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                SURGERY, MEDICATION, CHIROPRACTIC MANIPULATION 
                    AND OTHER FORMS OF MEDICAL INTERVENTION 
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       Back pain responds to changes in posture and exercise, but other 
       medical treatments are sometimes considered by patients. 
       Surgery, chiropractic therapy, medications and injections are 
       sometimes suggested to back pain patients. A brief background 
       regarding these paths is probably in order.... 

       Doctors of chiropractic and osteopathy attempt to manage back 
       pain and several other medical ailments by manipulating the 
       spine, joints and muscle tissues in an effort to relieve pain 
       and restore nerve function. Chiropractic practitioners may also 
       make recommendations regarding diet, exercise and rehabilitation 
       therapies. 

       Some surgeons and physicians consider forceful manipulation 
       dangerous and of dubious benefit. Others consider it one of 
       several possible beneficial therapies. The truth probably lies 
       somewhere between the two views: it may have potential but 
       within specific limits. The name chiropractic derives from the 
       Greek language and roughly translates as "practice by hand." 
       
       Chiropractic medicine was founded in 1895 by Daniel David Palmer 
       of Davenport, Iowa - a town which is also home to the Palmer 
       College of Chiropractic. By profession Mr. Palmer was a grocer 
       who was interested in the possibilities of manipulation in the 
       maintenance of health and relief of pain. 

       As proposed by Mr. Palmer, certain diseases and specific pain 
       have origins in pressures placed on the nervous system. The 
       restoration of normal function and relief from pain could be 
       achieved, he believed, by manipulation and treatment of the 
       structures of the body - especially the spinal column and back. 
       
       If pressure upon a nerve pathway is present, nerve impulses are 
       believed to be blocked to and from the brain which causes the 
       tissues served by these nerves to become more susceptible to 
       disease and pain. Disorders believed to be treatable by this 
       system, according to practitioners of chiropractic, can include 
       lumbago or back pain, high blood pressure, asthma and arthritis. 
       
       In chiropractic theory, dislocations and subluxations of the 
       vertebral bones cause pressures upon associated nerves which 
       leads to pain and decreased resistance to disease. A subluxation 
       is described as a partial separation or slippage of two joint 
       surfaces while a dislocation is the complete separation of both 
       sides of a joint, frequently with tearing or rupture of the 
       joint capsule. 

       Fourteen chiropractic colleges are accredited in the USA and 
       Canada to award the doctor of chiropractic degree. Students 
       normally begin study with at least a high school degree and in 
       many cases an additional two year liberal arts college 
       background. Training during a four year chiropractic college 
       normally includes courses in chemistry, neurology, X ray 
       diagnosis, anatomy and clinical practice. Currently all 50 
       states of the U.S. license chiropractic practitioners. Medicare, 
       Medicaid and workers compensation usually covers the cost of 
       certain chiropractic treatments. 
       
       Osteopathic doctors are also skilled in manipulation but unlike 
       chiropractors have attended a four year medical school of 
       osteopathy which is similar to mainstream medical training. In 
       most cases osteopaths are licensed to practice medicine like an 
       M.D. 
       
       Chriropractors are licensed to perform manipulations of the 
       body, back and spine and are limited for the most part to that 
       type of service. Chiropractic manipulation cannot push or move a 
       ruptured disc back into proper alignment - once a disc has 
       ruptured it is permanently weakened. Likewise a chiropractor 
       cannot treat meningitis, tuberculosis of the spine or tumors of 
       the spine. A herniated or ruptured disc cannot be treated by 
       manipulation and may even be dangerous if manipulated 
       improperly. Surgery may be the only course of action for cases 
       of severe disc rupture. Chiropractic practice has limits and 
       reasonable practitioners admit this. 
       
       Mobility and recovery from muscle spasm and joint facet problems 
       may, however, be benefits of manipulation. Beware, though, that 
       overly frequent chiropractic manipulation sessions can sometimes 
       cause swelling of tissues, delayed muscle spasm and a further 
       visit to the chiropractor - a vicious cycle which serves to 
       perpetuate further sessions. 
       
       A prudent course following chiropractic treatment is to protect 
       against further joint damage and embark on a program of exercise 
       rather than additional chiropractic manipulations immediately. 
       
