Back Pain Lessons from Outer Space

NASA, and other Space Agencies placing astronauts in Space, and doctors have noted the increased risk of both Lumbar and Cervical Disc Herniations with resulting Back Pain and Neck Pain in Astronauts. "The ongoing research on these astronauts can shed light on the causes and treatments for those suffering from Back Pain back on Earth, " comments Dr Prem Pillay, a Spine Specialist who deals with Back Pain relief in his practice.

A narrative literature review published in the European Spine Journal has concluded that the increased rate of intervertebral lumbar disc (IVD) herniation is most likely caused by an increase in lumbar disc hydration due to the reduced spinal loads experienced in space. Given the dramatic paucity of even basic biomechanical research into the cervical spine, however, the authors were unable to speculate as to the cause of elevated rates of cervical disc herniation after spaceflight.The National Aeronautics and Space Administration (NASA) have previously observed an increased risk of disc herniation (10% (n=321) vs. 3.5% (n=983), respectively) in US astronauts, compared to the general population. Thirty-two of these herniations took place within the first week, post-flight, while another 32 took place within the first year. Investigating this high rate of disc herniation, the authors propose a mechanical mechanism—that overhydrated discs are swollen, as annular structures are stretched and nucleus pressure increased—to explain the increased rates of lumbar disc herniation. The nucleus of the disc can then herniate more easily in flexion, offering an explanation for the increased risk of disc herniation in the first few days after space flight. Data from bed rest studies were analysed to show that the effects of reduced load in space could take weeks, or even months, to fully return to normal. The authors recognised that, while bed rest may not be a good model for the effects of spaceflight on the cervical spine, it could be an acceptable model for the lumbar spine. The authors argue that IVD hyperhydration in astronauts “can be inferred from increases in spine length and body height during spaceflight”. Lead author, Daniel Belavy, said, “Cervical disc herniations are probably more common in astronauts for the same reason that lumbar herniations are: disc hyperhydration. However, this is not clear. Nonetheless, it would be a big coincidence if there were another reason.” Ergonomic issues, such as the position held by astronauts during spaceflight and on landing, as well as the potential cumulative effects of injury to the spine prior to space flight, may compound the risk of post-flight disc herniation. The authors also considered how research into the effects of spaceflight on the spine could improve understanding of the spine more generally. The role of mechanical loading of the IVD may be better understood given more extensive research into the spines of astronauts. This data, plus that of back pain starting before 12pm, for example, support the notion that the effects of diurnal variation in the spine might influence risk windows for back injury. “Differences in back pain incidence over the course of a day is likely related changes in disc hydration during a normal sleep-wake cycle,” Belavy told Spinal News International. Such research could help evaluate which times of the day are safest for activities such as spine flexion, and shed light on the role of mechanical loading in lumbar disc herniation more generally. Belavy commented, “What we gain from understanding why astronauts are more likely to experience a disc herniation will help us understand and manage spinal disorders in the general population.”
Dr Prem Pillay a Spine Specialist agrees stating "This research on Back Pain in Astronauts from Space, shows that avoiding Lumbar flexion or forward bending of the spine especially in the early morning, on getting up from bed or in tying shoe laces for example, can reduce injury and stress to the lumbar discs. This could prevent or reduce Lumbar disc herniation in conjuction with other measures."

References and further info:

