for bone health, but also for the health of the heart and lung, brain, kidneys, skin, sinuses, mouth, teeth and blood vessels.  Not smoking is one of the best health decisions a person can make.

Diagnosing Osteoporosis

  An important tool in the prevention and diagnosis of osteoporosis is a dual energy x-ray absorptiometry (DEXA) scan.  This scan is very accurate and used to determine bone mass density. It detects osteoporosis and even early loss bone mass.  It is important to note that regular x-rays will not show bone mass loss until there has been 30-50% lossanother reason to stress the importance of the DEXA scan. The US Preventative Services Task Force recommends all women, 65 years and over, have a DEXA scan to evaluate bone density.  Women who have had early or surgically induced (hysterectomy) menopause should be tested as well.  After the initial scan, a repeat DEXA scan is recommended (and covered by Medicare) every 2 years.

Treating Osteoporosis

  Once a diagnosis of osteoporosis is made, there are effective prescription medications available to help increase or maintain bone density.  Medications that slow down bone loss are Fosamax, Actonel or Miacalcin.  Fosamax or Actonel are taken once weekly and can decrease the risk of hip and spine fracture.  Miacalcin, although not quite as effective, can be tried if Fosamax or Actonel are not tolerated or if you are have certain gastrointestinal disorders. A new medication that actually builds new bone is called Forteo.  Forteo is self-administered through a daily injection underneath the skin of the abdomen or thigh for one year.  It is the most effective drug available to fight against osteoporosis, although it is not used as a first choice because of cost.

What If A Fracture Occurs?

  If a spinal fracture(s) occurs as a result of osteoporosis, pain management is the first step. However, there are minimally invasive surgery options available as well with additional benefits. Although the fracture may heal in time, it heals in its compressed state. This can result in the humping over posture (Dowagers hump) as well as long term pain until healing is complete. For a compression fracture(s) of the spine, a simple procedure called Kyphoplasty can be performed to stabilize the fracture and immediately relieve the pain associated with the fracture. It also will restore the height of the vertebra itself, returning you to full activity within a day or two. It is best to have the procedure performed within 6 weeks of the fracture before too much healing has taken place. (Read more about Kyphoplasty in our previous Vertebral Views newsletter, Spring 2005 or at our website,

You Can Help!

  Of course, prevention is the best medicine.  The decade of the 2000s has been officially designated by our government as the Bone and Joint Decade, drawing attention to the underappreciated disease, osteoporosis.  As the U.S. population ages, more people will be affected by osteoporosis and the resulting bone fractures.  A healthy diet and regular exercise are key to healthy bones and a healthy body.  Taking time to exercise, eat well and obtain regular bone density scans will help you live the active lifestyle you desire and deserve.                


Food Sources of Calcium

Food Serving Calcium Calories
Plain yogurt, non-fat (13 g protein/8oz), 8-oz container  452 127
Romano cheese, 1.5 oz  452 165
Pasteurized process Swiss cheese, 2 oz  438 190
Plain yogurt, low-fat (12 g protein/8 oz), 8-oz container 415 143
Fruit yogurt, low-fat (10 g protein/8 oz), 8-oz container 345 232
Swiss cheese, 1.5 oz  336 162
Ricotta cheese, part-skim, cup  335 170
Pasteurized processed American cheese food, 2 oz  323 188
Provolone cheese, 1.5 oz  321 150
Mozzarella cheese, part-skim, 1.5 oz  311 129
Cheddar cheese, 1.5 oz  307 171
Fat-free (skim) milk, 1 cup  306 83
Muenster cheese, 1.5 oz  305 156
1% low-fat milk, 1 cup  290 102
Low-fat chocolate milk (1%, 1 cup  288 158
2% reduced fat milk, 1 cup  285 122
Reduced fat chocolate milk (2%), 1 cup  285 180
Buttermilk, low-fat, 1 cup  284 98
Chocolate milk, 1 cup  280 208
Whole milk, 1 cup  276 146
Yogurt, plan, whole milk (8 g protein/8 oz), 8-oz container 275 138

Food sources of calcium ranked by milligrams (mg) and calories per standard amount.

Source: Dietary Guidelines for Americans 2005, Center for Nutrition Policy and Promotion(CNPP), U.S. Department of Agriculture (USDA)


Over-the-Counter Calcium Supplements

CALCIUM SUPPLEMENTS are recommended for persons who do not meet their daily calcium requirements from diet alone. The two major choices are outlined below. Calcium is best absorbed if consumed throughout the day. Be sure to read and follow label directions, and to choose a national brand to ensure quality. Avoid bone meal or dolomite, as they may contain toxic ingredients. Dose should not exceed 500 mg at one dosing.

Calcium Carbonate Calcium Citrate
Relative Cost: $ Relative Cost $$$
Brand Names: Brand Names:
Alka-Mints, Caltrate, OsCal, Titralac, Tums, Viactiv, Rolaids Citracal Liquitabs, Citracal, Citracal-D
Take with food. Take with or without food.


© Copyright 2010. Arthritis Education by Professionals, Inc.



Spine Fractures Treated With Kyphoplasty
Promising Treatment Relieves Pain
By Dennis Crandall, M.D.

Osteoporosis and Spine Fractures

  Osteoporosis is a skeletal disorder in which bones become fragile and are more likely to break. If not prevented or treated, osteoporosis can progress painlessly until a bone breaks. These broken bones, called fractures, are most likely to occur in the hip, spine or wrist. Possible causes include hormonal imbalances, pregnancy, metabolic diseases or cancer in otherwise healthy people over age 60 to 65.

   Twenty-eight million Americans are at risk for developing osteoporosis. Every year, there are 1.5 million new fractures in people who have soft bone secondary to osteoporosis. Of these, annually, 700,000 people annually sustain spine fractures, 300,000 hip fractures 250,000 wrist fractures and 250,000 fractures of other bones, all as a result of osteoporosis. With 700,000 spine fractures a year, this translates to one compression fracture every 45 seconds. After a patient sustains their first compression fracture, the risk of an additional fracture goes up more than five fold (Annals of Internal Medicine).

Problems Associated with Compression Fractures

   When soft osteoporotic bone breaks, patients describe onset of significant back pain. Pain can be in the upper or lower back. When the fracture occurs, severe pain can cause a patient to be bedridden for a few weeks. If the vertebra collapses, a deformity forms in the back and the patient begins to hunch forward. This posture can lead to difficulty with breathing and digestion, problems standing up straight, increasing back pain, decreased ability to walk even medium distances, and an overall decrease in the quality of life. When the fracture settles and the patient begins to slouch forward, additional vertebra are much more likely to fracture, increasing the problem and the hunching forward even further.

The Human Cost of Compression Fractures

   The pain from a fractured vertebra causes a decrease in the level of activity. Patients describe the inability to be up and walking and performing daily activities. Often, depression sets in. Patients develop a lower self esteem as they become more reliant on others for their daily care. There is often anxiety as patients are concerned about their increasing dependence on others.

   According to a 1998 study there is a significant decrease in the lung function in patients with thoracic or lumbar fractures. Each thoracic or upper back fracture causes a 9% loss of vital capacity of the lungs (Journal of American Respiratory Disease).

   In a retrospective analysis of five-year survival rates done at the Mayo Clinic, patients with osteoporotic compression fractures of the vertebra were found to have a worse survival rate over the next five years compared to what would be expected. This decrease in survival rate was found to be similar to those patients who sustained a hip fracture. For these patients, the most common cause of premature death was pulmonary disease, emphysema and pneumonia.

Non Operative Treatment of Spinal Fractures

   The usual treatment for compression fractures has been management with pain medication. Narcotic pain medicines are used for a few months until the pain decreases. Pain from fractured bone can last from three months to more than a year, depending on the circumstances and the severity of the broken bone.

   After the pain from the fracture improves, patients need to build up bone strength. There are a few medications which are available to increase bone density. This treatment is slow and continues for years. It is the only treatment we have at this point to increase bone mass and therefore should be used by patients who are at risk for osteoporotic compression fractures, and those who have had fractures in the past. By building the bone density, we hope to prevent future fractures.

   Immobilization of the spine with a brace can help decrease pain from broken vertebra. The most appropriate brace is a soft elastic waistband with Velcro straps. Sometimes metal strips or a plastic insert in used in the back of the brace for added support. The brace is only helpful for fractures of the lower back.


   With the development of kyphoplasty, treatment of compression fractures is changing. Patients no longer need to put up with fracture pain and progressive hunching of the spine thanks to this new technique. The kyphoplasty technique involves a new technology whereby an osteoporotic compression fracture can be treated, pain relieved, the lost bone height restored, and the fracture immediately stabilized with the injection of bone cement. This is all done through two " incisions on each side of the effected vertebra. The technique involves the use of x-ray equipment to insert working tools into the collapsed vertebra. An inflatable bone tamp or expander is then placed into the fractured vertebra on each side and very slowly, the balloons are inflated, lifting up the fractured portion of the vertebra to a more normal height. The balloons are deflated and cement is slowly injected.

   Results from this technique have shown excellent restoration of fractures which are less than four to six months old, and better than 90% success at reducing pain associated with the broken vertebra.

   Complications from this procedure have been very few and have been primarily related to patients who have been on blood thinner medications. Potential complications could include cement leaking out of the vertebra and into inappropriate areas. To date, these have not been reported with kyphoplasty.

Who Would Benefit From Kyphoplasty?

   Patients who have experienced a recent vertebral compression fracture due to osteoporosis can benefit from kyphoplasty. Fractures are best treated and have the best chance at being restored to their original height when the fractures are less than four months old. For patients who are on chronic Prednisone or steroids, even older fractures can be treated and restored to full height.

Case History

   An 82-year-old woman presented to my office with recent onset of severe back pain. X-rays showed a fractured vertebra in the mid back. Examination of the patient showed she was beginning to stoop forward. Pushing along the spine revealed one area of maximum tenderness, which correlated, with the x-ray findings of the fracture. She was sent for an MRI scan, which confirmed the new fracture. No other significant abnormalities were found.

   This patient was a very active woman who had been married more than 50 years to the same man. The two of them enjoyed walking, traveling, shopping and socializing with friends. The patient was not able to perform any of her daily activities because of the pain.

   The patient elected to proceed with kyphoplasty. After this one-hour surgery, the patient noted immediate relief of pain and was "able to roll over in bed now without yelling out in pain". She returned to the office two weeks later for a check up and reported being back to full activity. She was very happy with her results. The x-rays showed excellent restoration of the fractured vertebra and immediate stability of the broken bone.

Other Surgical Options for Spinal Fractures

   Vertebroplasty is a procedure where cement is injected into the fractured vertebra without any attempt at correction of the collapsed bone. The pain relief is similar to kyphoplasty, though vertebroplasty has a higher complication rate from extruded cement going in places it was not meant to go. This is due to vertebroplasty requiring high pressures to inject very liquid cement into the bone. In stark contrast, kyphoplasty uses thickened cement injected slowly to fill the void created by the balloon and the cement technique is therefore much safer than vertebroplasty. Because of problems with cement filling, and inability to reduce the fracture deformity, vertebroplasty is clearly a second choice to kyphoplasty.

   When there is a severe collapse of several vertebra in a row causing the patient to be stooped forward, kyphoplasty will not help. These fractures are often too old or too severe to inject with cement. The only other option is to consider major surgery to straighten the spine and hold it in place with spinal instrumentation (screws, hooks and rods). Such an undertaking is only advisable after all other options have been exhausted and when there is significant pain and functional disability.

The Future

   I predict that kyphoplasty will become the standard treatment for patients who experience new osteoporosis related fractures in their spine. This technique has been shown to eliminate both the deformity and the pain from the fracture. It is all done through a small " incision on each side of the vertebra. Following surgery, these incisions are covered with Band-Aids and the patient is able to get up and walk immediately. There is no down time. This exciting procedure has changed the way we care for patients with osteoporotic compression fractures.

About the Author:
Dr. Dennis Crandall received his medical degree from St. Louis University School of Medicine and completed his orthopaedic residency at St. Louis University Hospitals in St. Louis, Missouri. He completed a fellowship in spinal reconstructive surgery, adult and pediatric spinal deformity and spinal trauma from the University of Maryland, Section of Spinal Surgery, Division of Orthopaedic Surgery at the University of Maryland Hospital and Maryland Institute for Emergency Medical Services in Baltimore, Maryland. Dr. Crandall is board certified by the National Board of Medical Examiners and the American Board of Orthopaedic Surgery. He is a member of the American Academy of Orthopaedic Surgeons, American College of Surgeons, the Scoliosis Research Society, North American Spinal Society and the Spinal Fixation Study Group to name a few of his affiliations. Dr. Crandall is chief of spinal surgery, Phoenix Orthopaedic Residency Program and the medical director of the Sonoran Spine Center in Phoenix, Arizona. Dr. Crandall has published numerous papers, book chapters and provided many presentations on spine treatment and surgery.

For more information, visit Sonoran Spine Center

© Copyright 2006. Arthritis Education by Professionals, Inc.


Osteoarthritis or Osteoporosis?
Learn the Differences Between These Two Confusing Conditions
by Jan Revella, R.N.

  Osteoarthritis and osteoporosis have become the dreaded "O" words in the field of orthopaedics. While both conditions can be debilitating, and both primarily affect people in their later years, you need to understand that these are two very distinct disease processes. Knowing the difference between osteoarthritis and osteoporosis can help you know what to do to feel better and to have better control over both conditions. This knowledge can be a powerful tool to use to make sure you receive timely and appropriate treatment to prevent or slow the progression of these disorders.


   Osteoarthritis is the most common of the more than 100 different forms of arthritis. Also called "degenerative arthritis" or "wear-and-tear arthritis," osteoarthritis appears as a person ages. As the body grows older, the cartilage between bones in our joints softens and deteriorates. Unfortunately, the body cannot regenerate cartilage. Gradually the joint spaces continue to narrow, which also causes the ligaments supporting the joint to loosen up. Eventually, the cartilage can virtually disappear, allowing the bones in the joint to rub together. This causes instability and pain. As the deterioration continues, the joint can become mechanically imbalanced, which in turn causes additional pain and instability.

  Joints which have been frequently used (and sometimes abused) over the years, such as the spine, hips, knees and hands, will most likely develop osteoarthritis. The primary sign of osteoarthritis is pain. In some ways, pain can be helpful because it's a signal telling you to take it easy for a while and to seek medical attention if symptoms don't subside.

  Effective management of osteoarthritis means having an understanding of the disease process, and being willing to undertake self-management in partnership with your doctor's recommended treatment plan.

  Once the diagnosis of osteoarthritis is confirmed through history-taking, physical examination and x-rays, your doctor will prescribe a treatment program designed especially for you, possibly beginning with physical therapy to promote maximum joint mobility and preserve the range of motion you have left. Other elements of an osteoarthritis treatment program may include instruction in body mechanics, an ongoing home exercise program so you can continue your joint exercises, joint protection and energy conservation techniques, and appropriate medication to relieve joint irritation and swelling.

  Remember: Just taking a pill will not help you live effectively with osteoarthritis, because medication doesn't slow the progress of the disease. Getting up from a chair won't be any easier unless you work to regain the function loss caused by arthritis. Building muscle is critical to independence and long-term health.


   Osteoporosis, which literally means "porous bone," is caused by an imbalance between the rates of bone formation and bone breakdown. Like osteoarthritis, this condition is also prevalent among older people, but can occur at any age. It especially affects postmenopausal women.

  Like all tissues in the body, bone is continually being replenished. An imbalance occurs when old bone cells are being absorbed into the body faster than new bone cells are being made. In women, this imbalance is accelerated by the loss of estrogen after menopause. Inadequate calcium intake in your daily diet, no matter what your age or sex, can adversely affect your bones, and a sedentary lifestyle compounds the problem by not giving bones the stress they need through physical activity.

  Osteoporosis can be a silent disease for years. You may not experience any pain until a fracture occurs or deformities develop. In fact, it's common not to know you have osteoporosis until you notice a deformity such as a dowager's hump, the hump seen in some older people when their upper back slumps forward. By then, it's most likely too late for any preventive action.

  Osteoporosis is diagnosed through history-taking and physical examination, combined with special x-rays called bone densitometry (DXA) to measure your bone mass. Routine x-rays will not detect osteoporosis until you've already lost 30 to 50 percent of your bone mass.

  Fortunately, today there are several effective medications now available to help people with osteoporosis.

  To protect yourself against osteoporosis, it's important to make the right choices at every different stage in your life. By reducing your risk factors you may be able to prevent osteoporosis; and, if you already have it, you may be able to slow its progression and live with it comfortably and safely.

