Spine Complications to ST
The bones of the spine and the muscles of the neck are intertwined in an elaborate dance that allows our necks to move. For many "normal" individuals who take their necks for granted, they are able to look to the left or to the right or to simply hold their heads straight. This is an unconscious process no one notices until they usually start having pain or discomfort. With torticollis it is important to try to understand when pain comes from the muscles strained by over-activity or from pain that originates from the spine.
The bones of the spine form the support structure for most of the trunk of the body. For most ST'rs, we are most interested in the cervical spine. It is here that the bones not only provide the stability of the neck in terms of structure, they provide protection to the spinal cord and they allow the muscles of the neck to attach to a stable structure. In addition, the interior of some of the bones helps with the production of blood and the bones themselves provide a ready source of calcium for bodily needs. The next time you watch a building being raised more than a couple of stories, you will notice the steel girders that are used to support and frame the structure. The bones of the spine act in a similar way to provide structure and stability to the neck. Recently, we have been paying more attention to the thoracic spine as a contributor to torticollis also.
Most people think of the bones of their spine as unchanging, static, very hard stuff that they take for granted. When they see some very usually dusty, professorial, thoughtful person on the Discovery channel uncovering a body or skeleton that has been in the ground for about 10,000 years, there is a certain understanding that bones in general don't change over many years. Think about the dinosaurs. The only way we knew that they were here before us is through the bones that they left behind so many years ago. However, while they are in your "living" body they constantly go through many changes. They go through the process of remodeling. Otherwise, how would a young baby grow to such an adult without their bones changing along the way with everything else that changes? In fact, scientists can often determine how old someone was by how the bones change through life. When a person dies those changes stop taking place, and a rough estimate of how old they were when they died can be made.
Although this remodeling process never stops, there are some estimates that on average it takes about seven years to completely remodel a specific area of bone. Old bone in areas of less mechanical stress will be reabsorbed and some of the "parts" will be recycled and used to lay down new bone in areas that are under more mechanical stress to help strengthen those locations. This process is how a bone spur may develop as a result of the mechanical stresses of the neck. If the bone spur grows in a direction where there are no critical structures, it may only cause some vague discomfort. If it grows into the spinal cord, it may cause severe pain, numbness, or weakness/paralysis. Most often it will grow in a direction that serves to block the exit of a nerve from the neck. This is one of the causes of a "pinched" nerve.
At each level of the spine, there exists a bone or vertebrae above and one below. Sandwiched between each of these pairs, is a hard substance made of some of the same material in our ears. This gelatinous material forms a ring of multiple layers with a softer, creamy "filling" inside. On occasion, a twist or turn is enough to rupture the ring and have this softer material spill out. This is a form of a herniated disc. The nerves that leave the spinal cord and come out to the remainder of the body, exiting between the little opening between a hole made from the roof of the upper vertebrae and the floor of the bottom vertebrae. This hole that is formed is known as the "neural foramen." That herniated cream filling can put enough pressure on a nerve to injure it.
The older we get the more often the discs have a tendency to thin out with age. When an adult starts to loose height, this is usually the first sign of the discs as a whole starting to thin out. This process usually occurs in conjunction with osteoporosis. Women are often more at risk from this than men but it can occur with males also. The groups most at risk for osteoporosis are small stature, short Caucasian or Asian menopausal and post-menopausal women. Certain behaviors such as alcohol or smoking may speed up this process of thinning bone and thinning discs.
Another form of a herniated disc can take place when the harder disc substance can be pushed in one direction or another. Very similar to a bone spur, this can push in a direction where it causes little to no damage. Or in the worst case scenario, it can push on the spinal cord causing pain, numbness or weakness/paralysis. It can push the disc to the sides and pinch off the exiting nerves, as they go through the neural foramen. This can occur near the spinal cord on the inside of the neural foramen, or it can occur on the outside just as the nerve exits. Either location the nerve is trapped and pressure is placed on the nerve. If the pressure occurs in a slow fashion, as with a bone spur, one may not even notice a problem until a sufficient portion of the nerve is pinched. At other times like in disc herniation which occur in shorter time periods, the nerves can swell or develop edema in area of injury, making a very bad situation worse.
Just to make things a little more complicated, there is a layer on the outside of every bone called the periosteum. This layer of outermost bone has a very intricate network of nerve fibers woven throughout this covering. When the outer covering of bone starts to wear down or rub together against other bone it is very painful. Just ask anyone who has had a compound fracture of an arm or leg. A simple fracture may not damage the periosteum very much but a compound fracture may disrupt this network of fibers and cause a great deal of pain.
There are more important structures in this one little area packed together like sardines in a can. Then each of these little zones are stacked one on top of the other in multiple layers that form our spine. Like a house of cards stacked layer upon layer.
Let's say that we are aware of this degenerative process of bones and discs thinning out to an extent, either by x-ray or simply we started to notice the height loss. Is there anything that I can do to stop it? Or slow it down? The answer to that is a definite --- maybe? There are several things that can be done. The first and foremost is that terrible word, exercise. It is only with exercise that the bones will remodel in a favorable way, most of the time without forming bone spurs. If necessary, seek out the help of a good physical therapist. I know most of you have tried this, but many physical therapists have never been exposed to a torticollis patient! So when they look at you with that painful expression on their face, it's because they usually don't have a clue as to what to do to help you. You will have to take the lead and help educate them about ST. However, they have at their disposal a series of exercises designed to help you with your neck. A word of caution here, start low and go slow. You might experience some pain at first, but just remember where you put that bottle of ibuprofen. However, severe pain is another story. Always check with your physician, before starting any regular exercise program. Make sure your doctor and you know if you have one of those dangerous bone spurs that can affect your spinal cord.
."I got bone spurs that jingle, jangle, jingle".
--- Happy trails,
Dr. James Auberle M.D.
