TAKING CARE OF YOUR BACK: GARDENING
The same rules apply to gardening jobs as to household ones: lift and carry carefully, using your legs and body weight; work upright whenever practicable; do not do too much at once, and change tasks often; keep the work as close to yourself as possible; get help when necessary. Avoid working in the cold or cooler weather.
Avoid prolonged bending and stooping by kneeling down or using a long-handled implement to do the job whenever possible.
For pruning and fruit picking, long-handled implements which allow one to avoid reaching high up above, should be used with care. While they may not be heavy items in themselves, when they are lifted or lowered they put a stress on the back.
Try to keep the sweeps of action in a forward or backward direction, with the minimum of twisting. Avoid any sweeping action across the body: it needs a good deal of work from the muscles of the trunk, and unless they are in working trim, your back may be strained. The secret is foot position, so that every action is a use of balanced body weight. Where space is too cramped, you may do better by getting down on your hands and knees.
Kneeling is a very sensible posture for many jobs in the garden. For a gardener who can neither stoop nor kneel nor squat, raised borders for flowers or a greenhouse with shelves would be possible outlets.
Digging is a traditional back-breaker for those untrained to it. Do not attempt to dig too much at one time. Stand over the job and try not to overload the fork or spade.
The wheelbarrow puts considerable stress on the spine because it has to be lifted and at the same time pushed – all very well if the ground is hard and level, but a great effort when the ground is soft and steep or uneven. If you need to make use of a wheel-barrow, choose one which takes the load well forward over the wheel; then, when you load it, make sure to place the load over the wheel so that the lifting effort needed is small. Be sure to lift the barrow correctly: stand between the shafts, bending at the hips and knees to reach the handles, then straighten at the hips and knees, lean forward with your body weight – and move off. It is better to make two journeys with small loads than to struggle with one.
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WHAT AN OPERATION CAN DO: SPINAL FUSION
This operation is designed to stiffen a section of the spine, in order to prevent an instability such as spondylolisthesis from increasing; to fix a section where movement is painful, such as a degenerated disc giving an abnormal pattern of movement, secondary changes in the facet joints; to stabilise the spine in an area weakened during surgery necessary for the removal of diseased or damaged discs; or encourage healing if the spine is fractured or dislocated.
Most commonly, the operation consists of the laying down of a bone graft to increase the stability of the spine across one, two or three vertebrae. The bone for fusion is usually taken from the hip bone; this leaves no deformity or weakness. Often, metal rods or screws are also inserted to achieve a more rapid, secure fusion.
Spinal fusion is a much more serious operation than discectomy. Until a few years ago, it meant lying in a plaster shell for a month, and in bed for up to three months before being allowed up. Nowadays, however, this is less common. Some surgeons allow patients up after a week or two, provided there is nothing to contraindicate this; a corset may have to be worn. If the bones are fixed together with wires, rods or screws, the patient may be allowed up after seven to ten days, to still allow adequate healing of the ‘soft’ tissue surrounding the spinal column.
The back muscles may take quite a while to recover from the operation and to regain normal strength. The patient will later be given exercises by the physiotherapist to stabilise the spine and strengthen the muscles, and in a few months the patient could be back to full activity. Some patients take a year or more to recover completely. A lot depends on the pathology, the patients’s age and past history of the patient’s lifestyle: the physiotherapist and the occupational therapist will show the way but the patient is still the most important member of the ‘team’.
The social worker at the hospital may be necessary to provide home assistance for the convalescant patient.
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UNDERSTANDING BACK TROUBLE: FURTHER TESTS-MAGNETIC RESONANCE IMAGING (MR OR MRI), ELECTROMYOGRAPHY (EMG) AND BLOOD TESTS
This is available at some hospitals for use in diagnosis. It is very helpful in diagnosing disc prolapse because it shows fluid/solid interfaces very clearly. It can demonstrate epidural fat, root sleeves, nerve roots and the vertebral canal, neural foramina and facet joints. It is particularly useful in identifying problems in the brain and spinal cord and may, eventually, become the preferred method of investigation for disc problems. It does not use X-rays but a powerful magnetic field to observe and measure ‘spins’ of atomic nuclei. It cannot be used if you have any metal artificial joints, plates etc, so you would have to tell the doctor or radiographer about them.
