“We take an in depth review of how the best Neurosurgeons, Orthopaedic surgeons and Chiropractic physicians look at your Posture & Spine, and determine it’s direct impact on your overall health and quality of life.
J NEUROSURGICAL TRAUMA 2015
EUROPEAN SPINE JOURNAL 2018
JOURNAL NEUROSURGERY 2012
When it comes to being Healthy, it’s a lot like being rich. Everyone says they want it, but most people don’t have any idea what that actually means, or how to achieve it, or even believe they’re capable and worthy of it. If you don’t know what it means to be healthy, then you can’t set a specific and clearly defined goal to get there. Inevitably, your daily habits and routines must be built around these specific and clearly defined goals. You can track those daily habits and see whether you’re actually obtaining health, or heading towards disease. Just like being rich. If you are always eating out at restaurants, spending lots of money on food and inevitably alcohol, you are achieving two goals at once. Except, they are likely not the goals you want to achieve: financial stress and disease. You are draining your bank by always eating out, which means you are not getting rich. The second goal you didn’t want to achieve, but you are heading towards, is sickness. By inevitably making poor choices in nutrition, your health is being compromised. So what is health? How do we measure it? To answer that, we take an in depth look at what a Neurosurgeon, an Orthopaedic surgeon and Chiropractor all specialize in. I will give you a hint, it’s the Spine and your Posture.
To kick this article off, we’re taking a deep dive exploration in the world of neurosurgery and spine. We visit the top neurosurgical journals in the world of medicine to gather great insight and clarity on the most up to date literature and findings and how they directly impact you and your loved ones health, for generations to come. If there’s one thing we specialize in at Advanced Spinal Institute, it’s EliteCare procedures and protocols to deliver you to Generational Health.
Pain and Disability
If we want health, we need to change the way we talk about it, which starts by defining it. Let’s start with what most of us are currently used to: pain.
Posture is a direct reflection of your overall health. Postural distortions within the spine are outwardly expressed through your posture. Your posture is the window into your Spine and nerve system. When your Spine is unhealthy, your posture will show it, your body will express it, but often times people won’t have pain. In fact, pain and disability are correlated, but they don’t always happen together.
In a 2012 study in the European Spine Journal, Doctors took a look at over 1200 patients with zero symptoms of pain or stiffness. Through advanced imaging of the spine, this study, and others in the medical literature, determined that significant damage to the spine ranged from 14% to 40% depending on the persons in the study. The patients didn’t automatically link their Spine and Posture with the fact that they were unhealthy. This is largely because they’ve been brought up thinking that pain means you’re unhealthy, and that therefore having “no pain” means that you are healthy. This unfortunate concept is the same dilemma that patients suffering from various stages of cancer didn’t even feel pain. Until it was too late.
In fact a study on tumors and the spine showed that those with advanced staging of cancer, has far greater damage to their spines, whether in one region (like the neck) or overall (the entire spine and pelvis). The entire spine is one unit, although we like to say we have “neck pain” or “mid back pain”, or “low back pain”; as we’ll see later on, damage to the neck, means there’s damage to the low back as well, and vis versa. The cervical spine influences and is influenced by global spinal alignment, and is simultaneously supporting the head and providing stability for the cervical spinal cord. There are reciprocal changes in the cervical spine that occur naturally as byproduct to unhealthy spinal alignment below the neck. The presence of global deformity occurs as a result, and creates a substantial negative impact on pain and quality of life. [i]
Our children are suffering the consequences of spinal damage due to increased screen time and decreased activity. The increasing damage from the birthing process to compounded falls and texting postures have led to rising rates of spinal degeneration, instabilities and pathologies in children. Over 10% of our 9 year olds now have damage in their spines. In fact, it is so common that a group of researchers have made the grave mistake of classifying a neck that is bent in the completely opposite direction, as ‘a normal variant’. That is completely false, and deadly. The neck should be in a healthy c-shaped curve, also called a lordosis. As this article goes into detail, that lordotic curve gets lost, and increased pathology occurs in the person. Further, as the rest of the spine degenerates or becomes damaged, the neck attempts to compensate. These changes in the neck, towards an unhealthy and abnormal alignment, are directly related to drastically reduced health related quality of life (HRQOL).
