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Common Neck Problems Seen In Clinics

Musculoskeletal Consumer Review took an opportunity to sit with Dr. Razmi Rahmat, a Consultant Spine and Orthopaedic Surgeon from Centre For Spine and Orthopaedic Surgery to discuss about the common neck problems seen in his clinic and the management for those problems.

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What is Sciatica?

WHAT IS SCIATICA?

The sciatic nerve is the largest and longest nerve in the body with a diameter of almost 2cm. It starts from the sacral plexus, a network of nerves in the pelvis region, branching out down into each of the legs.

The sciatic nerve carries out two basic functions, namely motor (movement) functions and sensory (feeling) functions. When the nerve is compressed, the symptoms are called sciatica. Aside from sharp shooting pain, symptoms such as loss of reflexes, weakness and numbness are often present when both its motor and sensory functions are imparied.

WHAT CAUSES SCIATICA?

One common cause of sciatica is a herniated disc or "slipped disc". The herniated disc protrudes and places pressure on the nerve root which connects to the sciatic nerve.

As the longest nerve in the body, there are ample opportunities for the nerve to be compressed. They include:

1. Piriformis Syndrome is pain caused by the piriformis muscle that may be in inflamed, or irritated. This muscle is in your buttock and lies right on top of the sciatic nerve as it exits the spine and goes down your leg. When inflamed or irritated, this muscle swells and applies pressure on the nerve giving you the sciatica like symptoms.

2. Spinal Stenosis, which is the narrowing of the spinal canal can cause sciatica-like symptoms. The narrowing can be caused by disc problems as well as arthritis of the spine.

Sciatica-like symptoms may also be caused by other than compression on the sciatic nerve such as.

1. Sacroiliitis is an inflammation of your sacroiliac joint, where your hip meets the spine. Inflammation caused by trauma or arthritis can give you sciatica-like symptoms.

2. Lumbar Facet Joint Syndrome is pain that comes from the joints of your back causing not only back discomfort, but also it can give you sciatica-like symptoms. The facet joint, like any other joint of your body, such as the knee or elbow, can get inflamed and cause pain.

3. Iliolumbar Syndrome is simply inflammation or a tear of the Iliolumbar ligament. This ligament extends from the spine to the iliac crest, which is the back of your pelvis.

Your doctor or physiotherapists can perform one or more movement tests to determine the exact cause of your symptoms.

WHAT ARE THE SYMPTOMS?

One or more of the following sensations may occur as a result of sciatica:

1. Pain in the rear or leg that is worse when sitting.

2. Burning or tingling down the leg

3. Weakness, numbness or difficulty moving the leg or foot

4. A constant pain on one side of the rear

5. A shooting pain that makes it difficult to stand up

If severe pain symptoms occur along with bowel or bladder control problems, consider this as an emergency and is to be evaluated as soon as possible by a neurologist or orthopaedic specialist.

TREATMENT

As nerve pain is caused by a combination of pressure and inflammation on the nerve root, and treatment is centered on relieving both of these factors:

1. Manual treatments for sciatica including physiotherapy treatments such as mobilisation and manipulation to help relieve the pressure and inflammation with electrophysical agents.

2. Medical treatments for sciatica (such as NSAID’s, oral steroids, or epidural steroid injections) to help relieve the inflammation.

3. Surgery for sciatica (such as microdiscectomy or lumbar laminectomy) to help relieve both the pressure and inflammation may be warranted if the sciatic nerve pain is severe and has not been relieved with appropriate manual or medical treatments.

When sciatica has resolved, the patient should maintain optimum conditions for their spine. The fact that the spine has had a prolapse, and is not normal, does not preclude a relatively normal lifestyle. Specific exercises such as core stability exercises to maintain flexibility and strengthen the abdominal and spinal muscles are important.

 

Reprinted from www.CoreConcepts.com.sg

Dermatome Patterns

Why is it that if you experience a tingling sensation in your toes, your specialists will most likely first examine your lower back? Afterall, it is your toes that you are experiencing problems with. So why do they check out your lower back? Read more

Whiplash - Part II

In the earlier post on Whiplash - Part I, we looked at what whiplash is all about and the associated signs and symptoms. The treatment options were also discussed briefly. The quality of each of the treatment techniques can be viewed here.

Belt Up Your Unstable SIJ

An unstable Sacro-illiac Joint (SIJ) can cause pain in the lower back and pelvic region. This happens when the core muscles surrounding it are too weak to support the SIJ. A sacroiliac support belt can help to provide support and stability to the joints during the initial stages of core stability training. Read more

Medical Animation - Spondylolisthesis

Posterior Pelvic Pain (Sacroiliac Joint Pain) in Pregnant Women

Posterior pelvic pain (PPP) is pain felt at or near the sacroiliac joints of your pelvis as a result of sacroiliac joint dysfunction.