Electromyography (EMG)-This is done in some hospitals if damage to the nerve root is suspected. The functioning of the nerves which supply muscles is tested by using an apparatus for amplifying and recording the electrical activity produced in the muscles. A fine needle electrode is inserted into the muscles of the legs – sometimes those of the back also; this is usually not very painful, not more than an ordinary injection, and leaves no side-effects.
Blood tests-A blood sample may be taken, by means of a hypodermic syringe, from a vein in the arm, and sent to the pathologist for tests, in order to obtain more general medical information, particularly about the possibility of inflammatory joint disease, anaemia, and infections.
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AGEING AND DEGENERATIVE CHANGE: OSTEOPHYTOSIS
This is not a degenerative condition in its own right but may be a secondary manifestation to a degenerative disease. Osteophytosis is part of the healing of a fracture. It is the formation of osteophytes, bony growths or spurs, on bone, or fibrous tissue attached to bone. They are deposits of calcium, the material of bone; in the spine they form all round the edges of the flat sides of the vertebral bodies, and on the facet joints.
Osteophytosis is in fact a feature of osteoarthrosis (also called osteoarthritis), a degenerative disease of the joints, causing a thickening of the bone. (It should not be confused with rheumatoid arthritis, which is a very different and more distressing complaint.)
Although on X-ray osteophytes can look formidably hooklike, they usually cause trouble only if they happen to grow out into the chinks through which the nerve roots pass, or into the spinal canal itself: if nerve tissue is compressed, this can be very painful. Such problems are most likely to arise in the lumbar region, where the cauda equina, with its bundle of nerves, emerges from the dural tube.
Osteophytes can cause back trouble in people who have by nature a very narrow spinal canal. Where the spinal canal is trefoil shaped (rather than roughly round) the growth of osteophytes further reduces the space through which the nerve roots pass, and the person is likely to suffer from back problems.
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THE SPINAL CANAL
This is the conduit through which the spinal cord passes. It is formed by the backs of the vertebral bodies and the vertebral arches, and protects the spinal cord. The cord is surrounded by cerebrospinal fluid, and encased in the dural tube which is made up of three tubular membranes, one inside the other. The dural tube descends all the way to the sacrum, though the spinal cord ends in the upper lumbar region.
The spinal cord is an extension of the brain, and is the trunk road of the nervous system, conveying information from the brain to all regions of the body and back again, by means of nerve roots which branch out from it.
At the level of each vertebra, the nerve roots emerge through chinks, known as intervertebral foramina, between adjacent pedicles, one on each side of each vertebra. Each nerve root is enclosed in a dural sleeve. From all these pairs of nerve roots a vast network of nerves branches out throughout the whole body.
Since the spinal cord stops short at the first lumbar vertebra, there is a sheaf of pairs of nerve roots passing downwards from the lower segments of the spinal cord to reach their respective foramina. This sheaf is called the cauda equina, the horse’s tail, because that is what it looks like.
The network of nerves which originate in the nerve roots has a pattern of distribution which is much the same for everyone, with only minor individual deviations. It is therefore possible to trace a pain sensation in any part of the body, caused by a compressed nerve root, back to its point of origin in the spine. For example, a pain in the big toe that is caused by a compressed nerve must originate in the last two lumbar vertebrae or the upper part of the sacrum – nowhere else in the spine.
The spinal cord is not easily injured, except through fracture or dislocation of the spine or when the cord is penetrated by sharp instruments, bullets or shrapnel. In normal circumstances, the spinal canal and its contents are protected from injury by bone and ligaments and muscle. Occasionally the blood supply to the spinal cord is damaged and nerve function can be affected.
The spinal canal changes its length with spinal movement. When you bend sideways, it becomes longer on one side than the other. On bending forwards and flexing the spine, the whole canal lengthens, more so behind than in front. The change in length in the cervical and lumbar regions may be as much as 25 per cent, and the contents of the spinal canal adapt accordingly. When the spine is bent back and arched, the intervertebral discs tend to bulge forwards and the ligaments at the back of the spinal canal slacken.
In the course of vertebral movements, the gaps between each pair of vertebrae (the intervertebral foramina) open and close, as the neighbouring vertebral arches move closer together or separate, and the nerve roots move inside the foramina.
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