Quality of Life & Health
Health related quality of life is directly tied to the health of your spine, and how far from normal those curves are. As you can see the normal health curves in the figures below, you will also see unhealthy spines. Spinal health is also directly related to morbidity and organs conditions like cancer, diabetes, heart disease, chronic fatigue, GERD, asthma/allergies, immune and autoimmune functions, arthritic conditions, and that’s just naming a few. On a positive note, improvement of these spinal damages back towards normal, does lead to improved health related quality of life.
The variables we look at in the medical literature that substantiate health and quality of life when analyzing, diagnosing and treating the spine are: ODI, NDI, SF36, SRS 22 questionaires. The objective measures we can look at are heart rate variability for function of the central nervous system, fMRI’s of the brain and prefrontal cortical regions.
These patient questionaires encompass a wide variety of questions ranging from daily activities that the patients can complete, to the levels of pain and disability that they experience in important activities that a normal adult can and should be able to perform. One could argue that these questionaires are not a true reflection of peoples goals, if they truly knew and understood how their bodies were meant to function and perform. All too often, patients are led to believe that with old age comes nursing home lifestyles, inability to run and job, or even walk. That is a discussion for another article, however, at advanced spinal institute, we set goals that some Doctors call “audacious goals”. Yet we help patients achieve them. Pain and disability, or lack thereof, does not necessitate a truly high quality of life. We believe that if you have no pain, but still cannot walk, that is not a true healthy outcome. What if you could walk, even jog, without pain yes, but also with a healthy spine and body that functions at a high level? Would that not be a better goal?
Healthy normal alignment of the spine is shown in the figures below. It requires advanced imaging to analyze every vertebrae (back bone) in your spine to determine if any individual segment is distorted, weakened, damaged or injured, which will cause problems to the spinal cord, and nerves that exit your spine. Ultimately, these spinal distortions at any individual segment, will lead to distortions of entire regions of the spine. Think of it like water flowing down a river. If you damage your spine, that’s like putting a dam in the river. What happens when you dam a river? Exactly, the water slows down, or stops. The same thing happens to the vital energy that flows from your brain down your spine. If you stop that flow, or slow it down, now the vital energy can’t get through your spinal cord, and the organs at the end of those nerves, can’t get the vital energy they need to survive and give life to your organs.
Changes in the spinal curves correlate to health related quality of life. If those curves get worse, so does your health. That makes sense, because of the explanation above. You damage your spine, you’re going to damage the vital energy that flows through it, ultimately causing the organs to dysfunction, and progressively weaken and degenerate, causing disease. These measures of the spine also correlated with clinical measures of disability and health status, especially in those with scoliosis. According to Dr. Protopsaltis et. Al, spinal misalignments have been studied extensively in the literature with a majority of the literature focusing on thoracolumbar deformities and their effects on health related qualityof life. Positive sagittal alignment (being straight up and down from front to back), has been associated with pain and disability. Fewer studies have used these measures to analyze health, although this study confirms their theories and hypothesis. Amongst the factors looked at were how many millimeters the patients head was forward (think text-neck, and what happens when you slouch at a computer). They also looked at whether the patient was shifted to the left or right (think of all the people you know who have one shoulder that’s higher than the other, or rotated hips, or a hip that’s higher than the other). Those outward expressions of posture are directly reflections of the internal health of their spine. In those cases, you can’t have a higher shoulder unless the spine is translated and shifted to one side, or bent. That only comes as a result of weakness, damage or injury to the spine. This is exactly why people who have scoliosis have so many health problems. But it’s not just them. If you remember the discussion earlier, as much as 30% of people without symptoms have damaged spines on a global level, and even more so have symptoms and have damage to their spine.
Thinking back to the studies we already discussed, and ones discussing now, many studies have examined the direct link of severity of forward head posture (text neck) with severity of damage and likelihood for need for surgery. Those patients who’s head was more than 4cm over the midpoint of their spine (roughly at the level of their shoulders), had drastically different outcomes with surgery, and significantly worse health outcomes, pain and disability. Add to that risk factors like diabetes, smoking, sedentary lifestyle, poor nutrition, bone loss, and depression, and you’re not looking at a health outcome after surgery.