       Manipulation of the neck or cervical region of the spine is 
       extremely dangerous because the spinal cord lies within the 
       spinal canal at that level of the spinal column. Manipulation of 
       the lower lumbar region is less risky since the spinal cord ends 
       just under the first lumbar vertebrae and is thus less likely to 
       be damaged by manipulation. 
       
       On balance, though, there may be benefits to specific 
       manipulations especially when muscle spasm or facet joint 
       movement is impaired. The American Medical Association 
       recognized chiropractic practice in 1980 after many years of 
       often heated debate about its validity. 
       
       Current practice of chiropractic has also developed to include 
       the study of kinesiology as proposed by George J. Goodheart in 
       1964. This branch of chiropractic practice proposes that it is 
       possible to treat some disorders by locating muscular weakness 
       and then manipulating the spine in a manner that directly 
       stimulates and strengthens the muscle. A side effect of this 
       development is the recognition that muscle weakness can be 
       directly caused by allergy or nutritional deficiencies and is 
       thus correctable in some cases by changes to diet. The 
       discipline of chiropractic is served by the International 
       Chiropractor's Association and the American Chiropractor's 
       Association which promotes public education and provides 
       continuing education and training to members. 
       
       The most conservative course to consider if you are 
       contemplating chiropractic treatments is to visit your physician 
       or orthopedic surgeon and ask if muscle spasm or facet joint 
       impairment is involved. If that is the case would he or she 
       recommend a competent chiropractor or osteopath to solve that 
       part of the backache? 
       
       Mainstream medical professionals are now referring selected 
       patients to chiropractors and osteopaths for some treatments and 
       therapies, so manipulation is no longer the "dark science" it 
       once was. In addition, many chiropractors are now recommending 
       specific back exercises following manipulation which represents 
       a "mainstreaming" of chiropractic practice towards 
       recommendations and continuing care generally followed by 
       physicians. Nevertheless, ask questions of professionals on both 
       sides of the chiropractic issue regarding exactly what a 
       manipulation treatment can and cannot do for you since there are 
       limits to what chiropractic practice can achieve. 

       Medications are available for some types of back pain, but be 
       aware that there is no magic pill which will provide a quick 
       cure. Generally three classes of medications are available to 
       back pain sufferers: 1) pain relievers or analgesics, 2) muscle 
       relaxants and 3) anti-inflammatory agents. Analgesics or pain 
       relievers treat the symptom of a backache - the pain - but not 
       the source. 
       
       Tylenol and aspirin are the most commonly prescribed medications 
       and aspirin has the added benefit of also being anti-
       inflammatory. However aspirin and tylenol may be only partially 
       effective at relieving severe back pain. 
       
       Stronger pain relievers such as percodan, vicodin or codeine-
       tylenol are usually prescribed for severe back pain. Codeine is, 
       of course, addictive if taken over longer periods of time. For 
       the most part these strong pain relievers are only offered 
       during the first few days to a week of a painful episode and 
       then discontinued. 
       
       The strongest analgesics such as demerol and morphine are used 
       on patients suffering from back pain in a hospital setting or 
       after back surgery. They are obviously quite addictive. 
       
       Recent studies of patients recovering from a variety of surgical 
       procedures show that these patients tend to have a more rapid 
       recovery when correctly treated with stronger pain relievers. 
       Strong pain relievers such as morphine are dangerously 
       addictive, but over very short periods can actually hasten 
       recovery. 
       
       If you are in severe or chronic back pain, do not be afraid to 
       ask the doctor for a stronger pain medication if a low level 
       analgesic is not controlling the pain - you may be able to 
       recover more quickly and begin a suitable therapy or exercise 
       program that much sooner. Strong or addictive pain medications 
       are usually best discontinued within two or three days - a 
       practice followed by most physicians. Appropriate bed rest is 
       usually just as effective at controlling chronic pain as most 
       analgesics after the first day or so. 

       A different class of drugs, anti-inflammatory agents, reduce 
       swelling in the muscles, ligaments and joints of the spine. The 
       most effective are cortisone and related medications. Cortisone 
       is not without side effects and is used very carefully by most 
       physicians who watch and monitor a patient closely. Other anti-
       inflammatory agents include motrin, advil, nuprin, ibuprofen, 
       indocin, naprosyn, clinoril, felene and voltaren. Side effects 
       of these anti-inflammatory drugs include stomach irritation, 
       nausea, diarrhea and vomiting. 
       