Osteoarthritis and Osteoporosis:
Prevention and Treatment Tips


  Work with your doctor to develop a treatment program that includes:

  • Physical therapy to promote maximum joint mobility and preserve range of motion
  • A home exercise program that continues what you learned in physical therapy and includes aerobic, flexibility and strengthening exercises
  • Joint protection and energy conservation
  • Appropriate medication for pain or inflammation

    Remember: You cannot effectively treat osteoarthritis with medication alone. Medication may help the symptoms, but does not slow the progression of disease and joint damage.


  Effective osteoporosis treatment takes a three-pronged approach:

  Calcium--Maintain bone mass while you still have it! Be sure to get enough calcium through a balanced diet, with extra calcium supplements, if needed.

  Exercise--Bones become thicker or thinner in response to use. Get plenty of weight-bearing exercise, such as walking and weight training.

  Medication--If you have osteoporosis, ask your doctor about the prescription medications that are available. Hormone replacement therapy (HRT) is sometimes used in postmenopausal women but this alternative should be fully discussed with your doctor regarding benefits and risks of HRT.

© Copyright 2010. Arthritis Education by Professionals, Inc.



"Bone Up" on This Silent--But Preventable--Disease
by Jan Revella, R.N.

  About 32 million Americans, 80 percent of them women, suffer from osteoporosis, which literally means "porous bones." Most of these people, unfortunately, remain undiagnosed and untreated. The good news? Over the last 15 years medical research has given us prevention strategies, improved diagnostic techniques and new treatments to help us deal with this often debilitating condition.

  The deterioration of bone structure and bone mass associated with osteoporosis leads to increased bone fragility and susceptibility to fracture. The most common types of osteoporotic fractures are of the vertebrae, hips and wrist.

  Most of the body's skeletal bone mass forms during the adolescent growth years. Just how strong your bones become by the time you stop growing in your early 20s depends on a number of factors, including good nutrition (especially adequate calcium and protein), plenty of weight-bearing exercise and genetics. Peak bone mass is achieved by young adulthood. Men who remain healthy experience very little bone loss until their 70s; for women, bone loss begins after menopause.

  The impact of osteoporosis on the patient can be physically, mentally and financially severe. Pain, limitation of activity and frequent fractures often cause depression. Vertebral fractures can lead to painful curvature of the spine, and hip fractures often require surgery. Patients may face large medical bills for hospitalization, medications, physical therapy and long-term nursing home care. In fact, osteoporosis can often be traced as the primary factor that moved an independently functioning older person into the ranks of the institutionalized elderly.

  Fortunately, we can now diagnose osteoporosis prior to the first fracture. Even more important, we have therapies that can alter the course of this disease.

Are You At Risk?

   While osteoporosis is most often associated with older women, it also strikes men, and can occur at any age. Those most at risk are postmenopausal females of Caucasian or Asian descent; other factors include having a thin or small frame, a family history of osteoporosis, a low-calcium diet, smoking, alcohol use and long-term use of certain medications, especially steroids.

  Postmenopausal women are at such high risk for osteoporosis because estrogen plays a very important role in maintaining bone mass. The decrease in estrogen levels can cause women to lose 20 percent of their bone mass in the five years after menopause. Women who undergo early menopause, either naturally or due to surgical removal of the ovaries, have a very high incidence of osteoporosis.

Diagnosing Osteoporosis

   So how do you know if you have osteoporosis? If you have had one or more vertebral compression fractures, or other non-traumatic fractures, then you probably have osteoporosis. You should see your doctor for a thorough medical evaluation including x-rays and lab work.

  The most accurate way to diagnose osteoporosis is through bone densitometry, which encompasses a variety of imaging methods, including dual x-ray absorptiometry (DXA). This is a painless, 10- to 15-minute test that provides accurate bone density measurements with a very low dose of radiation. Measurements are usually taken of the lumbar spine, hip and forearm.

Treating Osteoporosis

  Effective osteoporosis treatment revolves around four components. They are:

  1. Calcium--from your diet, and also from supplements. Adequate calcium is very important for maintaining strong bones. The National Osteoporosis Foundation recommends that postmenopausal women on hormone replacement therapy (HRT) take 1,000 milligrams of calcium per day, and those not on HRT take 1,500 milligrams. Also know that smoking and excessive alcohol consumption decrease bone mass. Additionally, it is recommended that you take 800-1000 IU of vitamin D which is required for the body to absorb and benefit from the ingestion of calcium rich foods or calcium supplements.

  2. For postmenopausal women, hormone replacement therapy (HRT). The estrogen-bone density link is why HRT is the first line of defense against osteoporosis in postmenopausal women. HRT can reduce or prevent bone loss and reduce the risk of fracture and coronary artery disease. But HRT has risks of its own, so it's best to speak with your doctor. For women who cannot or should not take estrogen, Evista is another alternative.

  3. Physical activity that puts stress on bones. Weight-bearing exercise such as walking, jogging, tennis, weightlifting and dancing helps to maintain bone and muscle strength and agility. Non-weight-bearing exercise such as swimming is not effective.

  4. Medications to treat osteoporosis. For women who find either the risks or side effects of HRT intolerable or inappropriate, there are several prescription medications that are approved for the treatment of postmenopausal osteoporosis. 

  Patients should thoroughly understand the four components of osteoporosis treatment and address each area with their doctor. Each category needs to be considered individually, as well as part of the whole spectrum of possible treatments. Medications are not interchangeable, and have risks as well as benefits. Patients should be as informed as possible about their treatment options, and work closely with their doctors to devise the most effective treatment program.

  Prevention, of course, is the best solution. Osteoporosis should not be considered an inevitable consequence of the aging process. It's never too late to treat it!

Eating for Better Bones

Calcium (mg)
Yogurt (plain, lowfat)
1 cup
Sardines (canned, with bones)
3 oz.
Macaroni & Cheese
1 cup
Collard Greens (cooked)
1 cup
Skim Milk
1 cup
Lowfat Milk
1 cup
Whole Milk
1 cup
Swiss Cheese
1 oz.
Turnip Greens
1 cup
1 cup
Cottage Cheese
1 cup
1 cup
Cheddar Cheese
1 oz.
Mustard Greens
1 cup
Ice Cream
1 cup
Fresh Broccoli (cooked)
1 cup
Canned Salmon
3 oz.
4 oz.
Dandelion Greens
1 cup

Over-the-Counter Calcium Supplements

Calcium supplements are recommended for persons who do not meet their daily calcium requirements from diet alone. The three major choices are outlined at right. Calcium is best absorbed if consumed throughout the day, but taking it all at once is better than not taking it at all. Be sure to read and follow label directions, and choose a national brand to ensure quality. Avoid bone meal or dolomite, as they may contain toxic ingredients.

Calcium Carbonate
(Provides 40% elemental calcium)
Relative Cost: $
Brand Names: Alka-Mints, Caltrate, OsCal, Titralac Tablets, Titralac Liquid, Tums, Tums E-X, Tums 500
Calcium amounts vary from 400 to 1500 mg.

Calcium Citrate
(Provides 21% elemental calcium)
Relative Cost: $$$
Brand Names: Citracal Liquitabs, Citracal 950, Citracal 1500, Citracal 1500-D
The Liquitabs has 2376 mg calcium per tablet. The 1500-D formula includes 200 I.U. vitamin D.

Calcium Phosphate
(Provides 39% or 30% elemental calcium)
Relative Cost: $$
Brand Names: Posture, Posture-D
Both are 1500 mg per tablet for 600 mg of elemental calcium. Posture-D includes 125 I.U. vitamin D.

© Copyright 2010. Arthritis Education by Professionals, Inc.



Painful Shoulders
Successful Treatment of Shoulder Pain Depends on Proper Diagnosis

  The shoulder joint is unique among the large joints of the human body. It's the most moveable, and one of the most fragile, joints we have. For the most part, its flexibility enables our arms to be extremely useful.

  To discuss the painful shoulder, let's understand how the normal shoulder anatomy is put together first. The shoulder joint consists of three bones held together by muscles, tendons and ligaments. The clavicle (collarbone) attaches the shoulder to the rib cage and holds the shoulder out from your body. It connects with a large flat scapula (shoulder blade) at the acromion (top of the shoulder). The bones of the shoulder and the attaching ligaments form a ball-and-socket joint--better known as the shoulder joint.

  The shoulder joint is stabilized by the rotator cuff, a commonly known group of tendons that attach the shoulder to your back and chest muscles. Between the top of the shoulder and the rotator cuff lies the bursa, a small sac containing fluid to buffer friction between the tendon and the bone.

  What's important is that the shoulder affords us the ability to move our arms many ways. However, because of this ability the shoulder is also the least stable joint and most likely to develop problems.

  The shoulder is often the cause of much dysfunction and ongoing pain. Commonly, people think this pain is the result of arthritis. Although the symptoms can resemble those of arthritis, whether you are 29 or 89 it is more likely that the pain and dysfunction are a result of a process called shoulder impingement syndrome. Of course, there are exceptions, as in patients who have a history of rheumatoid arthritis or trauma of the shoulder, such as from an accident.

Causes and Symptoms

   Every time the arm is held out from the body in any direction, the rotator cuff and the bursa sac in the shoulder are squeezed. Over the years, too much of this friction can wear down the tendon and the bursa. This can lead to inflammation of the bursa and the rotator cuff and the development of bony spurs, eventually causing a tearing of this supportive cuff. Other causes of impingement syndrome include mechanical alterations of the shoulder and its surrounding structures.

  There are four stages of shoulder impingement syndrome. Stage 1, typically seen in younger patients (25-30 years of age), is caused by overuse and is a reversible process of tendon swelling and hemorrhage (tendinitis). In Stage 2, which usually occurs in patients up to 40 years old, changes include fibrosis and a thickening of the (subacromial) bursa. In Stage 3, usually seen in the older age group or associated with significant disease or injury, there is typically a tear (partial or complete) of the tendons that connect the rotator cuff and the head of the biceps muscle, and there also can possibly be some bone irregularities. Stage 4 is end-stage arthritis with a complete rotator cuff tear.

  Patients with a history of repetitive overuse, such as baseball players, may suffer microtrauma, may develop a fibrosis or inflammation of the lining between the cuff and top of the shoulder leading to a chronic bursitis or tendinitis. Remember, the diagnosis given as "bursitis" (inflammation of the bursa) is really a symptom of an underlying problem.

  Severity of the symptoms of these stages can vary depending upon the degree of the problem. Pain can be a dull ache in the shoulder but can become a sharp pain when trying to move the arm, particularly overhead. The pain may be worse at night, and you may have sleep difficulties as well.

  For each patient presenting with shoulder pain, it is necessary for the physician to obtain a complete history and physical examination. During your physical examination, the doctor will check for pain, tenderness and loss of motion. Sounds of popping, grinding or clicking can be key components of the problem, too.

  Other conditions that could be identified during this visit include cervical disc disease (neck), systemic arthritis, nervous system disorders and tumors, to name a few.

  To accurately identify the problem and to determine the severity of the impingement syndrome, it is also sometimes necessary to order an arthrogram (where dye is injected into the joint to outline the soft structures), an MRI scan of the shoulder, x-rays of the neck area, or chest or nerve studies.

  Once the diagnosis of impingement syndrome is made and the stage is determined, a treatment program is designed. Initial treatment is usually conservative. Depending on the patient's response to the program, treatment can become more aggressive if it's appropriate to the patient's needs. In Stage 1, heat and rest should be utilized. Ice is appropriate after an acute flare of symptoms typically seen after overuse. Examples include a young person throwing a ball repetitively, a middle-aged weekend athlete or a senior adult who decided to patch up his roof.

  Use of non-steroidal anti-inflammatory drugs for acute flares can be extremely useful. Physical therapy including progressive stretching and strengthening exercises is utilized until the patient has recovered. Rotator cuff strengthening must be done to prevent Stage 1 or 2 from advancing to a more severe stage. A maintenance program is recommended in most cases depending on the patient's symptoms after initial treatment.

  In stages 2 and 3, impingement syndrome can necessitate surgical intervention. The role of cortisone injections is somewhat controversial, because steroid injections can have the side effect of weakening the same tendon we are trying to protect and preserve with therapy or surgery. Cortisone can be used at infrequent intervals in appropriately selected patients. However, if the symptoms aren't alleviated or if pain persists, the surgical correction of impingement syndrome may be best in the long run.

Surgical Intervention

   There are a number of surgical techniques that offer relief for shoulder impingement syndrome. Arthroscopic surgery, which is relatively non-invasive, permits the surgeon easy access and excellent viewing of the joint and the surrounding tissues. With this technique, it is possible to clean out any of the fibrosis and thickened tissue. Small rotator cuff tears can be repaired and small bone irregularities (spurs) can be removed.

  Severe rotator cuff tears require a more invasive surgical procedure. Because of the differences in the application of these two surgeries, one can easily realize the value of an early diagnosis and treatment program. Early intervention can help you to avoid a more serious surgery later on.

  Following surgery, the patient returns to a physical therapy program with the same basic goals--maintenance of pain relief, return of range of motion and ultimately a stronger and more useful shoulder.

  The earlier the intervention the more likely it is to provide long-term function and pain relief. In fact, if a nagging shoulder problem does exist, it's possible ongoing damage is occurring, which will progressively become more severe and debilitating. Proper diagnosis, treatment and strength maintenance of the shoulder can improve or alleviate the shoulder problem and return you to a more active lifestyle.

The Stages of Shoulder Impingement Syndrome

Stage 1

Edema and Hemorrhage (Bursitis)
Common Age: 20s
Symptoms: Pain and soreness from overuse
Clinical Course: Reversible
Treatment: Conservative

Stage 2

Fibrosis and Tendinitis (Tendinitis)
Common Age: Up to 40
Symptoms: Pain with vigorous use above horizontal
Clinical Course: Recurrent pain with activity
Treatment: Conservative/surgical

Stage 3

Bone Spurs and Rotator Cuff Tears
Common Age: Older adults
Symptoms: Pain at top of shoulder/upper arm, weakness, inability to use arm effectively
Clinical Course: Progressive disability, can be chronic
Treatment: Surgical arthroscopy

Stage 4

Rotator Cuff Arthropathy
Common Age: Older adults
Symptoms: Severe pain with motion, inability to use arm
Clinical Course: Progressive disability
Treatment: Open surgery; may require joint replacement

© Copyright 2010. Arthritis Education by Professionals, Inc.



The Aging Spine and Back Pain
by Paul Saiz, M.D.

Back pain is as common as it is enigmatic. An estimated 90% of the population will experience at least one episode of back pain with the vast majority of symptoms resolving within one month. However, for certain people, back pain can become chronic and disabling.

  There are multiple causes of back pain. These include the muscles of the back, ligaments, nerves and the bony architecture of the spine to name a few. Unfortunately, the normal process of aging is responsible for the majority of changes in our spinal anatomy, some of which can cause pain. However, degenerative change is commonplace. In fact, a study was done on asymptomatic patients in their twenties and 30% were found to have some changes found by MRI. By the time people are fifty approximately 97% of the population will have degenerative changes found on MRI. While the process of aging cannot be stopped, its effects can be minimized.

  Symptoms from degeneration manifest themselves usually as back pain and/ or leg pain. These symptoms come from nerves that are being irritated as they exit the spine or spine anatomy that is wearing out and becomes painful when stressed.

  The spine is very similar to a car. An automobile is a series of moving parts that allow the vehicle to move in space. The more miles you put on the car, the more likely the vehicle will have some component wear out (tires, shocks, etc.). Our spine is the same way. As we get older, the various moving parts of our anatomy degenerate (discs, facet joints). One of the first areas to begin to degenerate is the discs. The disc serves two functions: motion and shock absorption. As we get older, the disc will lose this ability and shrink in height and distribute more stress to other areas (bone and joints). This change in stress distribution will cause arthritic change to occur in our surrounding anatomy. This degenerative cascade will manifest itself as increased back pain and stiffness.

  Nerve pinching or stenosis follows the same degenerative cascade. Nerves exit the central canal through holes in the spine called foramen. The foramen are bordered by disc, facet joints and ligaments. As the disc loses height and bulges, our facet joints are simultaneously becoming arthritic (enlarged from bone rubbing bone), the foramen becomes smaller and the exiting nerve becomes pinched. We notice this as leg pain.

  Another common manifestation of age is the fact our bones lose their mineral content over time (osteoporosis). This is more commonly seen in post menopausal women but occurs in men with increasing age. Our vertebra (spine bones) are unique in that they are designed to absorb stress. The bony architecture is similar to the Greek Pantheon. The bone has columns which support the roof and floor. With time, as we lose mineral, our vertebra lose columns and the roof is more at risk of collapse. If the spine sees a significant stress, you are at risk of sustaining a compression fracture. These injuries are extremely painful and may take weeks to months to heal.