These are joints located at the 2 dimples of the lower back. The pain often feels deep within your lower back and can occur on one or both sides of your back. In some cases, pain radiates down to the buttock and the back of the thigh.

While pain may begin at any time during pregnancy, PPP on average begins in the 18th week of pregnancy and becomes more intense as the pregnancy progresses. The pain usually spontaneously resolves within 3 months post delivery. But in some cases it can become chronic and disabling.

What are the Sacroiliac joints?

The sacroiliac joints (SIJ) are formed between the sacrum, a triangular-shaped bone in the lower portion of the spine, and the right and left ilium of the pelvis. The SIJ is a strong and stable weight-bearing joint that permits very little movement due to its natural structure. The main role of the SIJ is to allow forces to be transmitted effectively through the body, absorbing impact from the legs to the spine during activities such as walking, running and jumping.

The SIJ is kept stable through two mechanisms:

1. Firstly, the rough, groove-like connecting surfaces of the sacrum and ilium interlock and help stabilise the joint, like two pieces of Lego together.
2. Secondly, the SIJ is further strengthened by a complex mesh of ligaments and muscles such as the core stabilizers. These core muscles, such as the transversus abdominis and multifidus which surround the SIJ, act as active stabilizers by actively contracting to create a compressive force over the SIJ, gripping the joint firmly together. They act as a natural corset by providing that compression around the lower back and pelvic region -much like wrapping your fingers around the two Lego pieces, keeping them firm and tight.

Posterior pelvic pain arises from sacroiliac joint dysfunction, in other words, when the stability of SIJ is compromised.

Why does it happen?

During pregnancy, mechanisms stabilising the SIJ is affected. This instability allows for increased motion, stressing the SIJ.

1. Hormones released during pregnancy relax the ligaments of the body to allow the pelvis to enlarge, in preparation for childbirth
2. Due to the growing uterus, some of the core muscles around the pelvis get ‘stretched’ and weakened.

Moreover, the additional weight and altered walking pattern associated with pregnancy can cause significant mechanical strain on the sacroiliac joints, which may result in SIJ inflammation, giving a deep ache in the posterior pelvis.

What are the symptoms?

Of all the back pains experienced during pregnancy, posterior pelvic pain is the most common - you are four times more likely to experience PPP than lumbar pain.

You may have posterior pelvic pain / sacroiliac joint dysfunction if you have:

• Deep, boring pain in the back of the pelvis (around the sacroiliac joints)
• Pain may occasionally radiate to the groin and thighs.
• The pain is typically worse with standing, walking, climbing stairs, resting on one leg, getting in and out of a low chair, rolling over and twisting in bed, and lifting. The pain improved when lying down.
• If there is inflammation and arthritis in the SI joint, you may experience stiffness and a burning sensation in the pelvis.

Diagnosing Sacroiliac Joint Dysfunction in pregnancy

Your doctor and/or physiotherapist will conduct a thorough history and physical examination to determine the underlying disorders for your pain. That includes your description of symptoms, a series of tests designed to look at the stability, movement, and pain in the sacroiliac joints and surrounding structures. Imaging, such as computed tomography (CT) scan and X-ray may also help in the diagnosis. Another reliable diagnostic method involves injecting an anesthetic agent into the SI joint, guided by an X-ray machine, numbing the irritated area, thereby identifying the pain source. However, due to the concerns of fetal exposure to radiation, diagnostic procedures involving radiation is generally avoided.

Treatment and Management

The first-line treatment of pregnancy-related sacroiliac joint dysfunction is physiotherapy and exercises that focuses on core stability of the trunk and pelvic girdle. Sometimes, a sacro-iliac belt is prescribed to complement the core stability exercises and to give quick pain relief. Exercises will form a large part of the treatment and in some cases, mobilisation (a gentler form of manipulation) of your hip, back or pelvis may be used to correct any underlying movement dysfunction. Other manual techniques include muscle energy technique (MET) and myofascial release. It is vital to engage a physiotherapist who is skilled in treating pregnancy-related pain as she is aware of the studies that support the use of specific stabilizing exercises and other treatment techniques, thereby preventing the dysfunction from escalating into a chronic condition.
Other alternative treatments include anesthetic and steroidal injections into the SIJ that can help in pain relief, which lasts from one day or much more long-term. Oral anti-inflammatory medications are often effective in pain relief as well. However, these two treatments may be contra-indicated during pregnancy.

Posterior Pelvic Pain Home Advice

Here are some tips for expectant women with posterior pelvic pain..

Lying down

• Avoid lying on your back for long periods of time, particularly after the 19th week of your pregnancy.
• Try lying on your side (preferably your left) with a pillow placed between your knees and another under your tummy.
• If your waist sags down into the bed, try placing a small rolled up towel under your waist.