       Not all patients will experience these side effects when taking 
       an anti-inflammatory, but if you are taking one of these drugs, 
       watch for side effects. Some patients will have inadequate anti-
       inflammatory effect with one drug and may need to switch to 
       another medication under a doctor's supervision. This is common 
       with anti-inflammatory drugs and a period of "testing" may be 
       required by patient and doctor to find the one which gives best 
       anti-inflammatory result with little or no side effects. 

       Muscle relaxants loosen tight, spastic muscles. Robaxin, 
       flexeril, and norflex are common drugs in this classification. 
       Valium, a common but potent tranquilizer, is also a muscle 
       relaxant but can be addictive over long periods of time. Most 
       muscle relaxants work indirectly by affecting the central 
       nervous system or brain and NOT by working directly on the 
       muscle. In most cases these agents are useful during acute 
       episodes of back pain - especially painful sciatic attacks which 
       radiate down the legs. Some patients remain on these medications 
       for several months, but in most cases the drugs are discontinued 
       within a week or so after muscle spasm has decreased. 
       
       Medications administered orally are but one route to managing 
       back pain... 

       Local injections are sometimes used to relieve back pain. The 
       injected medications may consist of anesthetics alone or mixed 
       with cortisone. In most cases these injections are done 
       routinely in the doctor's office and provide only temporary 
       relief. They may be helpful in allowing a patient to overcome 
       the first day or two of pain after which adequate bed rest and 
       therapy or exercise is usually prescribed. 
       
       Epidural injections and facet joint injections are a variation 
       of the above idea. These injections are given into a much deeper 
       area - typically the irritated facet joint or exterior layer of 
       dura of the spinal cord. Usually these deep injections are given 
       by a licensed anesthesiologist under orders from a surgeon or 
       physician. Unlike a superficial local injection, the deep 
       epidural injection usually provides prompt relief for several 
       days. A combination of cortisone and anesthetic is usually 
       administered. Conditions such as disc ruptures, spinal stenosis 
       or compressed or irritated nerve roots are comfortably treated 
       in this manner. Relief does not last more than a few days and 
       further injections or other therapies and specific back 
       exercises are usually required in the end. 
       
       Ultrasound heat treatments are usually given by physical 
       therapists prior to additional massage or exercise of the back. 
       Diathermy likewise projects heat deep into the tissues of the 
       back and serves a similar purpose. By themselves, these 
       treatments have little permanent value unless combined with 
       additional exercises, massage or other therapies. 

       Surgical procedures for treatment of back pain are the most 
       drastic course of action. Frequently a physician will try other 
       courses to remedy the pain since surgery is useful only in 
       limited specific cases such as disc rupture. However, if a disc 
       has failed, an orthopedic surgeon may attempt to remove its core 
       via a variety of procedures. 
       
       Percutaneous aspiration of a disc describes the removal of the 
       pulpy core through a hollow needle which is inserted into the 
       disc. A modification of this method adds a tiny spinning burr or 
       reamer which is inserted through the needle and aids in breaking 
       up the disc core. It is important to note that only the core is 
       removed, not the entire disc structure. In most cases this 
       surgery will relieve direct pressure of a ruptured disc upon 
       adjacent nerve roots. However, the procedure has some risks such 
       as possible disc fragments remaining near the spinal canal. 
       Also, if back pain derives from nerve pressure due to overlying 
       ligaments and muscles or narrowing of the bone through which 
       nerve roots pass, this operation will have little beneficial 
       effect. 
       
       A surgical variation of disc removal is chemonucleosis which 
       makes use of an injection of the chemical chymopapain into the 
       core of the disc. This enzyme is derived from the papaya fruit 
       and can selectively dissolve the tissue collagen which is 
       contained within the disc core. Normally the needle is guided to 
       the injection site by X ray image. Once the injection has been 
       made, the core will slowly dissolve and in most cases relieve 
       pressure on irritated nerves. Side effects to this procedure is 
       the possibility of allergic reaction to the injection and the 
       possible irritation of nerve roots if the chymopapain leaks out 
       of the disc and comes into contact with nerve or muscle tissue. 
       The procedure has limits in other ways: completely ruptured or 
       extruded discs are not good candidates for this procedure. 
       Likewise, elderly or arthritic patients are not usually 
       recommended for chemonucleosis. 