  Patients with back pain secondary to degeneration usually respond to conservative treatments which include physical therapy (P.T.), anti-inflammatories (Ibuprofen) and steroid shots. P.T. is important to strengthen our trunk, neck and shoulder girdle musculature, which helps to minimize the wear and tear to which our spine is exposed. The increase in muscular endurance and strength from P.T. is similar to getting new shocks on the car. The speed bumps you encounter in life are not as significant. Anti-inflammatory medication helps break the pain cycle and minimizes the effects of the arthritic change. Steroid shots are used to decrease the irritability of the nerve roots. The shots also can decrease the swelling that nerve roots may exhibit from being pinched. The effects are similar to being stuck in Phoenix traffic, without an air conditioner, and taking a valium. You are still in traffic but you are less angry about your situation.

  If symptoms do not improve with conservative management then a surgical consultation may be needed. Surgical intervention should be viewed as a last resort and usually involves altering your anatomy to alleviate the pain source. This can be anywhere from a decompression (making the foramen bigger and relieving the pinching the nerve is experiencing) to a fusion (stopping moving parts which are causing pain from moving). There are newer techniques which focus on minimizing the physical insult of surgery by using smaller incisions (minimally invasive surgery) to Kyphoplasty. Kyphoplasty involves using a balloon to expand a compression fracture and fill the bone with bone cement to stabilize the fracture. All these techniques involve fewer days in the hospital and more rapid recovery.

  To conclude, conservative measures and surgery do not turn back the odometer. These treatments are attempting to improve quality of life and increase function. Everybody has some back discomfort and degeneration of the spine is a fact of life. Our goal at Sonoran Spine Center is to do whatever is needed to get your car running as efficiently as possible for the rest of your life.

© Copyright 2006. Arthritis Education by Professionals, Inc.



Adolescent Idiopathic Scoliosis
by Dennis Crandall, M.D.

What is Scoliosis?

  Scoliosis is defined as a curvature in the spine from side to side (spinal curves from front to back are called kyphosis). Since many people have very small curves in the spine that are of no real consequence, a curve must measure more than 10 degrees to be called scoliosis. There are many different causes for scoliosis.  When the vertebrae themselves are abnormally shaped because of failure of the vertebra to form correctly or separate correctly, we call it Congenital Scoliosis. When a spinal curvature occurs with another known syndrome or condition that affects the nervous system (such as cerebral Palsy or spina bifida), it is called Neuromuscular Scoliosis.  When there is no clear cause of the curvature in a healthy person, it is called Idiopathic Scoliosis.  This type of scoliosis is the result of an abnormal rotation of the vertebra. Scoliosis can involve the upper back (thoracic), mid-back (thoracolumbar), or in the lower back (lumbar). The neck is seldom involved in scoliosis, and is never part of idiopathic scoliosis.

  Adolescent idiopathic scoliosis is the most common type of spinal curvature. It occurs between the onset of puberty and age 18 in otherwise healthy boys and girls.  The prevalence of scoliosis in the USA is 2 4% for curves as little as 10. Girls are far more likely to have larger curves and curve progression than boys. We don't know why. For boys, curves are more likely to progress through the late teen years as long as skeletal growth continues.


  Unlike many types of scoliosis, the cause of adolescent idiopathic scoliosis is unknown. It does seem to run in families but is not strictly inherited. The likelihood of scoliosis is greater where there is a family history. Cases can also occur where there is no family history of scoliosis. The more that is learned about causation, the more complicated this deformity appears to be. Research is ongoing to try and connect the disorder to a specific gene or group of genes.

Signs and Symptoms

  Adolescent idiopathic scoliosis is a painless spinal deformity. The curve in the spine does not cause pain. If pain is present, it should be investigated further and not attributed to the curve.

  The most common physical finding in teens with scoliosis is the prominence of the ribs on one side. This so-called "rib hump" is best observed by parents or health care providers when viewing the teen bending forward. The ribs on one side of the back will often seem higher than the other side. Other findings include one scapula or shoulder blade that may seem more prominent than the other is. Careful observation of the standing teen may also reveal that one shoulder is higher than the other. One hip may seem higher and give the appearance that one leg is longer than the other is (it usually is not). Clothes fit differently than they used to. There are also patients who have a large curve and hide it very well clinically, without much noticeable deformity.

What Happens to Teens Who Have Scoliosis?

  For teens with scoliosis, the period of time carrying the greatest risk that the curve will get bigger (curve progression) is during the adolescent growth spurt. For girls, this may be from age 11-14 and usually lasts for 18 months after the first menstrual period. For boys, it is usually between ages 13-17. During this period of rapid growth, the curve can increase up to 1 or 2 degrees per month. It is not uncommon for parents wonder where the curve came from so quickly. Some parents feel guilty for not noticing the curve sooner. The nature of adolescent idiopathic scoliosis is one of possible rapid progression, and parents should not feel guilty.

  The likelihood of curve progression depends on the size of the curve in relation to the amount of growth the teen has remaining. For young teens who are still growing and have curves greater than 20 degrees, there is a 68% chance the curve will get larger over the next few years. If a teens growth is nearly complete and the curve is around 20 degrees, there is less chance the curve will ever increase. Most small and medium sized curves stop getting bigger once the body is finished growing. The spinal curvature will continue to be the same size throughout life that it was when the patient was a teen. If the curve is more than 40-50 degrees during the teen years, it will likely continue to get larger during adulthood, though at a much slower rate.

Conservative Treatment Options

  For simplicity and patient education, we break down scoliosis into three levels of severity.

  SMALL CURVES: 10-25 degrees. These patients are treated with observation. For teens still growing, follow-up x-rays are needed every 4 months until growth stops.

  MEDIUM CURVES: 26-40 degrees. If the patient is still growing, a brace should be considered. We use a custom molded TLSO (thoraco-lumbo-sacral orthosis) for most patients and our success rates have been similar to the national experience. The brace is about 70% successful at preventing curve progression. Nearly one third of patients that wear the brace experience curve progression anyway.  The brace does not make the curve improve or go away. Successful bracing means that the patient avoids surgery because the curve does not increase. Successful bracing keeps the curve at the same degree it was when bracing was started.

  Certain types of braces (TLSO, Boston, Milwaukee, and Charleston have been studied by members of the Scoliosis Research Society and are successful in treating scoliosis. Some other types of braces have been widely advertised by their entrepreneur developers but their use is not supported by adequate data. If you have any questions about whether your brace is adequate, contact the Scoliosis Research Society or a SRS member in your area.

  Treatments which have been shown to have no affect on curve progression include physical therapy, an exercise program, chiropractic manipulation, medications, and electrical muscle stimulation. A brace is the only form of conservative care shown to affect the progression of scoliosis when compared to no treatment at all.

  LARGE CURVES: 45 degrees and higher. These patients have a large enough deformity to warrant surgery in many cases. Remember that bracing does not improve a curve. It only prevents the curve from getting larger, if it works. Wearing a brace is a less attractive option for severe curves since the curve will still be large at the conclusion of treatment. For this reason, bracing is usually not an option for these patients. Without surgery, progression of these large curves during adulthood still remains a risk.

Surgery for Adolescent Idiopathic Scoliosis

  The decision to have surgery to correct scoliosis is a highly personal decision. This type of decision should always be made on an individual basis with consultation from the patient, parents, and their Spine Surgeon. Many patients and their families find additional information from national and local scoliosis support groups. We encourage our patients get in touch with the Arizona Chapter of the Scoliosis Association (480-839-9822).

Indications For Surgery (Who Needs It?)

  Patients with any of the following could be candidates for surgery:

  • Curves greater than 40 - 45 degrees in a teen who is still growing
  • Large curves which cause spinal imbalance
  • Curves associated with neurological signs and symptoms (Not adolescent idiopathic)
  • Curves larger than 50 degrees in patients who have stopped growing

Surgical Approaches

  There are three approaches to scoliosis surgery currently used, namely anterior only (from the front), posterior only (from the back), or combined anterior and posterior. There are various techniques using these approaches.

  Anterior - This is done by making an incision in the side of the chest or flank, removing the discs, and filling them with bone graft often taken from a rib. The bone goes on to heal and the spine becomes fused. Screws are inserted into the vertebrae and a rod connects the screws. The spinal curvature is corrected and held in place with the rod and screws. Screws, rods, and hooks are usually made from a titanium alloy or from surgical grade stainless steel.

  Posterior - This is the traditional technique for surgically treating scoliosis, approaching the spine from the back. The muscles are spread aside (not cut) and the spine is exposed. Bone screws and sometimes hooks or cables are used to attach to the spine and are connected together by rods. The hooks, screws, and rods are manipulated to correct the deformity, and bone graft is laid on top to fuse the spine in its new straightened position.

  Combined Anterior and Posterior (Front-Back) - This is reserved for very young patients or those with the largest and stiffest spinal deformities. Both front and back surgeries are usually done the same day under the same general anesthetic. The anterior part is usually done first and can often be done through the scope, saving patients from a large flank incision (see section on thoracoscopic surgery). The posterior surgery follows.


  The object of surgery is to safely straighten the curve and stop its progression. Safety is always first. In most cases, the severity of the curve can be improved at least 50% (average of 67%) with surgery. We do not try to make the spine perfectly straight since it is usually not safe to do so.

  Our success rate at achieving our surgical goals without any complications is about 92%. Patients and parents are almost always happy with the functional and cosmetic results.


  The most common complication is the failure of the spine to fuse solidly, despite good bone graft and instrumentation. These so-called "nonunions" occur in 5% of patients. If there is no loss of correction and if there is no pain associated with the nonunion, it can be observed without further surgery. If pain is present, revision surgery may be required to fuse the unfused segment.

  There is a 2% risk of infection with this type of surgery. It occurs despite antibiotics being given before, during, and after surgery and is usually attributed to bad luck. When it is diagnosed, usually in the first several weeks following surgery, a revision surgery is needed to thoroughly clean out the spine wound in order to prevent a chronic infection from setting in. Occasionally more than one "wash out" surgery may be required to get rid of the infection.

  The risk of instrumentation failure is about 1%. When this happens, revision surgery may or may not be required, depending on several factors.

  Other complications can occur but are very rare, occurring in less than 1 per 100.

According to the Scoliosis Research Society data, the risk of paralysis with scoliosis surgery is about 1 per 2000 cases. Thankfully, we have never had a case.

  We have our patients donate blood before surgery whenever possible. It they need blood, we give them their own blood back. The risk of contracting hepatitis from a blood transfusion from the blood bank is around 1 per 10,000. The risk of getting AIDS from infected blood is about 1 per 100,000. Neither of these risks applies if the patient receives their own blood back.

  The risk of death from surgery is about 1 per 1,000,000. Thankfully, we have never had a case.


  Even though we have come light years in our technology and approach to scoliosis surgery since the 1970's, it is still major surgery. Hospitalization is usually about 4-6 days. Teens are up walking right away and are ready to go back to school in 3 weeks (no lifting more than 5 pounds). No exercise more than walking is allowed for the first 6 months. After that, jogging and gentle swimming is started. After 9-12 months from surgery, patients are allowed to do most everything except collision sports (football, rugby, rodeo, etc.).

Long-Term Outlook After Surgery

  Once the spinal curvature is corrected and successfully fused, a normal or near normal life can be resumed. Most people do not have significant back pain, even long after surgery. Patients who were fused low in the lumbar spine (L4 or lower) while in their teens are more likely to have some back pain later in life.

  In some patients over time, arthritis develops in the next level below the fusion. When this occurs, back pain slowly increases as the arthritis increases. Bone spurs may form and pinch the spinal nerves, causing leg pain. This is called spinal stenosis. To alleviate the pain, surgery is required to clean out the bone spurs and extend the fusion lower in the lumbar spine.

  About 5% of patients will at some point in their lives need to have their hooks and rods removed for some reason. Occasionally, a fluid collection or bursa forms over the implants and they become painful to touch and hurt with changes in the weather. Surgery to remove hardware is no where near as major as the initial surgery.

What If My Curve Is Large But I Decide Not to Have Surgery?

  Spine surgeons who take care of both adult and pediatric patients with scoliosis as we do often have 30 and 40 year old women come in with moderately severe scoliosis. These women invariably tell stories of not being allowed to have surgery in their teens. Later, as mature adults, they want to have their curves corrected and regret that they did not do it as teens when it would have been more convenient with a quicker recovery and better correction while the spine is more flexible. This is a very common scenario.

  Thoracic curves that are allowed to become large can cause general health problems. As the curved spine takes up more space in the chest, patients become short of breath with exercise and minor activity. Very large curves can even lead to congestive heart failure. Measurable lung function decline begins when curves are in the 70-80 degree range.

  Large curves in the lumbar region often lead to premature spinal arthritis. This causes back pain, spinal imbalance, and spinal nerve compression during adulthood. The trunk shortens as the curve increases, and the ribs begin to rub on the rim of the pelvis. The lumbar spine does not have any outside support such as the rib attachments in the thoracic spine. Once the curve reaches a certain point, it often becomes relentlessly progressive.

  There are also some obvious cosmetic consequences to having a large untreated scoliosis. One study from Sweden even found that women with severe scoliosis were much less likely to get married. While no one would ever suggest that surgery should be done for purely cosmetic reasons, the body contour improvements that accompany surgery can be very gratifying.

© Copyright 2006. Arthritis Education by Professionals, Inc.



Adult Scoliosis
by Dennis Crandall, M.D.

Adult scoliosis is a condition where rotation of the spinal vertebrae leads to curvature of the spine in a person who has finished growing (usually by 18 - 21 years old). In order to be classified as scoliosis, the curve must exceed 10. Curves can occur in the chest area (thoracic spine) or the lower back area (lumbar spine). Occasionally, curves involve areas of the spine which lie in between, such as thoracolumbar. The neck or cervical spine is rarely involved.


  Adult Idiopathic Scoliosis - When curvature of the spine starts in adolescence in an otherwise healthy person, it is most commonly diagnosed as "adolescent idiopathic scoliosis". Idiopathic refers to the fact that the curve is not associated with other known problems such as cerebral palsy, spina bifida, neurofibromatosis, or a number of other conditions.

  After age 18, adolescent idiopathic scoliosis becomes "adult idiopathic scoliosis". It is the same curve present during the teen years but the spine does not behave the same way as the teenage spine. As a person with scoliosis ages, the spine develops premature aging changes in the back joints such as bone spurs, degenerative discs, and thickened spinal ligaments. This leads to a condition known as "adult idiopathic scoliosis with degenerative changes". These degenerative changes superimposed on a curve that is already present can sometimes cause back pain, leg pain, spinal imbalance, and progression or worsening of the curve.

  For adult curves greater than 50, natural history studies suggest a high likelihood of curve progressing at about 1 per year. For curves in the lumbar spine or lower back, there is a high chance of progression if the curve is greater than 35-40.

  Degenerative Scoliosis

  As arthritis begins to affect the spine, the discs lose their water content and consequently their ability to serve as the "shock absorber" of the spine. The facet joints in the back of the spine begin to wear out and lose their ability to maintain normal spinal alignment. The vertebrae begin to slip or abnormally move. This may lead to spinal instability, nerve compression, and pain. As both the disc and the facet joints lose their ability to maintain normal spinal motion, the spine can settle asymmetrically, leading to scoliosis.

  When the lumbar spine was straight as an adult but develops a curve later in life (usually in the 60 years + age group), it is termed De Novo or spontaneous development of degenerative scoliosis. This can occur earlier in patients who have had spinal surgery for laminectomy. It never occurs without significant arthritis.


  The most common sign of scoliosis is a prominence in the ribs on one side of the thoracic spine. In the lumbar spine, there is sometimes a prominence on one side, though often not. The prominence or "rib hump" is most apparent when bending forward. Sometimes there seems to be an asymmetry in the waist, with one side being indented more than the other. Clothes begin to fit differently than before.

  If the scoliosis is severe and unstable, spinal imbalance is common. Imbalance implies that patients lean to one side or forward when they try to stand straight upright. They may feel like they are tipping to one side, or have the sense that they are falling forward. Most people with adult scoliosis notice that they are not as tall as they used to be.

  Most young adults with scoliosis do not have significant back pain. The curve usually does not hurt unless or until it becomes degenerative. Sometime in life, however, because arthritis is age related and develops prematurely in this group, the adult with scoliosis is likely to develop back pain. When it occurs, the pain is worse when upright and active, and better when the patient is resting.

  Spinal instability occurs when the disc and facet joints are so worn out that they can no longer maintain normal spinal alignment. Pain comes from the arthritic joints as well as from the adjacent nerves, which are pinched and stretched as a result.

  Buttock pain can occur due to referred pain from the arthritic spine, or it could be a manifestation of a more significant problem with nerve compression. Spinal nerve roots become pinched when arthritic bone spurs form around them and block their exit route from the spinal column. This condition is called Spinal Stenosis. In addition to buttock pain, other symptoms such as leg pain, numbness, tingling, and weakness are common. If any of these findings are present, advice from a physician should be sought without delay.