NASA 2015
European Spine Journal, Belavy D, et al, 2016
Spine and Pain Info

Smoking Cigarettes Can Be a Pain in Your Neck

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SMOKING CIGARETTES CAN BE A PAIN IN YOUR NECK

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The cervical spine is located in the neck and is made up of bones called vertebrae. Between these bones are cervical discs that allow flexibility and movement of the neck and absorb shock to the spine. Through the normal aging process or through injury or poor posture and prolonged sitting, these discs  degenerate or deteriorate, which means they can loose height, or protrude into the spine nerve spaces, states Dr Prem Pillay, a Spine Specialist. This may result in a person experiencing chronic neck pain that may be difficult to treat. In some cases, the drying and deterioration of the disc may result in the formation of cracks and tears, through which some of the jelly-like central portion of the disc may spill out and irritate local nerves, which much of the time results in pain in the shoulders, arms, hands and fingers.
It isn't only wear and tear  that can damage these discs. Some unhealthy habits, such as smoking, can add to cervical disc degeneration, according to Mitchel Leavitt, MD; resident physician at Emory University's Department of Physical Medicine and Rehabilitation and the lead investigator of a new study looking at smoking and cervical disc disease. "Smoking is not healthy for a person's intervertebral discs given the risk of developing microvascular disease -- a disease of the small blood vessels -- due to nicotine abuse," Dr. Leavitt explains. "Intervertebral discs receive their nourishment from the microvasculature that line the endplates on either side of each disc; when these blood vessels are damaged, the discs do not receive nourishment and this may speed up the degenerative process."
While smoking has been associated with degeneration in the lumbar spine (toward the base of the spine), no studies have been able to make this association with the cervical spine. To address this, Dr. Leavitt's team evaluated the CT scans of 182 consecutive patients who were scanned for various reasons.
"There are more and more high-quality studies coming out that show an association between healthy lifestyle and improved quality and quantity of life as well as better disease management. Spine health is no different, and this study adds to existing studies that have looked at blood vessel health as it relates to chronic back pain," Dr. Leavitt says.
The patients evaluated by Dr. Leavitt's team were mostly female (57 percent), and 34 percent were smokers. The researchers utilized a radiologist with subspecialty training in neuroradiology and a physiatrist -- a physician who specializes in physical medicine and rehabilitation -- to review the CT scans, and they provided documentation on the severity of cervical degenerative disc disease.
Each disc was rated as normal (no loss of disc height), mild (one to 33 percent loss of disc height), moderate (34 to 66 percent loss of disc height), or severe with (greater than 66 percent loss of disc height or having a condition called vacuum disc where gas has accumulated in the discs). Based on this, scores of zero (normal) to three (severe) were given to each disc, and a cumulative cervical degenerative disc disease score was given for the entire cervical spine with a range of zero to 15.
The researchers considered each patient's smoking status and his or her number of pack years smoked, which is the number of packs of cigarettes the patient smokes each day multiplied by the number of years he or she has smoked. Finally, the researchers collected and considered other health information such as age, body mass index, high blood pressure (called hypertension), high cholesterol and diabetes.



Current smokers were found to have more cervical degenerative disc disease by one point, on average. Additionally, the researchers found that increased age was associated with worsening cervical degenerative disc disease, but co-existing diseases -- such as diabetes, hypertension, high cholesterol and high BMI -- were not associated with the disease.
"This is another example of the detrimental effects of smoking. Tobacco abuse is associated with a variety of diseases and death, and there are lifestyle factors associated with chronic neck pain," explains Dr. Leavitt of the study's findings. "Pain and spine clinics are filled with patients who suffer chronic neck and back pain, and this study provides the physician with more ammunition to use when educating them about their need to quit smoking."
Dr Prem Pillay Medical Director and Spine Specialist at the Neuro Spine and Pain Center Singapore agrees stating '' Holistic treatment of Spine Disc disease and injury includes asking patients to reduce or stop smoking especially before and after spine surgery or procedures to improve healing; together with physiotherapy and workstyle adjustments to reduce disease progression.''

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 References;
The above post is reprinted from materials provided by Association of Academic Physiatrists (AAP). Note: Materials may be edited for content and length.

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Association of Academic Physiatrists (AAP). "Smoking Cigarettes Can Be a Chronic Pain in Your Neck." ScienceDaily. ScienceDaily, 18 February 2016.

More information on the Spine at SingaporeSpine

ADVANCED MINIMALLY INVASIVE SPINE SURGERY-MISS AND AMISS

There are many people who need back and neck surgery but are afraid of it. Many have heard horror stories of severe pain, long recovery periods and even those who have become paralysed. There is however technology currently available that addresses these concerns. It is true however that these methods are available from some neurosurgeons/spine surgeons worldwide; those who have listened to  patients and understood their needs have been working hard to find solutions that are minimally painful, allow quick recovery and are effective treatments.

These solutions include but are not limited to several of the following:

1.Percutaneous Plasma Energy Discoplasty
2.Percutaneous Endoscopic Laser Disectomy-PELD
3.MicroDisectomy
4.Endoscopic Disectomy
5.Microsurgical Discetomy with Dynamic Implants
6.MicroEndoscopic Discectomy-MED
7.Microsurgical Spinal Decompression
8MicroEndoscopic Spine Microsurgery- MESM
9.Percutaneous Disc Regeneration Technology
10.Endoscopic Disc Replacement
11.Microsurgical Disectomy and disc replacement
12.Minimally Invasive Spine Fusion and Instrumentation

Some of these options allow the patient to arrive at a day surgery center, have the procedure under iv sedation and local anesthesia (no general anesthesia) and leave within a few hours of a fairly short procedure. Most patients walk out of the center themselves and can return to work in a few days.