       The most aggressive surgical method for treating a herniated or 
       ruptured disc is direct surgical dissection and removal of the 
       affected disc core. In most cases back pain which focuses on 
       irritated or compressed nerves may also derive from several 
       sources in addition to the damaged disc. Removal of the disc 
       core may thus be accompanied by surgical investigation of bony 
       growths between vertebrae, stenosis or narrowing of bone canals 
       through which nerves pass and compressed muscles and ligaments. 
       
       Typically removal of the disc by direct surgical intervention is 
       accomplished by direct incision over the affected spinal area. 
       Overlying muscles and ligaments are retracted to reveal the disc 
       space. The affected nerve root is usually revealed after 
       additional bone is removed. Finally the nerve root is retracted 
       and protected and the ruptured disc material is cut and 
       suctioned from the site. Other bony spurs which have grown in 
       proximity are trimmed with the idea of relieving pressure on the 
       irritated nerve root. Bed rest and specific therapy exercises 
       are usually prescribed depending on the recommendations of the 
       surgeon. 

       A different operation is attempted if a narrowing of spinal 
       canal places pressure on nerve roots or the spinal cord itself. 
       Sometimes this narrowing is a result of a disc rupture. Other 
       times it is a matter of aging or other disease processes. This 
       surgical procedure essentially opens a space around the nerve by 
       removing some of the bony surrounding tissue which encases it. 
       Foraminotomy is a similar processes but instead involves 
       enlarging the smaller bony canals through which nerves pass - 
       not the central spinal canal. Bony growths or spurs adjacent to 
       the facets of the vertebrae may also be trimmed to reduce 
       pressure on nerve roots during the surgery. Stenosis or 
       narrowing of the spinal canal or smaller foramen through which 
       nerves pass is more frequently seen in elderly patients over age 
       55. 

       Spinal fusion is another surgical procedure which is sometimes 
       attempted to relieve back pain. Sometimes damage or injury 
       causes the movements of one intervertebral bone to become 
       misaligned in relation to an adjacent bone or disc. The lower 
       lumbar area is notorious for instability and vertebral injury. 
       Back braces may be suggested to limit the range of motion in the 
       lumbar area of the back and prevent pain. However an external 
       brace may not be sufficient and a surgeon will attempt to 
       permanently fuse two vertebral bones together by taking bone 
       grafts from the large pelvic bone and bonding them to two 
       adjacent vertebrae. Bone tends to mend and grow together if 
       fractured or injured and this procedure makes good use of this 
       biological predisposition by grafting bone together at the site 
       of two adjacent vertebrae. Occasionally metal plates or screws 
       are added if the area is unstable or needs extra support during 
       healing. 
       
       Surprisingly, patients who have undergone spinal fusion still 
       retain a considerable range of motion in the back and over 
       several months may not even be aware of any decrease in 
       flexibility or function. Years ago surgical removal of a 
       ruptured disc core was accompanied by spinal fusion under the 
       theory that removal of the disc core necessitated spinal fusion 
       to strengthen the underlying area. However, today disc removal 
       is not usually accompanied by bone-to-bone intervertebral fusion 
       since appropriate rehabilitation and back exercises can 
       compensate to provide strength and support to the back. 
       
       It should be noted that surgical fusion requires several months 
       of recuperation for the grafted bones to heal and strengthen the 
       site while disc removal causes only a few weeks of recuperation 
       for most patients. The majority of patients who undergo surgery 
       are pleased with the results. However a program of exercise, 
       rest and specific medications are usually required - surgery is 
       only a foundation for relief from pain. Many months may be 
       required for complete recuperation and a return to a normal work 
       schedule. Fundamentally, removal of a disc or spinal fusion is 
       NOT the normal structure for a healthy back. In addition to 
       exercises, proper techniques for sitting, standing and lifting 
       will have to be learned by the recovering patient. 
       
       This tutorial is merely a starting point! For further 
       information on back care and back pain, be sure to register this 
       software ($25.00) which brings by prompt postal delivery a 
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       plus two software disks. From the main menu select "Print 
       Registration Form." Or from the DOS prompt type the command  
       ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO 
       Box 1506, Mercer Island, WA 98040. If you cannot print the order 
       form, send $25.00 to the above address and a short letter 
       requesting these materials. End of chapter. 
       