  If spinal stenosis or nerve compression in the back is severe enough, control of bowel and bladder function will be lost. This however is a rare event, but when it happens, it is a surgical emergency. If the pressure on the nerves is not relieved quickly, control of bladder and bowel may never be regained. Again, this is a very rare occurrence and we only see 2 or 3 cases each year.


  As the spine ages, it becomes stiffer. Flexibility is greatest in the teen years, and usually declines starting in the 40-50 age group. Stiffness of the spinal joints can become severe as bone spurs form and prohibit motion. In some cases, the bone spur formation is so severe that all motion is lost at one or more levels in the spine.

We all achieve our maximum bone density at about age 30-35. After age 35-40, there is a slow decline in the amount of bone present in the spine. After age 60, and particularly after menopause in women, the loss of bone becomes visible on x-rays. This is osteoporosis. If the bone loss becomes severe, spontaneous fractures can occur in the spine. These fractures can lead to scoliosis or kyphosis.

  As we get older, our general health can become more of a problem. Chronic disease processes such as high blood pressure, diabetes, and heart disease are prevalent among American Seniors. When scoliosis becomes a problem in seniors, other health issues must be considered when treatment options are considered.


  Nearly all patients with adult scoliosis will respond to conservative treatment and lead a normal, functional life. When pain is present, it is usually short term and manageable. Treatment for adult scoliosis should almost always begin with a non-invasive approach. Our philosophy is, "Try the easy things first."

  Non-steroid Anti-inflammatory Drugs (NSAIDS) have been the cornerstone of medical therapy for arthritic and inflammatory conditions. These medications can quiet the pain and stiffness caused by degenerating discs and joints.

  Physical Therapy is an excellent way to improve function, flexibility, endurance, and decrease pain. Usually the therapist will work with patients toward becoming less symptomatic, and maintaining the improvement with an active home exercise program. Working out in a supervised environment with the help of a physical therapist is the best way to achieve it. On average, therapy lasts 2-3 times per week for 4-8 weeks.

  It is very important that adult patients with scoliosis get into the habit of doing a daily exercise routine. This will improve the strength of the trunk muscles and take some of the stress off from the spine. Often when pain occurs, it is because the patient is not doing his or her exercises.

  Sometimes a back brace is helpful in getting some relief from back pain in patients with degenerative scoliosis. A word of caution is in order however: the brace should not be used without faithful compliance with an active exercise program. Brace wear without exercise tends to lead to a weaker spine that becomes dependent on the brace. Daily exercises and occasional (when needed) brace wear lead to the best results, where bracing is concerned.

  Medical management of osteoporosis and general health is important to maintaining an active lifestyle into old age, especially in patients with scoliosis. Solving small problems before they become big ones has always been good advice.

  Passive manipulation (Chiropractic) is not an acceptable treatment for scoliosis of any kind.  Passive manipulation of the spine provides short term symptomatic relief for muscle spasm, but does not impact the size of the curve or the rate of progression.  Patients with scoliosis are encouraged to not rely on chiropractic adjustments as a means of treatment since these are essentially equal to no treatment at all.

Reasons Surgery Might Be Considered

  Few patients with adult scoliosis will ultimately require surgery. When necessary, the goals of surgery are to stop curve progression, stabilize the spine, establish correct spinal balance, decrease back and leg pain, and increase function with as little surgery and as few complications as possible. Patients who require surgery to straighten, stabilize and fuse their spinal curvature are patients with:

  • Increasing curvature over time (it will continue to get worse)
  • Unstable spine that hurts despite conservative care
  • Nerve compression causing pain, numbness, or weakness
  • Spinal imbalance which is painful or progressive
  • Large curve which will progress (better to do these earlier while health is good and before osteoporosis starts or worsens)

Surgical Options and Results

  If the main problem is leg pain caused from a disc herniation, this can usually be taken care of with a small surgery to remove the disc fragment and decompress the nerve. A large procedure to correct the scoliosis and fuse the spine is not necessary.

  Sometimes leg pain is caused by bone spurs that are compressing the spinal nerves. This is spinal stenosis. If stenosis is the problem, the solution usually will require removal of the offending bone spurs to get pain relief. If adequate bone is to be surgically removed to decompress the pinched nerves (laminectomy), the spine is often rendered somewhat unstable in the process. Back pain will increase, leg pain may return, and the spinal curvature will get bigger if the spine is not fused at the same time. In these cases, correction of the curve and fusion with bone graft and instrumentation is required to stabilize the spine and prevent what would be a certain need for future surgery.

  When back pain, progressive deformity, or spinal imbalance are primary factors, the curve should be straightened and fused. The amount of correction obtained with surgery is sometimes limited compared to the corrections seen in the pediatric patients.  This is due to increased spinal stiffness in adults.

Surgical Technique to Correct Scoliosis

  Once the decision for surgery has been made, the operative plan is formulated. Patients are routinely asked to donate blood before surgery to be stored and used during their surgery. The spinal cord function is usually monitored throughout the surgery to make sure there is no compromise to spinal cord function. Bone graft material and spinal instrumentation may need to be arranged for ahead of time.

  Surgery to correct adult scoliosis is the most challenging surgery done in orthopedics, and is likely among the most complex and demanding surgeries of any kind being performed today. This type of surgery requires at least one assisting surgeon and often a surgical team, and can take from 3-14 hours to accomplish.

Anterior Surgery

  If the spine must be fused anterior or from the front, a thoracic or general surgeon will be a part of the surgical team to safely mobilize the great blood vessels off the spine where the spine surgeon will work. The incision may be through the side of the chest, through the side of the abdomen, or through the front of the abdomen, depending on what is needed at the time of surgery. The purpose of anterior surgery is to remove the discs, and fill the space with bone graft or Bone Morphogenetic Protein (see below). This serves to improve the correction which can be achieved and improve the reliability of the fusion.

  Sometimes the spine is "instrumented" from the front, meaning that screws are placed into the vertebra and attached to a rod that will correct the deformity and stabilize the spine.

  More recently, the thoracoscope has been used in spine surgery. We can now remove discs from the thoracic spine and insert bone graft without making a large incision. All of the work is done through a few one-inch incisions on the side of the chest.

Posterior Surgery

  Most of the correction of scoliosis is done from the back of the spine. If nerves are compressed by bone spurs or a disc herniation, the offending structures can be removed to allow more room for the nerves. The spine is then "instrumented" by the placement of hooks or screws that attach to the vertebrae. These hooks and screws are then attached to rods that span the curve. The instrumentation is then distracted, compressed, or rotated in order to correct the spinal curvature. Without instrumentation, the curve cannot be corrected.

  Bone graft is always used in scoliosis surgery. The spine must be fused in its new corrected and straightened position. The graft most commonly comes from the patient's own pelvis. Sometimes bone-bank bone is used when there is not sufficient bone available form the patient. Newer uses for Bone Morphogenetic Protein include posterior scoliosis fusions.


  Adult patients who undergo major spinal surgery to correct their scoliosis generally do well. Pain is greatly improved or eliminated in the majority (80% in our series). The fusion is successfully achieved and the correction maintained long-term in 80-95% of people who have mild to moderate scoliosis corrected with or without nerve root decompression. In our series of recent patients, curve correction is averaging 67 79%, depending on the type of scoliosis.

  Complications can occur however, such as failure of the spine to solidly fuse, failure of the spinal hardware (<2%), infection (2-4%), nerve injury (<1%), medical complications, and others. The patients who are at greatest risk for complications are smokers, people taking steroids and those with severe osteoporosis or poor nutrition.


Our Research

  We regularly present the results of our research to our Orthopedic and Neurosurgical colleagues at national spine meetings such as the North American Spine Society, Scoliosis Research Society, International Meeting on Advanced Spine Techniques, and others. One of our research interests includes improved fusion techniques using Bone Morphogenetic Protein.  This is a protein carried in a collagen sponge that turns on the bone forming machinery of cells.  Our results are impressive in achieving fusions without having to remove bone graft from our patients pelvis.  This means less post-op pain and quicker rehabilitation for our patients.

  Another exciting area of research is in the development of a new spinal instrumentation system (2002) that allows easier and more effective correction of scoliosis than what has been achievable before.  We now have biomechanical testing, FDA approval, and enough long-term results to recommend and release the new instrumentation system for fuse by spine surgeons worldwide.  The system is called 3D with Multi-Planar Technology, or MPA for short.  It is marketed by Medtronic Sofamor Danek.  We are continuing to investigate improved ways of correcting spinal deformity, achieving a more reliable fusion, and improving the function of our patients.

  Spine surgery has made tremendous progress in just the past 15 years. The future looks just as bright, if not brighter.

© Copyright 2010. Arthritis Education by Professionals, Inc.



Cervical Disc Herniation
by Dennis Crandall, M.D.

"A Pinched Nerve in the Neck"

What is it?

  In between the vertebrae of the neck are cervical discs. The cervical disc serves to cushion the weight of the head while allowing the vertebrae to move. When a piece of the disc escapes through a tear in its thick containment ligaments called the annulus, this is called a cervical disc herniation. Herniations occur into the spinal canal and can compress the spinal nerves or even the spinal cord.


  Most often, patients do not remember a specific event or injury that caused their disc herniation. It most often seems to start without any apparent reason. Occasionally, an automobile accident, work injury, or sports injury is the cause. The thick containment structure for the disc, the annulus, becomes thin starting around age 30 - 40. This leads to disc bulging and herniation. The annulus can also be torn from an injury. When the annulus tears, the disc material is no longer contained and can extrude or herniate through the tear in the annulus and enter the spinal canal.

Signs and Symptoms

  The most common symptom of a disc herniation is pain that radiates across the shoulder and into the arm, through the forearm and often into the hand. The area of arm pain depends on which disc in the neck is herniated. A herniated disc may also cause pain across to the shoulder only and not down the arm. It may cause pain only into certain fingers. Numbness over parts of the arm or hand is common. Weakness in muscle groups associated with the nerve is also not uncommon. An injured cervical disc can also cause referred pain around the shoulder blade or scapula. Headaches and neck pain are also common. If the disc herniation is large enough to compress the spinal cord, numbness, tingling or weakness in the legs might develop.

Nonoperative Treatment Options

  Most cervical disc herniations that cause radiating arm pain will improve over the first six to eight weeks after symptoms occur. The majority of patients who have arm pain will notice that the pain slowly improves over this two month time frame and numbness and weakness may also improve. The initial treatment approach should include anti-inflammatory medications such as aspirin, Advil or Aleve. Physical therapy including general traction can also play a roll and provide some relief. In some cases, epidural steroid injections may be appropriate.

  It is very important that patients with a cervical disc herniation not have passive manipulation of the cervical spine such as chiropractic treatments. Such forceful movement on the cervical spine can cause more of the disc to herniate, increasing the arm pain, numbness, weakness, with potentially catastrophic results. Such manipulation of the neck should be avoided completely.


  If radiating arm pain, numbness, tingling or weakness persists beyond six to eight weeks, surgery may be indicated. Surgery is also indicated if profound weakness exists, if there is progressive numbness or weakness, or if symptoms in the legs develop. If none of these are present, the decision to proceed with surgery is made on the basis of the patients desire to obtain relief from the radiating arm pain. Surgery for a cervical disc herniation is not recommended for patients who only have neck pain.

Surgical Procedure

  The procedure to remove the disc from the neck is very commonly performed in the United States with excellent results. A 1 1/2 inch incision is made in the left front of the neck. The trachea and esophagus are retracted toward the patient's right while the pulse and neck vessels are retracted leftward. The cervical spine is very close and accessible in the front part of the neck. The cervical disc is then removed and in its place, a piece of bone graft from the bone bank is positioned to maintain the height of the vertebrae and prevent neck pain from developing after the surgery. Often, a titanium plate is placed across the disc to make it more stable.  Surgery takes 1 to 1 1/2 hours and the patient awakens with a cervical collar in place. The collar is worn for six weeks while the bone heals. Following this, the collar is removed and the patient can resume most activities.

Surgical Results

  The results from cervical diskectomy have shown approximately a 95% chance at good or excellent relief from the radiating arm pain. Numbness generally improves. Weakness in the effected arm may require some physical therapy to fully recover. Improvement and strength in the arm is expected over time. After three to four months from surgery, the patient can resume full-unrestricted activities. About 7% of neck motion is lost when a disc is removed. Most people do not notice a difference in their neck motion after surgery.

Surgical Complications

  The complications from this surgery are very rare. The most common of these is the failure of the bone fusion. This happens in 5 to 8% of patients. When it occurs, half of the patients have no symptoms from it and nothing further is required. For the patients who do develop neck pain as a result of the failure of fusion, additional surgery may be required to obtain a solid fusion of the disc and alleviate the neck pain. The risk of paralysis with this surgery is one in several thousand. Infection rate is less than one in a hundred. Other complications are even more rare.

Long Term

  The long-term outlook for patients who have undergone cervical disc herniation is excellent. Patients are able to resume full activity, in some cases even including full contact sports. For patients who have several herniated discs removed, collision sports such as football should be avoided. Even for those patients involved with heavy labor jobs such as construction, the expectation is that these patients will be returned to work without restriction.

© Copyright 2010. Arthritis Education by Professionals, Inc.



Degenerative Disc Disease
by Dennis G. Crandall, M.D.

  As the spine ages, the normal buoyant capability of the disc is slowly degraded as the water content within the disc is lost and the disc becomes more fibrous in nature. Settling then begins within the disc and degenerative bone spurs can form around the disc and in the facet joints in the back part of the spine. For some patients, this degenerative process in the disc can become painful. Pain is most often noticed in the low back with sitting for an extended length of time, and when the body is maintained in one position for an extended period of time, whether sitting or standing. Relief is usually achieved with lying down. When discs become worn out and settle, we refer to the condition as Degenerative Disc Disease (DDD).

Nonoperative Treatment

   Initial treatment to degenerative disc disease is always conservative care. Acetaminophen (Tylenol) or non-steroidal anti-inflammatory medications such as aspirin, Advil or Aleve can be helpful at alleviating some of the backache associated with degenerative disc disease. Sometimes it is necessary to take a prescribed anti-inflammatory medication. It is critical to long-term and ongoing successful management of DDD that aggressive trunk strengthening programs in physical therapy be instituted. It is just as important to realize that one must continue a home exercise program performed on a daily basis at the conclusion of physical therapy. As the trunk muscles become stronger, some of the load across the spine is alleviated and patients feel less back pain. In some cases, strengthening and stretching can reduce the need for pain medications. Using a cane or walker can reduce stress to the spine as well.

Surgical Options

   For patients who have diligently tried anti-inflammatory medications, physical therapy, and an aggressive home exercise program for at least six to twelve months, the possibility of surgery can be entertained. Just because a patient has back pain, which has failed six to twelve months of conservative care, doesn't mean that surgery will help. Further investigation is required. For patients who have multiple spinal levels which are degenerative and causing pain, surgery is much less effective. The best candidates for surgery are those who have a single disc involved and who have failed their best effort at conservative care.

There are currently four surgical options for patients with isolated degenerative disc disease.

Intradiscal Electrotermal Therapy (IDET)

   IntraDiscal ElectroThermal Therapy (IDET) involves insertion of a catheter into the disc through a small incision in the back. This catheter is then heated which causes new scar tissue to grow into the disc, providing some additional stability and eliminating pain generating nerve endings within the disc. The scar tissue that forms from the disc heating provides additional support to the containing structures for the disc. This technique has shown some promise with a limited number of patients being improved after surgery. How long this procedure will provide the improvement from back pain remains unknown. Whether the procedure will lead to more disc pain in the future is also unknown. This treatment is best reserved for people who do not have advanced arthritis and dont have multilevel disease.

Anterior Interbody Fusion with a Cage

   Cage technology has emerged as an excellent technique in spine surgery. An incision is made in the front part of the abdomen and the spine is approached from the front. The disc is completely removed. Bone morphogenetic protein (BMP) is placed inside a special plastic or titanium cage to turn on the bone forming capability of the surrounding bone. These cages are then inserted into the disc with the hope that the vertebrae will fuse on either side of the cage. The success rate with this technique appears to be approximately 85 - 95%. This is the procedure of choice for many patients with isolated single level degenerative disc disease that has failed conservative care.

Posterior Spinal Fusion with Instrumentation

   This is the procedure with the longest track record in treating degenerative disc disease. The incision is made from the back part of the spine and painful vertebrae are fused together with bone graft, screws and rods. The success rate with this approach is approximately 70 to 80%. The long-term follow up appears to suggest that these good results are maintained over a number of years. This approach is presently recommended for patients who do not want surgery done through the abdomen, for patients who are overweight, and for patients who want a procedure with a longer track record of research and known long-term results.