Turning over in bed

• To turn to your right while lying on your back, arch your lower back, tighten your pelvic floor muscles and lower abdominal muscles and bend both knees one by one.
• Turn your head to the right and take your left arm over to the right of your body. Hold onto the side of your bed if you can.
• To turn, pull with your left hand and take both knees over to the right so that you roll to the right. As soon as possible, bend your knees up as high as they will go - this helps to lock out your pelvis and lessen pain.
• Reverse this to turn to the left.

Getting out of bed

• Roll onto your side with your knees bent up, move your feet over the edge of the bed and push yourself up sideways with your arms.
• Reverse the process when you lie down.

Standing from a sitting position.

• Sit on the edge of the chair.
• Keeping your knees apart slightly and lean forwards till your head is directly over your knees, keeping your back straight.
• Stand up by pushing up with your arms, with your back straight and tummy tucked in. This helps to hold your pelvic joints in their most stable position and may reduce your pain significantly.

Reference:

1. Fitzgerald CM and Le J. Back pain in pregnancy requires practitioner creativity. Biomechanics. 2007 November 
2. Ostgaard HC, Andersson GB, Karlsson K. Prevalence of back pain in pregnancy. Spine. 1991; 16:549-552.
3. Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994; 19:894-900.
4. http://www.sidysfunction.com/articles/lumbarbackandposteriorpelvicpain.html

    

 

Medical Animation - Degenerative Disc Disease

Whiplash - Part I

In this article, we will be looking at the three most commonly asked questions:

1. What is a whiplash?
2. What are the signs and symptoms of a whiplash injury?
3. What are the common treatment techniques available?

What is a whiplash?

Whiplash is a common term for sudden acceleration-deceleration forced on the neck. This is usually as a result of rear-end or side impact motor vehicle accidents or any other mishaps. The acceleration-deceleration forces cause the head into forward flexion (head down position) and very quickly the head gets whipped back into extension (head in a looking up position).

When this occurs, the forces may result in bony or soft tissue injuries such as in the disc, ligaments, tendons, neck muscles and nerve roots.

There are several grades to the severity of whiplash associated disorders (WAD).

Grade 0: No pain or discomfort. No physical signs of injury.

Grade 1: Neck pain, stiffness or tenderness. No physical signs of injury.

Grade 2: Neck pain, stiffness or tenderness. Some physical signs of injury such as point of tenderness or trouble turning the head.

Grade 3: Pain, stiffness or tenderness and neurological signs of injury, such as changes to the reflexes or weakness in the arms

Grade 4: pain and fracture or dislocation of the neck.

What are the symptoms?

The most common symptoms after a whiplash injury are neck pain or stiffness. This can occur immediately after the injury or even after a few days.

Other symptoms may include

• Headache
• Pain in the shoulders and arms
• Dizziness
• Altered sensation, pins and needles, numbness in the arms
• Weakness
• Visual and auditory symptoms
• Difficulty concentrating
• Difficulty in swallowing

What are some treatments available for treatment of whiplash?

There are many treatments available for the treatment of a whiplash injury. In this article, we will only list what is available but not grade the quality of each treatment techniques. This will be done in the next article.

Some of the treatments include:

Treatment	What it means
Act as usual	Staying as active as possible within tolerable levels.
Active treatment	Actively perform repeated movements of the neck in a pain free range.
TENS machine	The current from the TENS (transcutaneous electrical nerve stimulation) machine may inhibit pain in the tissues surrounding the electrodes. It works by distracting your nerves and brain from the pain sensation.
Exercise	Exercise improves pain, range of motion, flexibility, function and physical fitness. It is thought that exercise promotes the production of endorphins, naturally occurring hormones by the brain that can help with pain control.
Manipulation	Also known as ‘adjustment’ or ‘cracking’. It is thought that manipulation of a spinal joint may provide temporary increase in joint range of motion. It also corrects spinal alignment which gives relief from musculoskeletal pain.
Mobilization	A technique that entails gentle, controlled movements of the joints affected. This aims to improve mobility in areas of the spine which leads to a decrease in restriction. Hence, removes a source of pain and provides symptomatic relief.
Pilates	Aims to selectively increase the strength and endurance of the deep core muscles of the torso. By doing so, posture and stability is improved, reducing the amount of pressure on the spine.
Acupuncture	A treatment modality of Traditional Chinese Medicine (TCM). Acupuncture influences the nervous system and neurotransmitter which respond to needling stimulation and electro-acupuncture, which in turns influences pain relief. From a TCM perspective, acupuncture is thought to restore the flow of “chi” through the body.

Medical Animation - Kyphosis

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Knee Inflammation after a Marathon

"I suffered from inflammation in my right knee after running a marathon. What can I do to strengthen my legs and prevent the injury from occurring again?"... Read more »



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Musculoskeletal Consumer Review © 2007 - 2009 by Core Concepts Pte Ltd