There is grave urgency in fixing the problems in your spine. For many of the reasons we’ve discussed already, the most important is that as your spine becomes weakened, damaged or injured, the likelihood of a severe injury after trauma increases. Just talk to personal injury attornies we diligently work with. When it comes to protecting you in court, even something that seems as minor as a fender bender, can cause substantial trauma to the point where surgerical intervention is necessary. Whether the surgery is performed or not (patient preference), the spine has already set the stage to degenerate more rapidly. This makes sense though, doesn’t it? If your spine is already damaged and injured, and it’s out of alignment, how is it supposed to hold up your body, let alone keep the spinal cord relaxed inside of your spinal column (your back). Think of it this way. If you have a house that was hit by a car and smashed out the entire right side of bricks and siding, and put a hole into your kitchen. Would you just leave it there unfixed? No of course not. That house is going to begin to collapse very soon. You’ve just lost it’s foundation, now the bricks that are above the hole having nothing to help keep them propped up and withstand the forces of gravity, let alone wind, snow, the weight of the roof, etc.
Is it starting to make sense here how important it is to keep your spine checked out, see where you’re currently at with your health. If you have health conditions currently, it’s very likely that you’re having spinal issues, especially if you’ve been involved in a crash, minor or major sports injuries, sit at a desk job, compromise your posture for work (dental hygienist, car mechanic, factory work, desk job worker). If that’s not enough, the cost per year that having a healthy spine can save you is as low as $8,000, up to $28,000 per year, according to extensive articles we’ve written from medicare work related compensation costs. If you know anything about medicare, they don’t pay well. Which means those numbers, if you spent your own money, would be much higher, to the tune of at least 200%..
If you have a spinal issue now, is it going to just ‘correct’ itself and get better? Absolutely not. There are no exericses that fix the structure of your spine. The only thing that can do that is advanced structural correction by a Doctor of Chiropractic using standard chiropractic adjustments, with advanced rehabilitation techniques and state of the art equipment traction devices. Its worth your health, and your family, to fix the problem now. The alternative is surgery, which as you’ve seen throughout this article, is extremely risky, typically provides minimal relief, and is compounded with serious side effects and complications. It also costs hundreds of thousands of dollars. And your insurance is not likely to cover the whole surgery. The other dramatic reason to fix your spine now is that those patients who’s spinal alignment was improved had significantly greater improvements in health related quality of life outcomes, and disability indexes (the measures performed to analyze the extent of disability in patients). Most of the studies discussed in this article either discussed these improvements in health related to the improvement in spinal alignment, or made mention to improved pain and or disabilities, even if they didn’t directly track health related quality of life statistics. Given the emergence of medical literature tracking HRQOL, and the studies to date, we can safely predict that had all of those studies tracked HRQOL, that we would have seen similar findings. On the contrary, patients demonstrated that those with baseline sagittal malalignment had detrimental outcomes in health measures, worse global deformities, and worsened HRQOL than those with healthier baseline spinal alignment. That may seem like common sense, but the research still needed to be done to prove or substantiate the results.
Neurosurgeons & Surgical Intervention
Surgeons use these parameters before performing surgery. It’s important for surgeons to have reliable, simple and reproducible parameters to analyze spinal alignment, both segmental and globally speaking, in order to predict outcomes, evolution and plan surgery for the specific pathologies (diseases or conditions) of the spine. Without getting into details so heady that you get lost, just know this. The specific angles (that can only be measured by advanced imaging techniques like x-ray) and must be analyzed on each and every vertebrae in your spine, are crucial to know. If your surgeon doesn’t know these numbers and how they correlate to your global spinal health, they can’t be effective with their surgeries. Some of these angles and measurements, in layman’s terms, are amount of forward head posture, the integrity of your neck curves compared to your midback and low back curves, how normal or abnormal your hip angles are, whether you’re exhibiting injured patterns of damage in your spine, or normal ones that compensated due to less severe injuries.
In other words, there are certain injury patterns that we can assess based on a digital posture exam that show us, whether you remember or not, that you were in fact involved in some type of major trauma. When we combine those with advanced imaging, we can see exactly which vertebrae, or segments of vertebrae, are causing those abnormal postures, exactly where the damage in your spine is, to what extent it is damaged, and if there’s any underlying complicating factors like osteoporosis, fractures, disc herniations or disease, or tumors.