The Artificial Disc

   Artificial disc replacement is a motion-preserving technology that shows promise in replacing the disc and allowing motion between two vertebrae. We are optimistic about the results in carefully selected patients. This procedure is definitely not for everyone with back pain or arthritis of the spine.

The Future

   Since aging is a fact of life, almost everyone will develop degeneration in his or her lumbar discs. Just because a lumbar disc is degenerative doesn't mean that it will cause pain. Just because the patient has pain in their low back and also has degenerative discs, doesn't mean that the degenerative discs are the cause of that back pain. Care must be taken by a skilled and experienced physician to evaluate the appropriate treatment approach for degenerative disc disease. Until we are better able to exactly choose which patients will benefit from fusion, surgery will continue to be the last resort for these patients.

© Copyright 2010. Arthritis Education by Professionals, Inc.



Diagnostic Tests
by Jan Revella, R.N.

Sometimes it is necessary to have a diagnostic test or a series of tests that will help your physician define the origin of your problem. The test or study by itself will rarely make the diagnosis but when used in conjunction with a thorough history and physical examination of the patient, specifically selected tests or studies can prove very helpful.


  New or acute low back pain will usually resolve within about six weeks. When pain does not improve or go away, and your doctor suspects a herniated disc or spinal stenosis or other nerve related problem, an MRI, or magnetic resonance imaging, can provide information about the soft tissue inside the body that cannot be obtained from an x-ray, ultrasound or CT scan. An MRI is not routine contrary to some peoples beliefs. Imaging tests can be costly and usually provides no helpful early information and will not answer all questions.

  Both the MRI and CT scan are equally capable of collecting images of a herniated disc, spinal stenosis or other nerve-related problem. The MRI has an advantage of not using the ionizing radiation that the CT scan does.

  An MRI is a painless diagnostic imaging test that uses a magnetic field and pulses of radio wave energy to provide images or structures inside the body. In many cases, the MRI is superior with certain conditions beyond what an x-ray, ultrasound or CT can provide. The MRI can detect changes to normal structures or tissues. Changes seen may indicate diseases caused by traumas, infection, inflammation or tumors.

  In some cases, a contrast material is used during the MRI to enhance the images obtained of certain structures. The contrast can help evaluate blood flow, certain types of tumors and specific areas of inflammation.

Indications for an MRI

  • Detects problems of spinal discs such as a herniation. An MRI can help determine whether a disc is putting pressure on a nerve.
  • Detects tumors or infection of the spinal cord.
  • Evaluates areas of joint inflammation (arthritis) or abnormal bone loss that has been seen on an x-ray or bone scan.
  • Identifies inadequate blood supply in areas of the spinal cord.
  • Detects areas of nerve damage in the spinal cord resulting from trauma or disease such as multiple sclerosis.
  • Evaluates congenital problems of the spine.

  Tell your doctor or health professional if you have a pacemaker, artificial limb, metal pins or fragments in your body, particularly in your eyes, metal heart valves, metal clips in the brain, metal implants in your ear, tattooed eyeliner or metallic-based tattoos, or any implanted or prosthetic medical device. Additionally, if you have worked around metal or you have had recent surgery on a blood vessel, you may not be able to have an MRI. Other reasons not to have an MRI include having an intrauterine device (IUD) in place or that you are or suspect that you are pregnant.

  In most cases except when using the open MRI, you will be confined to small space during the test. If you historically become nervous in a confined space you may need to undergo the test with open MRI equipment that is not as confining as the conventional machines, or you may need medication to help you relax. For certain MRI studies, including the legs or lumbar spine, your head or body may be out of the confined space.

  An MRI takes about 30 to 60 minutes and is done by a MRI technologist and interpreted by a radiologist. For utmost accuracy, you will be asked to remain motionless and still. Many spine specialists will want to review the actual films themselves at your office visit as well. You will be asked to hand-carry your films to your physicians in most cases.

  MRI is generally a safe and painless procedure. However, the magnet of the MRI machine is so powerful that it can send loose metal objects flying across the room. This is why it is important that you remove all clothing and metal objects that could be affected by the magnets power. There are those who have permanent metal like a pacemaker or other medical device that will be unable to undergo an MRI.

  Results from the MRI test will be interpreted by the radiologist and sent to your physician with a couple of days from the procedure date. Some very obese patients may not fit into the opening of some standard MRI machines.

  The MRI is under constant change and improvement. It is the procedure of choice to confirm specific diagnoses and is often used instead of other tests including a CT scan or a myelogram.


  Although somewhat controversial, a discogram is another diagnostic tool which can be used to determine the structural integrity of an intervertebral disc(s) and if a particular disc may be responsible for the patients back pain complaint.

  The test is either performed by a radiologist or surgeon in an out-patient facility. After a local anesthetic is used to numb the specific area, fluoroscopy (an imaging technique that projects an x-ray type picture onto a monitor) is used to guide the spinal needle into the suspected intervertebral disc. A radiopaque dye is injected through the spinal needle into the center of the disc.

 A discogram is indicated when the patients are severe and persistent, despite conservative therapy, when results of other diagnostic tests such as an MRI prove inconclusive or if a disc abnormality is suspected. A discogram is used to confirm a diagnosis.

 During the procedure, the dye pattern is evaluated for leaks outside the walls of the intervertebral disc. The patients symptoms such as back pain or a tingling sensation may be replicated due to the pressure created by the dye injection. This is called provocative discography. A discogram takes about 30 minutes.

 Since a radiopaque dye is used, the patient should inform his or her physician if allergic to an IVP or other contrast dye. Adverse reactions can include hives, swelling or difficulty breathing. After the Discogram, the patient will be directed to drink plenty of fluid to clear the dye from the body.

Myelogram (myelography)

  The myelogram is used to diagnose spinal canal and cord disorders including nerve compression which causes pain or weakness. Performed on an out-patient basis by a neuroradiologist, a myelogram involves introducing a radiographic contrast eye into the sac or dura that surrounds the spinal cord and nerves.

  To undergo the myelogram, you will be asked to fast for 8 hours after midnight on the day of the procedure. You are allowed to take your customary medications with a small amount of water; however, there are some medications that you may be asked to temporarily stop. Examples include anti-coagulants or blood thinners and some diabetic medications. Certain medical conditions, medications or allergies should be shared with your physician prior to scheduling a myelogram including allergies to IVP or other contrast dye, history of seizures, angina or kidney disease.

  With the patient lying prone during the procedure and the skin area is numbed, dye is injected into the spinal sac followed by x-rays, CT or MRI scanning. A neuroradiologist interprets the findings and sends a report to your physician.

  After the procedure, the patient spends time in the recovery area lying down with his/her head elevated for several hours. Upon returning home, its recommended to engage in quiet non-strenuous activities giving the puncture site time to heal. Fluids are encouraged to clear the dye from the body.

Electromyography (EMG) and Nerve Conduction Studies (NCS)

  EMG and NCS are often ordered to determine health of peripheral nerves. These tests are valuable adjuncts to the patients overall evaluation when needing to establish if a nerve is pinched, how severely and where it may be pinched.

  An EMG measures the electrical activity in the muscle. Normally a muscle receives constant electrical signals from healthy nerves resulting in a returned response of its own. To measure this electrical activity, the physician places acupuncture-like needles into specific muscles to record the electrical signals in the arm or leg. If the muscle doesnt respond normally, the signal becomes confused.

  During the NCS, electrodes similar to EKG patches are placed along the course of the specific nerve. The nerve is stimulated with a small electrical current and in turn the nerve should transmit the signal along its course. A healthy nerve transmits faster and stronger.

  During the Nerve Conduction portion of the test, electrodes much like EKG patches are placed along the known course of the nerve. The nerve is stimulated with a tiny electrical current at one point. The nerve must then transmit the signal along its course, and an electrode placed further down the arm or leg captures the signal as it passes it. A healthy nerve will transmit the signal faster and stronger than a sick nerve.

  From the Nerve Conduction Test and the EMG's, the doctor can correlate which nerves are pinched and the seriousness of the condition. This information can then be used to help formulate further treatment plans.

  The test can last anywhere from a half an hour to an hour. The quality of the results is quite dependent on the skill of the person administering the test.

© Copyright 2010. Arthritis Education by Professionals, Inc.



Lumbar Disc Herniation
by Dennis Crandall, M.D.

What Is It?

  When the disc wall becomes disrupted either from injury or as a consequence of ageing, disc material can escape from its usual space between the vertebrae and enter the spinal canal. If a large amount of disc is herniated into the spinal canal, it can pinch nerve roots and cause buttock and leg pain. The disc material can also cause inflammation of adjacent nerve roots. Typically, the pain (sciatica) radiates through the buttocks, back of the leg, and down to the ankle or foot. Numbness, tingling, and weakness may be present depending on the severity of the nerve compression. Back pain may or may not be present.

Nonoperative Treatment

  Ninety percent of patients with sciatica from a disc herniation improve on their own without surgery. Treatment initially consists of 2-3 days of bed rest, anti-inflammatory medication (aspirin, Aleve, or Advil), followed by increasing activity levels as tolerated. Sciatica treatments that have not been shown to provide improved relief over no treatment at all include passive spinal manipulation (chiropractic), Vax-D, traction, and physical therapy. None of these methods can take the pressure off the pinched nerve. In smaller disc herniations, epidural steroid injections may be helpful.

Surgery for Lumbar Disc Herniation

  For the 10% of people who still have sciatica after at least 6 weeks of conservative treatment, surgery becomes an option. The only time surgery becomes a true emergency is when genital numbness starts and bowel and bladder control is lost. If there is a worsening of leg numbness or weakness, surgery may be indicated sooner than 6 weeks. If there is significant ankle weakness, surgery sooner than 6 weeks is also necessary since delaying nerve decompression has been shown to have a less favorable outcome. Other than these reasons, the purpose of surgery is to relieve buttock and leg symptoms and is therefore usually elective as to its timing. When the patient decides the pain is bad enough, surgery is scheduled.

  BENEFITS: The success rate in obtaining relief of radiating leg pain with surgery is about 95%. That leaves 5% who still have leg pain after surgery for unknown reasons. Relief of the back pain is less reliable. Disc surgery should not be done with the expectation of improved back pain, though it does often occur.

  RISK OF SURGERY: There is a 5% chance that over the 20 years after lumbar diskectomy, the same disc will re-herniate causing recurrence of the same leg pain. One long-term study has suggested that between 5-15% of patients may require future surgery at the level of the herniation for future problems, including fusion to treat back pain. There is a 1% chance of infection. A small number (<2%) will develop new numbness, tingling, or weakness which was not there before surgery. Most of these patients improve on their own within a matter of weeks to months. Other risks are less than 1%. It is extraordinarily rare to require blood transfusions after surgery.

Surgical Procedure

  The skin incision in most cases is 1-2 inches long. The muscles of the back on the side of the herniation are retracted to expose the spine. The compressed nerve is gently retracted off the herniated disc and the offending disc fragment is removed. Any other loose fragments within the disc space are also removed. No attempt is made to remove all of the disc material, as this would cause the spine to be unstable and painful. The incision is then closed with dissolvable sutures beneath the skin. No staples or stitches need to be removed. Patients enter the hospital on the morning of surgery and go home the same day or the following morning, depending on how they feel. They are free to get up the afternoon or evening of surgery to use the bathroom. The day after surgery, a regular diet is resumed, activity levels are increased, and pain pills control the pain.


  THE INCISION: The dressing on the incision should be changed daily for 5 days using a small bandage. After that, no dressing is required. The incision should remain dry without any drainage, redness, or other signs of infection.

  SHOWERS: You can resume regular showers/baths and get the incision wet after 3 days from surgery. The skin healing has sealed the incision by then. Take the bandage off before showering but leave the steri-strips on. The steri-strip tapes will fall off the incision on their own. If they are still attached at 4 weeks, they may be removed.


  Initially, standing and laying flat are the most comfortable. You can sit as much as you want so long as you don't mind the discomfort. Sitting becomes less painful after a few weeks. Walking is encouraged. At week 3-4 physical therapy will be started for abdominal and back strengthening and conditioning.

  WORK: By week 6, most patients are ready to return to unrestricted work. For those who have less physically demanding jobs, part-time work can be resumed at week 1-3 and advanced to full-time as soon as symptoms allow. Back pain from the incision improves by week 3 or 4 and is nearly gone by week 6. Before 12 weeks, there should be no lifting more than 30 pounds and limited bending and stooping. After 3 months, there are no restrictions.

  DRIVING: Driving can be resumed as soon as you feel safe. Take a test-drive in an empty parking lot first to be sure your reaction time from the accelerator to the brake is quick enough to make an emergency stop. Short trips (5-10 minutes) are recommended at first to assess your comfort level.

  SEX: The incision should be completely healed before regular intimacy is resumed. Pressure on the early incision will be painful. Being a passive partner in a comfortable position can be safely tolerated after week 4. After 6 weeks, there are no restrictions.

Long Term Results

  LEG PAIN: Most people have excellent and lasting relief of leg pain. Occasionally, there may be episodes of mild recurrence of pain, which is associated with increased activity and from scar formation in the surgical site. If this occurs, it is usually at a low level and is managed by stretching exercises and anti-inflammatory pain medication. Significant and sudden increase in leg pain can signify a recurrence of the herniation.

  BACK PAIN: This may develop as a result of the disc injury and subsequent surgery. Treatment starts with trunk-strengthening exercises, which can be initiated in physical therapy and continued daily at home. Rarely does anything beyond therapy need to be done. Severe or new back pain a few days to several weeks after surgery can signify a disc space infection and should be reported to your doctor.

© Copyright 2010. Arthritis Education by Professionals, Inc.



Minimally Invasive Spinal Fusion

What to Expect

Every patient is unique. Every spinal surgery is unique. Even so, there are many common questions and topics concerning recovery. This information is provided as a general guide. This guide does not replace any specific advice you receive from your surgeon. 

The Day Before Surgery

 What To Bring To The Hospital One of the benefits of minimally invasive surgery is a shortened stay in the hospital after your surgery. You will either go home the same day or the next day after surgery.  

Here are some suggestions on things to bring with you to the hospital:

         Insurance card


         Loose fitting clothes

         List of your medications, dosage, frequency

         List of your allergies

minimally invasive Spine Surgery

If you are to have minimally invasive spinal fusion, the surgery most often is performed through the back. The fusion is done both in the front and back region of the spine.  This technique increases the rate of fusion and also stabilizes the spine, thus decreasing the amount of pain postoperatively.  Minimally invasive fusion surgery allows you to go home either the same day or the day following surgery.  You will most likely have four small incisions on your back.  Two larger incisions (one to two inches) will be in the lower area of the spine fusion.  Two smaller incisions (about a centimeter in length) for passage of the rod will be above or below the other two incisions.  Your skin is numbed prior to surgical intervention. No muscles or other tissues are cut. At the end of surgery more numbing medication is placed around the incision and into the muscle to help with pain control. 

The Night Before Surgery

 DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT BEFORE SURGERY. If you do, your surgery may be canceled by the anesthesiologist.

In The Hospital

 Pain Control Pain medication such as Lidocaine is given during surgery. While in the recovery room, patients are given IV medication as well as the oral medication such as Percocet and Valium to take home. 

 Eating Patients are allowed to eat and drink small amounts of food such as ice chips and clear liquids.  Bland foods such as soda crackers will also be introduced in the recovery room to tolerance. Temporarily the anesthetic can cause nausea or vomiting which can be exacerbated by food intake.

 Walking A physical therapist will see you in the hospital and make sure that you are stable with ambulation.  You will most likely be sent home with a front-wheeled walker to assist with your ambulation. 

  Bowel Movements Bowel movements can be slowed by medications. Taking a stool softener while at home or a laxative is recommended. 

  Length Of Hospital Stay Most patients either go home the same day of surgery or the following day after surgery. 

  Rehabilitation Every patient who undergoes minimally invasive surgery is placed in an extensive rehabilitation program for approximately twelve to thirteen weeks. Physical therapy begins the day of surgery.  We will help you get your initial appointment with a physical therapist as soon as possible after discharge.  Within two to three weeks, you should be in aquatic therapy strengthening and stretching the back.  It is important that you continue your therapy for the entire duration and until we feel you have maximized the therapeutic benefits of the rehabilitation. 

The First Two Weeks After Surgery

  During the day of surgery, you will take it easy and do some mild abdominal contraction type of exercises.  The day after surgery this will continue.  We strongly recommend that you walk about hour daily. The physical therapist will provide instructions so you begin and continue mild strengthening exercises and pelvic tilts.  Pain medications given to you in the hospital will be used for your postoperative pain.  You will return to see us in the office at two weeks after surgery for wound checks and a general evaluation. 