Unlike taking pain medications or pain injections; these procedures do address the root of the problem. They allow reduction in nerve pressure and therefore can prevent ongoing or future nerve damage. Spinal nerves especially the spinal cord, cannot be effectively replaced at this point in time. Stem cell treatment is still experimental and not consistently successful. Taking away spine nerve pressure to reduce the risk of spine nerve injury is still the best strategy.

These procedures are also evolving and becoming more successful with experience, technology and the passage of time. Many of us who are Minimally Invasive Spine Surgeons believe that more spine doctors need to know and be trained to do these procedures. An informed patient can also help to accelerate these changes worldwide by insisting on the latest and least invasive spine treatments.

References

Dr Prem Pillay, Singapore Spine Specialist and Neurosurgeon

Neuro Spine and Pain Center Singapore

Leg Pain can occur from Back Problems!

Leg Pain can come from Back problems that may start as

back pain and then spread to the legs. This is also called
Sciatica or psuedo claudiation leg pain.

Back Pain used to be seen mainly in those who worked
 in physically demanding jobs like builders, bricklayers,
 plantation workers, heavy industry workers , construction
 workers and miners. However, nowdays Dr Prem Pillay 
 has noticed that there are more executives who come

 to him for back pain. He has identified prolonged sitting,
 a poor posture, overuse of computers , frequent business
 travel and a unhealthy  executive lifestyle as major reasons
 for this problem. When you sit too long, he explains, there
 is increased pressure in the spine discs. The spine is not
 one bone but about 33 bones with a soft gel like substance
 called the disc in between. The disc allows flexibility and

 movement in the spine.  An Executive Lifestyle with 
computer work and  a lack of movement can cause the
 spine discs to break down and come  out or slip out.
 These slipped discs can pressure on the nerves  and cause
 back pain, leg pain, numbness, tingling, and as the problem 

 gets worse even weakness in the legs. The worse case
 scenario is becoming unable to walk, unable to pass urine
 or pass motion. This  can happen gradually or in some people
 it can happen suddenly even  from a small accident or injury 
once the pressure on the spine nerves is already present.

People who have back pain and leg pain often go for 
massages or manupilation  to therapists and chiropractors.
If the pain does not get  better  after three visits to the 
therapist , or gets worse after the first visit, or comes back
after the therapy  , its best that you see a real spine specialist.
Dr Prem Pillay does warn that massage therapy or 
physical therapy done in the wrong way by unqualified people
can  make the problem worse.  A proper spine and nerve 
examination followed  by an MRI of the spine can reveal
and confirm the problem. X rays alone cannot show the
nerves or pressure on the nerves from  a slipped disc.

In some older people, the back pain with leg pain is 
caused by spine stenosis. This is a narrowing in the spine 
canal which squeezes the spine  nerves. A common story
that Dr Prem hears is that the person cannot  walk far
without the legs feeling uncomfortable. He or she has 
to stop  and rest first before walking further. This is called
spinal claudication pain  or psuedo-claudication leg pain.

Back pain and leg pain can often be treated without
 surgery. The proper  medications and  therapy organized
 by a spine specialist can help the  person recover faster 
and return to his normal lifestyle. Some people require
 spine injections including nerve blocks,  Neuroplasty, 
facet injections, Annuloplasty, Biacuplasty, and RF to the 

medial branch nerves to reduce pain. The better and 
more advanced  type of spine injections such as Discoplasty
treat the root of the problem.  This involves a laser like spine
njection to the disc to reduce the disc pressure on the nerves. 
This can be done as a day procedure  without any surgery.

In some people the problem has become too serious
and requires surgery.  Fortunately modern surgery including
microsurgery and keyhole type spine  surgery has advanced
to a stage that the risks are low and the recovery  can be  
quick. These are minimally invasive spine procedures with
a keyhole  like approach.  Dr Prem gives the example of a
 patient who came to see him because of back pain with leg pains 

 that was worse on sitting for  too long and on walking a short distance.

The test showed that he had  spinal nerve pressure from 
slipped discs and spine narrowing. A minimally  invasive 
advanced microsurgery was done without any metal screws
but  using modern gel implants. He has now recovered
well after a short hospital stay and is walking and working
with a good quality of life.

In conclusion, more people including home and  office
 workers are suffering  from back pain. If this back pain 
is frequent or spreads to the legs, Dr Prem Pillay recommends
 that you see a spine and nerve specialist  for a proper check
 up to find out the root of the problem. Once the causes

 for the back and leg p[ains are found and treated at the source;
 a healthy lifestyle with less sitting, the right exercises and a good
 diet can also work together  lessen or solve frequent back pain 
and leg pain. 