The surgeons want to see these objective measures: i) physiological alignment of the cervical, thoracic, lumbar, lumbo/sacral, and lumbo/pelvic spine, ii) cervical, thoracic, and lumbar parameters in asymptomatic cohorts and teir relation to HRQOL scores, iii) parameters that define god outcomes in surgical candidates, as well as iv) relationships between pelvic and upper neck parameters.
Surgical intervention is typically a last resort. Patients often try physical therapy, thousands upon thousands of dollar in steroid injections (just to alleviate the pain, not to improve function), hundreds of dollars in pain medications, or worse opioid narcotics. They try stem cell therapies with out of pocket expenses ranging from $7,000 to $15,000 per injection. Meanwhile these injections last a mere few months, and repeat injections are typically necessary. When these alternatives fail, patients are already typically depressed. Several studies showing severe depression rates around
Spines do not decay with age. Spines decay with abnormal wear and tear on them, abnormal alignments due to acute or chronic injury patterns, traumatic injuries to the ligamentous and soft tissue structures that support the spine, abnormal kinematics of the spine, abnormal load and shearing stresses (biomechanical loading) on the spine in ways that were never intended for the spine to withstand. If spines decayed with age, then your entire spine would look the same age, which once you see your x-rays, you will see exactly where damage has occurred, if it has, and where the misalignments are. If spines decayed with age, then no one under elderly age groups would need surgery (not counting the exceptions for emergency medicine of course). TO substantiate this point, asymptomatic populations undergoing surgery, and published in the European Spine journal, showed many studies where this is the case. One in specific had hundreds of patients who needed to undergo spine surgery, due to the damage of the spine. The youngest was 19 years of age, with the oldest being 88 yrs. of age. As we’ve seen in clinical practice, as well as throughout the spinal medical literature, younger and younger patients are exhibiting signs of early degeneration, which has never before been observed. One of these major implications is the text neck due to increased screen time by children. Many adults call it the ‘iPad generation’. This has very serious and deleterious ramifications.
As a result of surgery patients can experience complications. And it’s not the exception, it is largely the rule. Several studies show complication rates of 80% and 94% (this study respectively showed 53% minor complications with 40 major complications; however it did not report if there was or was not overlap). These numbers are likely for two main reasons. One, previous literature substantiates these very high complication rates. Two, more spinal literature describes the health of patients as severe, for those seeking surgical intervention as a last resort. For these reasons alone, we can suspect that complication rates as high as 93% may be accurately interpreted. When the surgeries do go as performed, the ‘relief’ seen may be short lived. One study explored the results of surgery. Patients were able to achieve reduced leg pain and back pain in 60% of the short term follow up, while 40% saw reduced disability to varying degrees.
Many subjects undergoing surgery unfortunately do not change the health of their spinal alignment, nor do they change symptomatic expression. Many begin the return to baseline after approximately 16-24 months, or are already worse by 2 year follow up. As shown by the team Passias, P. et al in their 2015 study on postoperative cervical deformity in the journal Spine. Worse is that approximately 50% actually exhibited a new cervical deformity of the spine at 2 year follow up, while 63% of the total patients studied still had cervical deformities of the spine. Keep in mind as discussed earlier, that due to many factors, including reciprocal reflexive nature of the body to attenuate the compression of the spinal cord, a dysfunction in the cervical region inevitably leads to, or is caused by, an issue within the thoracic or lumbar region. Many of these issues are overlooked due to the examination procedures placed upon Doctors and their strict exam guidelines dictated by insurance companies.
While pain relief is great, and degrees of disability improvement is definitely the operant motive here, the overall health related quality of life has been shown in long term follow up (3-5 years) to decreases with surgical intervention. Furthering the problems, these surgical interventions cause unique problems in spinal damages and ligamentous issues leading to rapid degeneration of the spine, including conditions known as adjacent segment disease. Regional changes in spinal alignment after surgery affect the align of the cervical region in the early postoperative period, as reported by five surgical studies. This is by no means an exhaustive list, while the overall goal of this article was to go more in depth with the studies we did collect on health related quality of life and the spine.
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