Week 2-6 After Surgery

  Physical therapy will continue with strengthening and stretching exercises as well as aquatic therapy once your wounds are well healed.  You will continue to strengthen your back and your legs throughout this entire period and increase your walking endurance.  Aerobic activity will be prescribed in this time frame.  Most patients can discard the walker two to four weeks postoperatively.  Many patients can go back to work depending on the type of work.  At the end of six weeks, you will return for another evaluation at which time x-rays of your back will be taken to assess the fusion. 


  You will continue to increase activity. Some patients are back to full duty at this time. Some patients are still having some minor discomfort, which is usually alleviated with mild medications such as Tylenol and muscle relaxants. At three months postop, you will return for another evaluation including x-rays.  Most patients are progressing well towards a solid fusion at this point.  At three months, patients are usually released from physical therapy and can return to full duty regardless of the type.  Activity can continue to increase.  At three months after surgery, patients are permitted to use non-steroidal anti-inflammatory medications such as Aleve or Advil. 


  At three months postop, patients are released to regular activity and will follow up with us for more x-rays.  At 6-12 months, patients are back to normal activity levels and their pain is controlled with minimal medication such as non-steroidal anti-inflammatory medications only or some mild muscle relaxants. 


  At 1-2 years after surgery, you have no restrictions. We will obtain final x-rays at the two-year mark to assure that your fusion is completely healed.  


  Many patients will continue to have mild discomfort in their back.  In most cases, further surgical intervention is not helpful for this. Patients can use Tylenol, non-steroidal anti-inflammatory medications and occasional muscle relaxants. No narcotic medication is provided after the three-month time frame.  Some patients may experience other degenerative segments in their back within five to ten years following surgical intervention.  If this should occur, about 20% may need further surgical intervention above or below the previous fusion. If further surgical intervention is necessary, previous instrumentation will need to be removed.  Generally speaking, minimally invasive surgery can not accomplish removal of instrumentation and a subsequent fusion at the same time. 


  Patients can eat a normal well balanced diet.  Calcium intake is within the FDA Guidelines which should be about 1500 mg a day (in split doses) and 800-1000 IU vitamin D.  No bracing is done during the postoperative time frame.

Bathing - Showering is allowed postop but do not allow water to directly hit your incision and dry it as soon as you are out of the shower. No submerging in water is permitted until the wound is well healed and after your first two-week evaluation. Aquatic therapy begins soon thereafter. 

Back To Work - You may return to work depending on your job as soon as you start to feel that you can handle sitting or performing some activity of your job.  Most patients are able to return to some function by four to six weeks postoperatively. Some patients involved in manual or heavy duty jobs must wait full three months. 

Postoperative Symptoms/Precautions Some patients will experience slight temperatures such as 100 or 101.  These can be decreased with Tylenol and with increased ambulation and getting up.  These slight increases in temperature are most likely a result of either pain or decreased breathing from lying down. When the lungs are fully expanded and pain is well controlled, temperatures are very rare.  However some people will have increased body temperature with healing.  We are not significantly concerned about increased temperatures unless you experience excruciating back pain and/or the wounds become red and drain purulent material.  If the temperature reaches 102.5 or greater, you should contact your surgeon.

  Back Pain After Surgery Patients will experience back pain after minimally invasive surgery related to muscle spasms.  Valium is given to all patients unless you have an allergy for control of muscle spasms.  Percocet is also given for pain control.  This regimen is fully capable of handling all pain that patients have after minimally invasive spinal fusion. 

 Leg Pain After Surgery Very few patients will have some leg pain. This is due to irritation to the nerve roots during the surgical intervention and may be the most significant pain postoperatively.  It is usually controlled with medications such as steroids and or nerve medications such as Neurontin or Lyrica.  It may take several months to improve but it should improve with time.

Exercises Patients should get used to being involved in a regular exercise program specifically aerobics and strengthening and stretching exercises to their core muscles which will be taught in physical therapy. In the long run, you will feel better and be able to do more after you are fully recovered if you learn to include exercise in your daily routine.

© Copyright 2010. Arthritis Education by Professionals, Inc.




Spinal Fusion
by Dennis Crandall, M.D.

What to Expect

  Every patient is unique. Every spinal surgery is unique. Even so, there are many common questions and topics concerning recovery. This information is provided as a general guide. This guide does not replace any specific advice you receive from your surgeon.

The Day Before Surgery

  What To Bring To The Hospital - Whether your stay is just overnight, or a few days, there are some things you will like to have with you in the hospital. Here are some suggestions:

  • Insurance card
  • Toiletries
  • Loose fitting clothes
  • List of your medications
  • Robe and slippers
  • T-shirts (if brace is used)
  • List of your allergies
  • Reading material

Anterior Spine Surgery

  If you are scheduled to have your spine fused from the front through the abdomen or side, we recommend you give yourself an enema the night before surgery. This will help your bowels get moving quicker after surgery, and makes surgery technically easier for the surgeon doing the exposure of the spine.

The Night Before Surgery

  DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT BEFORE SURGERY. If you do, your surgery may be canceled by the anesthesiologist.

In The Hospital

  Pain Control - Most patients are placed on a PCA pump (patient controlled analgesia). When pain is present, push your pump button to get immediate delivery of medication. The pump prevents overdosing, even if you push the button more than you should. If pain is still present, additional pain medication is available. At the appropriate time, pain pills will replace the PCA pump. There will always be more pain medicine available if you have pain.

  Eating - For most surgeries involving the back part of the spine, patients begin drinking clear liquids the night of surgery. Over the next few days, a regular diet is resumed when we are sure you are tolerating liquids first. For patients requiring surgery from the front of the spine (through the side or through the abdomen), it often takes 1 - 3 days to regain bowel function and be ready to eat. Eating too soon can cause nausea and vomiting since the stomach and the intestines have not fully awakened from surgery. If you are able to eat regular food, friends and family may bring in food from outside the hospital

  Walking - Unless specifically instructed, you should plan on getting up and walking the day after surgery. Physical therapists and the nursing staff will help you. You may require a walker at first to keep your balance safely. As soon as you don't need the walker, you can walk on your own. Plan on walking three times a day, increasing the distance as you are able.

  Bowel Movements - Since the bowels are slowed by surgery and some of the pain medicine, it takes time to get them going again. You will be placed on a daily stool softener pill, and you may be given a suppository to help get things going. In some cases, an enema may be required. Things which you can do to help your bowels awaken quicker include sitting up in a chair several times during the day, and going for at least two walks a day. The more you are up, the faster you will get back to a normal bowel schedule. Be aware however that it may take up to 2 weeks to get back to a normal bowel routine.

  Length Of Hospital Stay - Most patients are ready to go home from 2-4 days after surgery, depending on what was done in surgery and your general health. The more motivated patients are, the faster the recovery tends to be.

  Going Home or to a Rehabilitation Center? - When you are ready for discharge from the hospital, a decision will be made as to your immediate needs. If the hospital's physical therapist considers you independent, or if you have help at home, you will be released to go home. A visiting nurse or therapist may be requested by your physician to visit you at home on a daily basis for a few weeks, if it is covered by your insurance plan. For patients who still require additional therapy before they are independent, or for those without any help at home, discharge to a rehabilitation center or skilled nursing unit may be appropriate. At the care center, the focus will be on physical therapy and becoming independent.

The First Two Weeks After Surgery

  Help at Home - For patients going home, it is very reassuring to have someone there who can physically help and provide positive emotional encouragement for the first few to several days. Help is most often needed with making meals, getting in and out of bed or a chair, and with bathroom and bathing activities. Some patients do not need the help, while others require assistance with bathroom and bathing activities for a few weeks. Plan accordingly.

  Pain control - Strong narcotic pain medication is used immediately after surgery for the first two weeks. After that, you will slowly be weaned to a lesser strength pain medication. Often, additional medication will be prescribed along with the pain pills to "boost" the effect and pain relief. Patients who follow our pain medication recommendations will not become addicted. We will make certain.

  Eating - It is common to have a decreased or absent appetite after major surgery. However, it is very important to begin eating a normal diet as soon as possible after surgery. A large number of calories are needed to heal a large surgery such as spinal fusion, and to prevent infection. This is not the time to go on a diet! Try several small meals and snacks until a healthy appetite returns.

  Bowel Regularity - For the first few weeks after surgery, it is very common to have some constipation. This is usually caused by the narcotic pain medicine used to control your pain, and from the general anesthetic used to put you asleep for surgery. If you continue to sit up several times a day and walk at least three times a day, thing will get back to normal. You may have to continue an over-the-counter stool softener such as Colace for a few weeks, and you may require an occasional enema. Ask your family doctor or call our office if you have any questions or concerns.

  If you have been asked to wear a brace, you need to learn to use the bathroom with the brace on. Wiping your bottom is a challenge but can often be managed by slightly loosening the brace. You may require help with keeping your bottom clean, if you have to wear a brace.

  The Incision - This is easier than you may think. Your incision was closed with self- dissolving suture. There are no staples or stitches to remove. You will notice that under the dressing are "steri-strip" tapes on the incision edges. Do not remove the "steri-strip" tapes that hold the skin edges together. They will begin to peel off all by themselves after a week or two. If they are still there after 3 weeks, you can peel them off if you want.

  Change the outside bandage or dressing once a day and replace it with a light dressing held in place by minimal tape. Keep your incision clean, dry, and covered. Please do not put any salves, Vaseline, Neosporin ointment, vitamin E, aloe vera, or anything else on it during the first 3 weeks. Keep it covered with a clean light bandage for the first week.

  After 7-10 days, you may stop putting a dressing on your incision if you want, or you can continue with a daily light dressing for an additional week if it feels better covered.

  It is not uncommon to have a small amount of clear yellow fluid drainage from the incision. This should decrease in amount daily and should be completely dry by one week. If you notice any drainage beyond a week, any increase in drainage, or drainage which becomes cloudy (pus), or if the edges of the incision become red, please call us immediately. If you have any concerns about your incision, it is better to call.

  Showering - If you want to shower during the first week, tape plastic over the incision to keep it dry. After the first week, you do not need to put anything on the incision. An alternative to showering is to sponge bath for the first week.

  Avoid bending in the shower. Make sure the soap, shampoo, etc is within reach while standing. Have someone else wash your legs, dry your legs, and shave your legs (if you are so inclined). Some people are more comfortable with an elevated bar stool to sit on in the shower.

  No baths yet. It is too much stress on the fusion to get in and out of the tub. You can take a bath after 3-5 months, depending on your surgery.

  Walking - Plan to take at least 3 slow walks each day. The distance you walk should slowly increase. No matter how good you feel, do not walk more than mile at a time. This is the time to let your spine heal, not to exercise.

  Activity Level - Avoid bending, stooping, kneeling, crawling, and lifting more than 5-8 pounds. Try not to spend the entire day lying down. The more you are up, the better your appetite, digestion, circulation, lung function, and mental attitude will be. Sitting is permitted and encouraged. Lie down to rest when you need to.

  It is too soon to exercise. The fusion must have a chance to heal without stress. For this reason, walking is the only form of physical activity permitted. It is too soon for swimming.

  You can go for short trips in the car as a passenger. It is too soon to be driving though.

Week 2-6 After Surgery

  Help at Home - The need for assistance with the activities of daily living becomes much less between weeks 2 and 6. Patients become more independent with personal care, food preparation, getting the brace on and off, and moving around the house. Assistance in the bathroom is sometimes still needed, however. Most patients do not need constant assistance at home after 6 weeks. Family, neighbors, or friends who stop by or call once or twice a day is usually sufficient.

  Pain control - Pain medication is safely used as needed during this time. Post-operative pain from the surgical procedure is much less by 4-6 weeks and the need for narcotic pain medications decreases. Often by 6 weeks, people are taking only a rare pain pill, and managing their pain primarily with extra-strength Tylenol or something similar. In some cases, pain pills are needed up to 3 months. After 3 months, we want our patients off narcotic pain pills and taking over-the-counter medications such as Tylenol for pain.

  The incision - The incision should be completely dry. Dressings are no longer required. If the steri-strips are still present, peel them off. You do not need to cover the incision when you shower. After 4-6 weeks, if you really want to put lotion, salve, or vitamin E on the incision, it is safe to do so. We do not know of any value from such topical treatments, however. The size and thickness of your scar is related to your body's scar forming tendencies, not which lotion you apply.

The incision will be a pink to light red line. The color of the scar will fade to normal skin tone after several months.

  Walking - Start increasing your slow and casual walking. You can now walk up to a mile at a time, so long as you do it slowly. This is NOT power-walking. It is meant to maintain baseline muscle tone and circulation, and help your mental attitude. It is not meant to be exercise.

  Activity level - Continue to avoid bending, lifting >10 lbs, stooping, crawling, and kneeling. Short rides in the car are permitted. If you are still using a walker and feel stable, consider switching to a cane.

  Back to School - For children and teen-agers of school age, plan to be back in school in 3 weeks. No carrying more than one book at a time, and no back packs.

Week 6-12 After Surgery

  Activity Levels - Now is the time to start doing a bit more than you have been doing. Walking can be increased to up to 2 miles a day. You can begin to walk at a faster pace to where you become slightly "winded".

  Bending, stooping, crawling, kneeling, and lifting are still avoided, though may be done on rare occasions if needed. Limit your lifting to 10-15 pounds. If you are wearing a brace, you still must wear it when ever you are up.

  You may travel for long distances if you want. This includes air travel.

  Driving - You may begin driving for short trips.

  Work - Some patients want to get back to work as soon as possible. It is safe for you to return to work on a part-time or full-time basis if you feel up to it. This must be sedentary or light duty work. You must still adhere to the activity guidelines (no lifting, etc.) and wear your brace as directed.

  Sex - After 6 weeks, sexual activity can be resumed. It is advised that you assume the role of being a passive partner on the bottom. This will decrease the stress across the healing spine fusion, and will avoid back pain. If sex is painful, tell your hopefully understanding partner that you need to stop. After 3 months, your fusion should be solid enough to allow you to become more active. After 3 months, there are no restrictions.

3 Months

  Pain Control - By 3 months from surgery, you should be off all of your narcotic pain pills. Ninety percent of people are successful at achieving this goal without much difficulty. We will help you accomplish this while keeping you as comfortable as possible. Use over-the-counter pain relievers first. If the pain does not go away, an occasional pain pill can be helpful.

  Home Exercises - After 1-2 months of therapy, patients are ready to continue the program learned in physical therapy at home. It is very important to perform the daily exercise program learned in therapy in order to avoid injuring a vulnerable and deconditioned spine. All of the progress made in therapy will be lost if the home program is not followed. After a few months of exercised, the spine is stronger and less likely to hurt. Make your home exercise program a part of your daily routine.

For overall fitness, an exercise bike is excellent. Swimming is great. Jogging can be started. Try to walk or run 2 miles each day.

  Work - With the help of physical therapy, by 3-5 months, most patients are ready to return to a light duty status at work. Lifting can be increased to 25 - 45 pounds, and patients can do some occasional bending, stooping, crawling, and kneeling. There are no restrictions on driving.

  Physical Therapy - Patients are usually ready to begin a supervised gentle strengthening and flexibility program by 3 months. This is usually done through a physical therapist. Therapy is usually 2-3 times per week for a month or two. During that time, spinal flexibility is reestablished with stretching exercises. Endurance is increases with a cardiovascular workout. The trunk muscles (abdominal and back) are strengthened to take stress off from the spine. Pain decreases as fitness, flexibility, and endurance increase.

6 Months

  Activity Levels and Sports - Time to get back to sports and other more physical types of exercise. This includes golf, tennis, basketball, and other non-collision type sports. Weight lifting restrictions are dependent on the person. Fifty pounds is usually the limit. The main limiting factor is the rehabilitation of the back muscles and their ability to perform at demanding levels. Even if the spine is fused, function will be limited if the trunk muscles are not strong.

  Work - Most patients can return to full duty by 5-7 months from surgery. When the job demands very heavy lifting, it may be 6-9 months until the patient is ready to return. We do not view spine surgery as a disabling event. To say it another way, just because you have had spine surgery doesn't mean you should be disabled. The whole purpose of surgery is to get patients back to a higher level of function. Most people get back to work. This is our goal and we want it to be yours. It is extraordinarily rare that a patient is unable to do some type of work.

One Year

  Activity Levels - There are no restrictions after one year if your fusion is solid (based on x-rays and clinical evaluation). No limitations. Patients are free to bend, lift, stoop, crawl, or anything else. If the back is fully rehabilitated, patients can play football, weight lift, snow ski, and participate in rodeos. Remember though, just because you are not restricted from an activity doesn't mean you should do it. Use good judgment.