Furthur information is available at 

http://www.spine-neuro.org/
 and http://www.singaporespine.org/
or by contacting clinicsg@yahoo.com or calling +6568354325 for assistance.

Motivation Can Enhance Recovery from Spinal Cord Injury

Motivation can promote recovery after spinal cord injury

Researchers  confirm that motivation can facilitate recovery after spinal damage.
Clinicians have known for a long time that motivation can enhance a patient’s recovery from spinal cord injury or stroke, and that depressive symptoms resulting from brain injury can delay functional recovery. To date, however, the mechanism has remained elusive and there has been no neuroscientific evidence as to how motivation affects recovery of motor function in rehabilitation.
A research team led by Yukio Nishimura and Hirotaka Onoe has found that the nucleus accumbens, which controls motivation in the brain, stimulates the activity of the motor cortex of the brain, and then promotes recovery of motor function during the early stage of recovery after spinal cord injury. This result was published in Science.
The research team focused on the relationship between the neuronal activity of the nucleus accumbens and that of the motor cortex, which controls motor function, in a monkey suffering from spinal cord injury. When the researchers temporally blocked the activity of the nucleus accumbens of the monkey one month after spinal cord injury, they observed that motor cortex activity was suppressed and a transient deficit of amelioration in finger dexterity was obtained by rehabilitation. In the intact monkey, and also in the fully recovered stage (three months after spinal cord injury), such deficit in hand movement by blocking the activity of the nucleus accumbens was not observed. This suggests that the nucleus accumbens makes a causal contribution to the functional reinstatement of hand control during early stage recovery, and the activity of the nucleus accumbens successfully promotes functional recovery.
“Our result suggests that in the early stage after brain injury including spinal cord injury, it is important to motivate the patients for promoting functional recovery in rehabilitation. Psychological support may also be important,” said Nishimura. "My experioence in treating Spine injuries is quite similar in finding that depressed and poorly motivated spinal injury patients don't recover as well or as fast as those with a positive attitude" states Dr Prem Pillay, a Neurosurgeon and Spine Specialist from the Neuro Spine and Pain Center in Singapore."its clear that this evidence gives us good reason to pursue furthur research into medications and even brain stimulation to specific nuclei to promote motor recovery after brain and spinal cord injury" said Dr Prem Pillay. "In the meantime, it is important for the whole treating team and the patient's family to provide psychological support for a positive attitude to rehab and recovery" states  Dr Prem Pillay.



Reference: M. Sawada, K. Kato, T. Kunieda, N. Mikuni, S. Miyamoto, H. Onoe, T. Isa, Y. Nishimura. Function of the nucleus accumbens in motor control during recovery after spinal cord injury. Science, 2015; 350 (6256): 98 DOI: 10.1126/science.aab3825

Eureka Alert

Spinal Surgery News Dec 2015

 Neuro Spine and Pain Center Singapore

Flexibility is overlooked in preventing Back and Joint Pain and Stiffness

Singapore Spine

"Keep yourself flexible as part of a regular exercise regime" states Dr Prem Pillay from the Neuro Spine and Pain Center Singapore.
Effective fitness programs should include cardiovascular training, strength building and flexibility exercises, but the flexibility component is often overlooked, according to the American Academy of Orthopaedic Surgeons.
"Increasing your flexibility improves your ability to move easily," orthopedic surgeon Dr. Raymond Rocco Monto, of Nantucket, Mass., said in an academy news release. Dr Prem Pillay agrees and says "Don`t focus on strength and cardiovascular excercises only"
"Some joints lose up to 50 percent of motion as we age. There are many ways to improve your joint flexibility, including controlled stretches held for 10-30 seconds, stretches that rely on reflexes to produce deeper flexibility, as well as yoga and pilates," explained Monto.
Including flexibility exercises in your workouts helps reduce back and joint pain, increases circulation, improves joint motion, boosts athletic performance and improves muscle health.
To get the most out of flexibility training, always warm up before you stretch, Monto said. Stretching cold muscles can lead to injuries.
He advises stretching slowly and gently, and breathing into your stretch to avoid muscle tension. Relax and hold each stretch for 10 to 30 seconds.
Don't bounce while stretching because doing so can cause injuries. Also, stretching should not hurt, Monto said. If you feel pain, go easier on the stretch, breathe deeply and relax into it.
"Certain sports such as Table Tennis and Badminton incorporate flexiblity as a part of the sport movement and this is useful to those who practise it" says Dr Prem Pillay. Akido,"Wu Shu and other martial arts also have a good flexibility component that is useful"states Dr Prem. However Back pain that persists despite the correct exercise regime should be check out by a Spine Specialist as it may be linked to Spine nerve irritation and not a simple muscle strain.