  Common Sense - Having invested a year of your life solving your spine problem, you should be cautious about causing new problems. Use good back posture and lifting mechanics. Do your exercises faithfully. Keep your abdominal muscles strong and your weight under control.

  The more repetitive stress the spine endures, the more likely it will show signs of wear (degenerative arthritis of joints and discs). Consider just how important it is to you to continue such activities as working a heavy construction job, golfing every day, continuing to driving a cross-country truck, or other similar activities.

  The Future - Plan on obtaining x-rays every few years to follow the status of your fusion and the joints adjacent to the fusion. For some patients, there is a 20% chance that another joint in the spine will wear out and require fusion to alleviate pain. For this reason, it is important to use good common sense about your back and to keep in touch with us through the years.

General Guidelines

  What to Eat - Spine surgery can be stressful on your body's nutritional requirements. A large number of calories are required to heal the surgical incision and promote healthy fusion of the bones. Because of the high calorie requirements for healing, it is very important to eat, even if your appetite is low. If you don't eat enough, your body will take the calories from your muscles and other tissues and you will lose weight. This is not the time to go on a diet! A well balanced diet is best for meeting your nutritional needs. If you have a hard time eating enough, we recommend a can of Ensure drink with each meal (Ensure may be purchased at grocery stores and pharmacies without a prescription).

  Calcium - If you already eat a well balanced diet including dairy products, you will not need to take extra calcium. If you have any doubts, you can take 500-1500 mg of extra calcium per day. Women after the age of menopause should be taking 1000-1500 mg per day. Additionally, it is important to supplement your calcium intake with 800-1000 IU vitamin D.

  For Those Who Are Asked To Wear A Brace - Unless otherwise directed, you need to wear your brace 24 hours a day whenever you are out of bed. Do not get up without it on. You may take it off after you are in bed and it can remain off as long as you are lying down. The brace goes on before you get up.

  Showering is permitted out of the brace. Take the brace off and step into the shower. Pretend the brace is on while showering, which means no bending over to pick up the shampoo. Someone else will have to wash your legs for you. You may sit on a stool or shower chair while in the shower. Everything in the shower should be reachable without bending. When finished, step out of the shower and towel off. Someone else will have to dry your legs. While standing, put on your underwear, a soft cotton T-shirt, and then the brace. Then you are ready to finish getting dressed.

When prescribed, the brace is usually worn for 2-4 months.

  Back To Work Or School - You may return to work or school as soon as you feel up to it. This will likely be between a few weeks and a few months, depending on your surgery, your motivation, and other factors. Follow the activity guidelines listed above. If you need a note for your boss or you teacher, let us know.

  Fever - It is common for a low-grade fever to occur during the first few days after surgery. This is most often due to the lungs needing to be fully expanded to their normal size. Deep breathing exercises help this to happen. If a fever occurs after the first few days or is greater than 100.5(please call your family physician or call us.

Back Pain After Surgery - During the first few months after surgery, it is very common to have some back pain. The trunk muscles become weak due to healing from the surgery and the sedentary level of activity that is required. It is common for this type of back pain to improve with physical therapy as the trunk regains its strength and endurance. After 6 months from surgery, back pain should be mild and occasional.

  Leg Pain After Surgery - If your leg hurt before surgery, your spinal nerves were likely compressed and irritated. The longer your leg hurt before surgery, the more likely it is that the nerve may be somewhat irritated after surgery and hurt for some time (days to weeks). The leg pain after surgery should be much better than before surgery. With time, leg pain usually gets better. When leg pain starts or worsens weeks or months after surgery, it may be the result of scar tissue around the nerve that can cause irritation when you are especially active. If the leg pain becomes intense at any time, please call your surgeon.

  Leg Swelling - The more you sit or stand after surgery, the more your legs are likely to swell. Put your feet up when you sit or lay down. This will help the swelling. If you notice swelling in only one leg, please call us since that can be a sign of a blood clot in the deep veins of the leg.

  Dental Work - Although it is not well documented, our experience convinces us that taking antibiotics before and just after having dental work is a good idea for those who have had spinal fusion with instrumentation. Ask your dentist for a prescription.

  Exercises - Plan to establish a daily habit of exercise to keep your trunk muscles strong and flexible. This is the single most important thing you can do for the long-term health of your spine. It is the most reliable way to avoid episodes of back pain in the future. Just do it.

  Chest Pain, Abdominal Pain, Or Shortness Of Breath - If you experience any of these symptoms, please call your surgeon or your family physician immediately. If you have a hard time getting through, go to an emergency room to be evaluated.

© Copyright 2010. Arthritis Education by Professionals, Inc.



Spondylolisthesis - "A Slipped Vertebra"
by Dennis Crandall, M.D.

The term spondylolisthesis is used to describe several different spinal disease processes where one vertebra is out of its normal alignment with the adjacent vertebra.  The term means "spine slip".  This is clearly seen and measurable on routine x-rays.  It should not be confused with the chiropractic community's concept of a vertebra being "out" (without any imaging abnormalities, including x-rays). 

  The typical appearance of spondylolisthesis is one vertebra slipping forward on the vertebra below. Retrolisthesis is a term used to describe when a vertebra is slipping backward on the vertebra below.  Lateralolisthesis describes the vertebra that is displaced to the side of the vertebra below.  Rotatory listhesis is a degenerative condition where a vertebra rotates on the vertebra below.


  Routine standing spinal x-rays are the best way to diagnose vertebral malalignment such as spondylolisthesis.  Flexion and Extension (patient bending forward and backward with maximum effort) x-rays of the spine are also helpful to assess whether the spine moves excessively and is unstable. 

  Often, spinal stenosis (pinched spinal nerves) accompanies spondylolisthesis and additional imaging studies are required to detect the presence of nerve compression within the spinal canal.  A MRI scan is an excellent test to show the soft tissues of the spine in a way not possible with x-rays.  A myelogram combined with a CT scan is another excellent way to evaluate nerve compression, especially when it is related to bone spurs and other arthritic processes which can narrow the spinal canal and compress nerves.

  A CT scan by itself (without a myelogram) may be useful in diagnosing the type of spondylolisthesis caused by a stress fracture.  This type, called "isthmic spondylolisthesis, can usually be diagnosed on the basis of oblique x-rays.  Occasionally, isthmic spondylolisthesis is diagnosed with a CT scan.

  A bone scan can be helpful at identifying a recent stress fracture that could lead to spondylolisthesis.  This has an important role in children who have back pain from an undiagnosed cause, and isthmic spondylolisthesis is suspected.   


  There are five general causes for spondylolisthesis.  Isthmic spondylolisthesis results from a stress fracture in the back part of the spine, and most commonly develops between ages 5 and 8.  It may or may not cause back pain.  Five percent of the American population has it.  Fifty percent of Eskimos and 10% of professional football linemen playing in the NFL have it.  It is also a common source of back pain in highly competitive gymnasts, occurring in up to a third of these athletes. 

  The most common type of spondylolisthesis is caused by degenerative changes in the spine, particularly in the facet joints.  As these joints wear out, they become lax and fail to maintain normal spinal alignment.  The same arthritic process that wears out the joints in the spine can also cause bone spurs to grow which then cause nerve compression and spinal stenosis. Stenosis and degenerative spondylolisthesis occur together very often.

  Rare causes of spondylolisthesis include tumors or infection that destroy the back part of the spine, and acute fractures through the back of the spine.  These destructive processes disrupt spinal stability and allow the affected vertebra to slide forward on the one below it.  Somewhat rare is the congenital type of spondylolisthesis that features malformed joints in the back of the spine which allow the spine to slip.

Signs and Symptoms

  Back pain is the most common complaint in people who have spondylolisthesis.  The pain tends to correlate with the level of physical activity, with worsening pain with activity and improvement with rest.  Most people find that the back pain is worse with standing and walking, and often better with sitting.    

  Another common complaint is ache in the buttock region.  This can be pain referred from the degenerative joints in the low back, or could be a symptom of nerve root compression.  Buttock pain can accompany back pain or occur by itself.  

  Leg pain that descends through the buttock, back of the thigh, past the knee, and into the calf or foot is a common sign of nerve root compression.  When a spinal nerve is pinched or irritated, burning, numbness, and tingling can also be present.  Muscle weakness can also result.

  The type of discomfort people have varies from person to person.  In early stages, patients with spondylolisthesis may not have any pain.  Pain may slowly increase to become intermittent, or even constant.  Patients may also live their entire lives with this condition and not ever have any significant pain. 

Conservative Treatment Options

  Most people with spondylolisthesis will find improvement in their back pain with conservative care.  The foundation of a conservative program typically includes a short course in physical therapy leading to a daily home exercise program. 

  Developing a strong trunk (abdominal, oblique, and back muscles) is vital to removing stress and pain from the spine.   Patients find that when they remember to do their back and abdominal exercises regularly, they have less back and buttock pain.  The time commitment for exercises need not be longer than 10 minutes a day, in most cases. 

  Medications can play a role in pain control.  Pain killers such as Percocet, Vicodin, and other narcotics are used sparingly except in times of new onset of severe pain.  These narcotics are best used short term.  They are very addictive.  Non-steroidal anti-inflammatory medications are the medications of choice.  They can be helpful at controlling back and leg pain by reducing the inflammation from arthritic joints.  Muscle relaxants are rarely helpful, with the possible exception in the case of an acute muscle strain.  

Surgical Options

  Who Needs Surgery - There is only one circumstance where surgery is an emergency: cauda equina syndrome.  This is a condition where the nerve roots within the spinal canal are severely compressed.  The end result is loss of bowel or bladder control, severe leg pain, and numbness in the genital region.  If the pressure on the nerves is not released immediately, control of bowel and bladder may never be recovered.  For this reason, we consider cauda equina syndrome a surgical emergency.

  For all other patients with spondylolisthesis, there is no emergency.  Surgery is planned when symptoms or circumstances warrant it.  Reasons to consider surgery include:

  • Back pain failing to improve with conservative care
  • Leg pain failing to improve with conservative care
  • Progressive leg or foot numbness or weakness
  • Progression in the amount of vertebra slippage
  • High grade spondylolisthesis (grades 3 - 5)
  • Signs, symptoms, and presence of nerve compression failing conservative care

"What If I Don't Have Surgery?"

  Since surgery is usually done for relief of pain, the decision to postpone surgery is essentially a decision to live with the pain a bit longer.  Most patients know very clearly when they are ready to have their spinal problem surgically corrected.  Their pain is intrusive and constant, work is difficult, social life or hobbies are impossible, family life is compromised, and the level of function is in every way sub-optimal. 

  Risks of Surgery - As with any surgery, there are risks with spinal surgery to correct spondylolisthesis.  The risks depend on the procedure being performed, the complexity of the spinal problem, and the health of the patient.  Some of the more common problems with posterior surgery (surgery from the back) include infection (1-3%), failure of fusion (3-15%), nerve root injury (1%), dural leak (1-5%), hardware failure (1%), and excessive blood loss (5%). 

Complications unique to anterior surgery (surgery through the abdomen) include prolonged resumption of bowel function, injury of blood vessels or bowel, incisional hernia, and retrograde ejaculation in males (1-3%). 

  General complications that can occur with any surgery include blood clots, deep vein thrombosis, pulmonary embolus, heart attack, pneumonia, urine infection, incision infection, virus transmission through blood transfusion, and many others.  The general health risk from surgery depends on the health of the patient.  A complete physical is recommended for anyone with health problems before undergoing major spinal surgery.

Possible Surgical Approaches

  POSTERIOR SPINAL FUSION - This approach involves placing bone graft on the back and/or sides of the slipped vertebra and the one below.  When the bone heals, it will fuse and stabilize the slipped vertebra.  Fusion rates in children are excellent.  In adults, failure of fusion can approach 60% if spinal instrumentation is not used.  As in all cases of spondylolisthesis, if nerves are compressed, a LAMINECTOMY is also performed.  Performing a laminectomy and fusion without instrumentation is the historic approach for this disease and still has a place in current surgical practice for low-grade slips in children, and in degenerative listhesis in adults who do not have much back pain.

  POSTERIOR SPINAL FUSION with INSTRUMENTATION - This is the most common technique used today to address the instability caused from spondylolisthesis.  Adding spinal instrumentation (screws in the vertebrae linked together with rods to immediately stabilize the spine) greatly increases the success of the fusion.  Postoperative pain is improved and long term outcomes are better than with fusions without instrumentation.  Fusion rates when instrumentation is used are about 95%.

  ANTERIOR INTERBODY FUSION - This technique was renewed in the mid 1990's and involves placing a titanium or plastic cage into the disk below the slipped vertebra.  This is done through an incision in the abdomen.  The cage or dowel contains the patient's own bone.  Success rates are good if the procedure is limited to vertebrae that are not slipped more than a few millimeters in patients without significant nerve compression.  Fusion rates are likely in the 85% range when bone is used and 95% or better if Bone Morphogenetic Protein is used.  The rehab after surgery is quicker than with posterior procedures.

  POSTERIOR INTERBODY FUSION - The spine is approached from the back and anything pinching the nerves is removed.  The disc below the slip is removed from the same approach and a cage is inserted into the disc to fuse it.  This technique has a higher fusion rate than the two above techniques, since it combines fusions on both the front and back of the spine.  Spinal instrumentation is used to further stabilize the spine and add to the success rate.

  COMBINED ANTERIOR AND POSTERIOR - In complex cases involving revision surgery, or in instances of marked instability, there is an advantage to fusing the spine both from the front and from the back.  When the spine is fused from the front, the disk can be distracted better than from the back.  Distracting the disk maintains or improves the natural arch in the low back and allows patients to stand erect effortlessly.  Spinal instrumentation is used posteriorly (in the back) to stabilize the spine.  With bone in the front and back of the spine, fusion rates approach 98%.  The tradeoff is in the increased complication rate from 2 different surgeries (front and back).

  REDUCTION OF THE SLIPPED VERTEBRA - With high grade or severe spondylolisthesis, there is significant trunk shortening, arching of the low back, and instability.  Correction of the slip in these cases is generally thought to be superior to fusing the spine in the deformed position.  Reduction is accomplished from posterior, and instrumentation is always required.  In experienced hands, this technique provides very good results with few complications.


  Most patients leave the hospital 2 to 4 days after surgery.  Help is needed at home for a few weeks with some of the more common activities of daily living.  For patients who do not have help at home, a short stay at a rehabilitation center can be helpful in becoming more independent.  From the first day home from the hospital, patients should be able to get in to the bathroom, and get in and out of bed or a chair on their own.

  If a patient wants to get back to work at a sedentary job, this can be done as soon as 4-6 weeks in a part-time status.  During the first 3 months, walking is the only exercise permitted.  After 3-4 months, physical therapy is started in an effort to regain trunk strength and stamina.  Therapy usually lasts 4-8 weeks, culminating in a home exercise program to be done on a daily basis. By 6 to 9 months, most people are safe to release to unrestricted activities. 

  Patients are followed on a yearly basis for several years.  This is necessary to make certain the fusion is solid, and to watch for degenerative changes that can develop next to the fusion (15% risk).

© Copyright 2010. Arthritis Education by Professionals, Inc.



When Does Spinal Arthritis Become SPINAL STENOSIS?
By Dennis Crandall, M.D.

  As a part of normal aging, the spine can develop arthritis. The discs lose their water content and begin to collapse, bone spurs form, and the ligaments around the joints of the spine begin to thicken. After age 50, these slowly growing bone spurs and thickened ligaments may begin to narrow the spinal canal and compress nerves. The result is slowly worsening pain into the buttocks, hips, thighs, and legs. Walking and standing are often worse than sitting. Feet or legs can become numb or tingle. Walking distances becomes more difficult as the legs begin to "feel heavy." Often, patients find themselves standing or walking in a stooped forward position in order to ease the pain. This process of spinal nerve compression is called spinal stenosis. Back pain may or may not be present. Over time, if signs and symptoms of spinal stenosis are ignored, bowel and bladder control can be lost.


  Unfortunately, conservative care has not been very effective at providing lasting relief from pain caused by spinal stenosis or pinching of the spinal nerves. Early stenosis can be treated with arthritis medications with some success. Steroids pills or steroid injection into the spinal canal (epidural) can provide some improvement in symptoms if the nerves are not too badly pinched. However, the effect of the steroids usually wears off within several days, weeks, or months and the pain returns. Other treatment methods such as wearing a back brace, physical therapy, or spinal manipulation (Chiropractic) have not been shown to provide any lasting improvement when significant nerve compression is present.


  Spinal stenosis most often requires surgery to decompress nerve roots and alleviate the pressure caused by the overly narrowed spinal canal. The surgery is called Laminectomy and is commonly done by spine surgeons all over the country.