SOURCE: American Academy of Orthopaedic Surgeons, news release, Nov. 4, 2015
Neuro Spine and Pain Center Singapore (http://www.singaporespine.org)
Medline Plus,USA

Wireless Pain Relief is Coming. Singapore Spine : Advanced Treatments for Back Pain 

A new generation of wireless pain relieving devices can be implanted or injected to sites in the body to relieve pain.

Building on wireless technology that has the potential to interfere with pain, scientists have developed flexible, implantable devices that can activate -- and, in theory, block -- pain signals in the body and spinal cord before those signals reach the brain.

The researchers, at Washington University School of Medicine in St. Louis and the University of Illinois at Urbana-Champaign, said the implants one day may be used in different parts of the body to fight pain that doesn't respond to other therapies.
"Our eventual goal is to use this technology to treat pain in very specific locations by providing a kind of 'switch' to turn off the pain signals long before they reach the brain," said co-senior investigator Robert W. Gereau IV, PhD, the Dr. Seymour and Rose T. Brown Professor of Anesthesiology and director of the Washington University Pain Center.
The study is published online Nov. 9 in the journal Nature Biotechnology.
Because the devices are soft and stretchable, they can be implanted into parts of the body that move, Gereau explained. The devices previously developed by the scientists had to be anchored to bone.
"But when we're studying neurons in the spinal cord or in other areas outside of the central nervous system, we need stretchable implants that don't require anchoring," he said.
The new devices are held in place with sutures. Like the previous models, they contain microLED lights that can activate specific nerve cells. Gereau said he hopes to use the implants to blunt pain signals in patients who have pain that cannot be managed with standard therapies.
The researchers experimented with mice that were genetically engineered to have light-sensitive proteins on some of their nerve cells. To demonstrate that the implants could influence the pain pathway in nerve cells, the researchers activated a pain response with light. When the mice walked through a specific area in a maze, the implanted devices lit up and caused the mice to feel discomfort. Upon leaving that part of the maze, the devices turned off, and the discomfort dissipated. As a result, the animals quickly learned to avoid that part of the maze.
The experiment would have been very difficult with older optogenetic devices, which are tethered to a power source and can inhibit the movement of the mice.
Because the new, smaller, devices are flexible and can be held in place with sutures, they also may have potential uses in or around the bladder, stomach, intestines, heart or other organs, according to co-principal investigator John A. Rogers, PhD, professor of materials science and engineering at the University of Illinois.
"They provide unique, biocompatible platforms for wireless delivery of light to virtually any targeted organ in the body," he said.
Rogers and Gereau designed the implants with an eye toward manufacturing processes that would allow for mass production so the devices could be available to other researchers. Gereau, Rogers and Michael R. Bruchas, PhD, associate professor of anesthesiology at Washington University, have launched a company called NeuroLux to aid in that goal.

Dr Prem Pillay,  Medical Director of the Neuro Spine and Pain Center Singapore calls this advance , an important breakthrough in pain treatment particularly for pain patients who have intractable pain that cannot be relived with the usual treatments of pain meds, physiotherapy, pain injections and spinal surgery. He states that the current devices include Spinal Cord Stimulators that may need more invasive surgery to implant, are more bulky and require battery sources  that need to be replaced.

References:

Science Daily : Nov 2015

Sung Il Park, Daniel S Brenner, Gunchul Shin, Clinton D Morgan, Bryan A Copits, Ha Uk Chung, Melanie Y Pullen, Kyung Nim Noh, Steve Davidson, Soong Ju Oh, Jangyeol Yoon, Kyung-In Jang, Vijay K Samineni, Megan Norman, Jose G Grajales-Reyes, Sherri K Vogt, Saranya S Sundaram, Kellie M Wilson, Jeong Sook Ha, Renxiao Xu, Taisong Pan, Tae-il Kim, Yonggang Huang, Michael C Montana, Judith P Golden, Michael R Bruchas, Robert W Gereau, John A Rogers. Soft, stretchable, fully implantable miniaturized optoelectronic systems for wireless optogenetics. Nature Biotechnology, 2015; DOI: 10.1038/nbt.3415

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