  As with all surgery, a patient's decision to proceed is a very personal one. Surgery for this condition is usually elective in that it can wait until the patient decides it is time to get rid of the pain. A decision to avoid surgery is a decision to live with the symptoms a while longer. The only time surgery cannot wait is if significant leg weakness is present or if bowel or bladder control is lost.

RISKS OF SURGERY: The risk of infection is 1-2%. If the incision becomes infected, an additional trip to the operating room is usually required to wash out the infection. Antibiotics are required, sometimes through a vein.

  If nerves have been compressed for an extended time, return of function and relief of pain may not be as complete as hoped for. There is also a risk (less than 5%) that new numbness or weakness could occur. If this happens, it usually improves on its own.

  There is a risk that the fluid filled sack (dura), which surrounds the nerve roots, can adhere to the surrounding bone and ligaments being removed. If the dural sack is torn, it must be repaired during surgery. Rarely, an additional operation is required to repair a dural tear that hasn't healed.

   In some patients, adequate decompression of the pinched nerve roots requires removing some of the bone that contributes to spine stability. Fusion of the unstable segment would then be required to restore spinal stability and relieve back pain.
Other risks not listed here are even more rare and are not therefore listed. There are also medical risks as with any major surgical procedure.


  Patients enter the hospital the morning of surgery. The surgical procedure involves an incision along the spine and back muscles moved aside (not cut). Decompressing nerves involves removing arthritic bone spurs and thickened ligaments, which pinch nerve roots and cause pain. This can take 1-4 hours depending on the severity. If fusion is required to establish spinal stability, this involves removing some of the thick bone on the back of the pelvis and placing it along the side of the spine. Spinal instrumentation (rods and screws) is usually required to promote successful fusion. The incision is closed with self-dissolvable sutures covered with steri-strip tape. There are no staples or stitches that need to be removed later.


  Usually patients are up walking a day after surgery. Most people are ready to go home after 1 - 2 days depending on how quickly they become independent. When additional physical therapy is needed, a therapist can visit patients at home. Sometimes a short-term stay at a rehabilitation facility is required in order to obtain additional therapy and nursing care.


PAIN: Relief of leg and buttock pain is often immediate and can continue to improve for several weeks to months. By 4-6 weeks, the incision pain is mostly gone. Patients may return back to work around that time. A back and abdominal strengthening program is started in physical therapy at 3 - 4 weeks.

ACTIVITY LEVEL: Walking and swimming are excellent and can be resumed any time after week 3. Sitting is not usually a problem. Bending and lifting more than 10 pounds should be avoided until physical therapy can strengthen the back (starting week 4-6).

DRIVING: Before driving can safely be resumed (1 - 4 weeks), a practice session in a parking lot is needed to be certain that the patient can get from the accelerator pedal to the brake quickly enough for safe driving.

SEX: Intimate relations can be resumed after 6 weeks when the incision is well healed.


  With adequate surgical decompression of pinched nerves, about 80% of patients get good to excellent relief from buttock and leg pain. Numbness and leg weakness usually improve to some degree, if not completely. If significant back pain was present before surgery, it will likely be present after surgery. Patients with spinal instability, listhesis (slipped vertebrae) or scoliosis (curvature of the spine) do not usually do well with decompression alone. Instead, fusion of painful vertebrae along with nerve decompression is required to address the causes of back pain.

About Dennis Crandall, M.D.
  As a resident in Orthopaedics at St. Louis University, Dr. Crandall found it both challenging and gratifying to alleviate pain and restore function in patients with complex spinal disorders. After residency, he continued spinal fellowship training and served on the faculty of the University of Maryland. He taught the medical students and orthopaedic surgery residents about spinal diseases and surgery. Dr. Crandall chose to return to the Phoenix area because of the weather, lifestyle and family ties. He has been in practice in the Phoenix and East Valley area since 1994. In 1999, he founded the Sonoran Spine Center with a commitment to provide quality spine care to both children and adults with all types of spinal disorders. Furthering his focus on spinal research, he founded the Sonoran Spine Research and Education Foundation, a non-profit corporation that funds spinal research and educational seminars such as the annual Arizona Spine and Scoliosis Symposium.

© Copyright 2010. Arthritis Education by Professionals, Inc.

Arthritis: Understanding the Role of Medication
by Jan Revella, R.N.

  Hundreds of medications are available to treat arthritis, and it seems as if new ones are coming into the market every day. People often ask me, "Which is the best one to use?" The answer is that there is no "best" medication. They all work in different ways on different types and symptoms of arthritis. Each has an expected benefit, and the potential for side effects.

  It's very important that you and your doctor communicate effectively in order to choose the most appropriate arthritis medication for you. For example, because some arthritis medications have been associated with birth defects, a rheumatologist would consider whether his patient is a 32-year-old woman who plans to have children, or a 65-year-old who will not have more children. Drinking alcohol can increase the risk of stomach ulcers from some arthritis medications. People with impaired kidney function should not take certain arthritis medications, because they can interfere with kidney function. Many people with arthritis, particularly older adults, often are taking several different prescription medications for other conditions as well as the arthritis medication. This could set the scene for potential drug interactions that could have serious effects. If you have a managed care insurance plan, certain arthritis medications will be included on your plan's formulary (list of approved medications) and others will not. For some patients it may be easier to take their medication once a day, rather than remembering to take it four times a day. Finally, some patients would prefer a less expensive generic version to make it easier on their budget.

  Your rheumatologist will learn these things about his or her patients and will consider these facts when prescribing arthritis medication.

  Here's a quick overview of the main categories of arthritis medication and their characteristics. We've also listed individual medications by category.

Arthritis Medication Categories

 Non-steroidal anti-inflammatory drugs (NSAIDs) are the most widely prescribed arthritis medications. They block substances called prostaglandins that promote inflammation and pain. NSAIDs are known to cause harmful effects on the stomach, leading to ulcers and bleeding. In fact, 15,000 deaths occur each year due to chronic NSAID use. These drugs cannot differentiate between the prostaglandins that promote inflammation and the good prostaglandins we need to protect our stomach lining and kidney function. When decreasing all prostaglandins, NSAIDs put certain patients at risk. Another category of NSAIDs called COX-2 inhibitors was introduced (Celebrex is solo in this category). A COX-2 drug targets only the inflammation-related prostaglandins, making them safer for the stomach and kidneys. NSAIDs can relieve the symptoms of arthritis but do not alter the progression of the disease itself.

   Salicylates are aspirin-based medications that relieve pain and inflammation. They also can lead to stomach, kidney and bleeding problems, but are available in forms that minimize this potential.

   Glucocorticoids are powerful cortisone-based drugs that fight inflammation. Because they suppress the immune system, they are beneficial to patients with rheumatoid arthritis (RA) and and other inflammatory rheumatic conditions. They can be given orally, by IV or as an injection. When a steroid is considered in the course of treatment it is given serious thought.

   Unlike NSAIDs, disease-modifying antirheumatic drugs (DMARDs) actually work to stop the progression of inflammatory joint disease. They are used primarily in inflammatory conditions such as RA, lupus, psoriatic arthritis and ankylosing spondylitis. They are not appropriate for degenerative conditions such as osteoarthritis. DMARDs are a good first line of defense for people newly diagnosed with inflammatory arthritis, since they can help keep the damage from progressing. 

  Biologic response modifiers are more targeted agents that inhibit the immune responses related to arthritis, while sparing other immune system function. There are several biologics now available in this category. This category is prescribed when other antirheumatic drugs are not effective and the goal is to slow or arrest the inflammatory type of arthritis (such as rheumatoid or psoriatic arthritis).

      Viscosupplementation is approvedby the Food and Drug Administration (FDA) for the treatment of knee (only) osteoarthritis. By replacing hyaluronic acid, the substance that lubricates the joint, they help reduce pain. There are several brands of viscosupplementation which offer different frequency of the injection. There are options of 1, 3 or 5 injections in as many weeks available every six months. Each is injected directly into the knee joint. The purpose of this treatment is to protect the knee joint surfaces and reduce pain. It is recommended that a course of viscosupplementation be tried before considering total knee replacement.

   Analgesics provide simple pain relief but do not decrease joint inflammation as non-steroidal anti-inflammatory medications do. Acetaminophen (Tylenol) is an example. Topicals such as BenGay, BioFreeze and capsaicin-based creams also belong here.

  The other categories include drugs for fibromyalgia, gout and osteoporosis.

  The main thing to understand is that if you're being treated for a chronic problem, such as arthritis, simply treating it with medication over the long term increases your risk of developing side effects. Try to stay away from medications as much as you can, but don't put your comfort at risk. Take a balanced, active approach to managing arthritis that includes exercise and joint protection as well as medication. It's important to follow a treatment program based on your individual goals.

Arthritis Medications By Category

Acetaminophen (Aspirin-Free Anacin, Excedrin, Panadol, Tylenol), Acetaminophen with Codeine (Fioricet, Phenaphen with Codeine, Tylenol with Codeine), Propoxyphene hydrochloride (Darvon, PC-Cap, Wygesic), Tramadol (Ultram), Tramadol + Acetaminophen (Ultracet)
Topical Analgesics: ArthriCare, Aspercreme, Ben Gay, BioFreeze, Capzasin-P, Flex-all, Icy Hot, Therapeutic Mineral Ice, Zostrix

Biologic Response Modifiers
Etanercept (Enbrel), 
Etanercept (Enbrel), Adalimumab (Humira), Anakinra (Kineret), Golimumab (Simponi), Tocilizumab (Actemra), Infliximab (Remicade), Abatacept (Orencia), Rituximab (Rituxan)

Disease-Modifying Antirheumatic Drugs (DMARDs)
Azathioprine (Imuran), Cyclophosphamide (Cytoxan), Cyclosporine (Neoral, Sandimmune), Hydroxychloroquine sulfate (Plaquenil), Methotrexate (Rheumatrex), Leflunomide (Arava), Minocycline (Minocin), Penicillamine (Cuprimine, Depen), Sulfasalazine (Azulfidine)

Fibromyalgia Medications
Antidepressants: Duloxetine (Cymbalta), Amitriptyline hydrochloride (Elavil, Endep), Doxepin (Adapin, Sinequan), Fluoxetine (Prozac), Nortriptyline (Aventyl, Pamelor), Paroxetine (Paxil), Sertraline (Zoloft), Citologram (Celexa)                                                                                          Muscle Relaxants: Cyclobenzaprine hydrochloride (Flexeril), Metaxalone (Skelaxin), Carisoprodol (Soma), Tizanidine hydrochloride (Zanaflex), Diazepam (Valium), Methocarbamol (Robaxin), Cyclobenzaprine hydrochloride (Amrix)

Gout Medications
Allopurinol (Lopurin, Zyloprim), Anturane (Sulfinpyrazone), Colchicine (Colcrys), Febuxostat (Uloric), Probenecid and Colchicine (ColBenemid, Proben-C, Col-Probenecid), Probenecid (Benemid, Probalan)

Osteoporosis Medications
Alendronate (Fosamax), Calcitonin (Calcimar, Miacalcin), Denosumab (Prolia), Ibandronate sodium (Boniva), Raloxifene hydrochloride (Evista), Risedronate (Actonel), Zoledronic acid (Reclast), Teriparatide (Forteo)

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Diclofenac potassium (Cataflam), Diclofenac sodium (Voltaren), Doclofenac sodium with misoprostol (Arthrotec), Diflunisal (Dolobid), Etodolac (Lodine), Fenoprofen calcium (Nalfon), Flurbiprofen (Ansaid), Ibuprofen (Motrin, Advil, Motrin IB, Nuprin), Indomethacin (Indocin), Ketoprofen (Orudis, Oruvail, Actron, Orudis KT), Meclofenamate sodium (Meclomen), Mefenamic acid (Ponstel), Meloxicam (Mobic), Nabumetone (Relafen), Naproxen (Naprosyn, Naprelan, Naprosyn-E), Naproxen sodium (Anaprox, Aleve), Oxaprozin (Daypro), Piroxicam (Feldene), Sulindac (Clinoril), Tolmetin sodium (Tolectin)
COX-2 Inhibitor: Celecoxib (Celebrex)

Non-Steroidal Anti-Inflammatory Drugs NSAIDS)                                                                                      Diclofenac potassium (Cataflam), Diclofenac sodium (Voltaren), Diclofanac sodium with misoprostol (Arthrotec), Diflunisal (Dolobid), Etodolac (Lodine), Fenoprofen calcium (Nalfon), Flurbiprofen (Ansaid), Ibuprofen (Motrin, Advil, Motrin IB, Nuprin), Indomethacin (Indocin), Ketoprofen (Orudis, Oruvail, Acton), Meclofenamate sodium (Meclomen), Meloxicam (Mobic), Nabumetone (Relafen), Naproxen (Naprosyn), Naproxen sodium (Aleve), Oxaprozin (Daypro), Piroxicam (Feldene), Sulindac (Clinoril), Tolmetin sodium (Tolectin)                                                                       COX-2 Inhibitor: Celecoxib(Celebrex)                                      

Salicylates                                                                             Aspirin (Anacin, Ascriptin, Bayer, Bufferin, Ecotrin, Excedrin), Choline magnesium trisalicylate (Trilisate), Choline salicylate (Arthropan), Magnesium salicylate (Magan), Salsalaate (Disalcid)                                                            

Viscosupplementation                                                      Hyaluronan (Hyalgan), Hylan G-F 20 (Synvisc, Synvisc-One)

© Copyright 2010. Arthritis Education by Professionals, Inc.






Using Cortisone
by Jan Revella, R.N.

  Occasionally, the use of corticosteroids is necessary to gain rapid control of rheumatoid arthritis or another inflammatory rheumatic disease after an early diagnosis or during a painful flare. To avoid or reduce side effects, the goal is to limit the use of oral corticosteroids to the short-term. Oral corticosteroids do not play a role in the treatment of osteoarthritis or fibromyalgia.

  In treating rheumatoid arthritis, oral corticosteroids, such as Prednisolone and Prednisone, work rapidly to control inflammation and pain. The possibility for serious side effects associated with long-term steroid use, however, does raise some concern. Studies have found that mortality rates in people taking long-term corticosteroids are twice that of other RA patients, although this may be due to the fact that people taking these medications generally have a more severe form of the disease. Your physician may inject corticosteroids directly into joints for relief of flare-ups when only one or a few joints are affected. Experts suggest no more than two or three injections into a joint per year since it is well-known that corticosteroids are an irritant and can destroy tissue.

Side Effects of Corticosteroids
  Undesirable side effects of long-term corticosteroids include weight gain, hypertension, susceptibility to infection, capillary fragility, acne, excess hair growth, cataracts, glaucoma, diabetes, wasting of the muscles, accelerated hardening of the arteries (atherosclerosis), menstrual irregularities, irritability, insomnia and psychosis. Steroids appear to cause premature death of bone-forming cells and slow their replacement; osteoporosis and bone damage are of particular concern because of the severe long-term side effects. Long-term use may also affect brain cells, causing memory loss. Certain side effects such as hypoglycemia, edema and hypertension can be minimized by treatment. Because of potential bone loss, the American College of Rheumatology recommends that patients take 1,500 mg of calcium a day and 800-1000 IU of vitamin D supplementation. Medications that can prevent osteoporosis include parathyroid hormone (Forteo), risedronate (Actonel), alendronate (Fosamax), ibandronate sodium (Boniva), denosumab (Prolia), zoledronic acid (Reclast), raloxifene (Evista) (for women only) and in some cases, hormone replacement therapy. 

  It is important to know that long-term use of steroid medications suppresses secretion of natural steroid hormones by the adrenal glands. Slow withdrawal from these drugs is required because use of oral corticosteroids suppresses the ability of your own adrenal glands to produce natural steroids. Never simply stop taking a corticosteroid without the advice from your physician. It can take the body a while (sometimes up to a year) to regain its ability to produce natural steroids again. The risk increases during times of stress. Undergoing surgery is a form of physical stress that requires steroid monitoring and adjustment of your medication.

  If you have questions about the appropriate use of cortisone in the treatment of arthritis, do be sure to discuss your concerns with your primary care physician or rheumatologist.

About the Author:
Jan Revella, R.N., Arthritis Nurse Specialist, is Founder and Director of Arthritis Education by Professionals, Inc., a Phoenix based company dedicated to providing educational services to people with arthritis worldwide. As a nationally renowned speaker and educational specialist on the subject of arthritis, Jan serves as the Director of Research and Education for the Sonoran Spine Research and Education Foundation based in Phoenix Arizona. 

 Over the past 30 years, Jan has conducted educational programs that have helped tens of thousands of people throughout the United States and Canada. Her mission is to empower people with arthritis, osteoporosis and specific back disorders through knowledge so they can make more informed decisions and better manage the treatment of their disease.

© Copyright 2010. Arthritis Education by Professionals, Inc.


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