Lecture in spinal column.

 

1. Herniated intervertebral disc (Nucleus pulposus)

 

2. Spinal stenosis

 

3. Degenerative spondylitis

 

4. Strain & sprain

 

5. Spondylolysis and spondylolisthesis

Principle of traction therapy

 

1. Neck traction therapy

 

2. Back traction therapy

--- Summary --- (principle of functions and therapy)

 


    As we live our lives throughout the life, humans may have to live struggling with countless diseases. Among them, one of the common problems is the spinal disease.

    It seems that there are rare who is free from lower back pain, neck or shoulder pain. Most people experience symptoms such as tingling sensation, numbness or deep pulling sensation on the extremities.

   What do we think of the causes when we feel such symptoms on the arms, hands, legs and feet? Many would reach a quick wrong conclusion that these symptoms come from insufficient blood circulation. Hence, it is easy to try to find inadequate treatments. Time and money are wasted, not to mention the loss of confidence to treat their disease.

   Such symptoms mostly come from compression of nerve in the neck or lower back. As the spinal cord originates from brain, and descends till lumbar spine, it branches a pair of nerve roots from each intervertebral foramen. Nerve is responsible for sensory, motor and endocrine function on their dominating area. The underlying causes are in the neck or lower back, however, symptoms appear unexpectedly in the other areas such as the shoulders, arms, hands, hips, legs or feet, unilaterally or bilaterally. We definite it radiating, radicular pain.
 
   
Then, what could compress nerve? These are mainly three categories. The first, protruded intervertebral disc can compress and irritate nerve root. It is the slipped, herniated intervertebral disc.

The second one is the narrowed intervertebral foramen through which nerve root come out, due to the enlarged posterior articular facet joint (hypertrophy or edema) and, or decreased intervertebral space. It is spinal stenosis. The hypertrophied or edematous joint could compress nerve on erect.

The third, the muscle spasm of cervical or pelvic could compress the nerve passing through them, and it takes up much of the tension headache and migraine we commonly know of.

    Other than that, the neighboring ligaments that are enlarged or calcified, or less frequently tumor can compress the nerve and cord. As said, the diagnosis is different and treatment is a bit changed.

If it is due to a herniated disc, you have to reduce the protruded disc back into its proper place or get surgery, excision, if indicated. It will be completely treated if prevented from protruding again by keeping desirable posture.

    In spinal stenosis, you may widen intervertebral spaces and intervertebral foramina by traction and reducing the lordosis with continuous abdominal muscle exercise, and reducing intervertebral disc, coexist by traction treatment. If intervertebral foramen is too narrow, they should request surgical intervention.

   You can use a heat therapy such as hot pack, infrared, ultrasound or diathermy, or massage to relieve muscle spasm in the neck or shoulder. The most fast and effective method to relieve muscle spasm and strain is the traction therapy to stretch and relax muscles. You can prevent recurrence by keeping correct posture - pulling the jaw and head backward so that the cervical muscles are not overloaded again.

 

  In order to have a proper understanding, we will look into an outline of the anatomy.

Spinal column comprises the 7 cervical vertebrae (nerves are C1~8) from the top), 12 thoracic vertebrae (T1~12), 5 lumbar vertebrae (L1~5), sacrum (S1~3) and the coccyx. Each shape or size is similar but different, yet the structure can largely be elucidated as follows:

 

 

 

 

 

    It comprises a vertebral body, which is the main body of the vertebra; a spinal canal which a spinal cord passes through behind the body; 2 intervertebral foramina which nerve roots branch out; spinous processes; 2 pedicles that connects between vertebral body and lamina; the lamina like as roof; pair of superior and inferior articular processes, which prevent spine not to slip forward from their alignment. Superior and inferior articular processes make an articulation to posterior articular facet joint. Intervertebral discs exist between upper and lower vertebral bodies.



    Since the vertebrae are wrapped with many the durable bands, ligaments, that connect bone to bone. The vertebrae are arranged in a line collectively, forming a straight line from the front view, and an S-shaped curve from the lateral view.
 
    The anterior longitudinal ligament wrap around the whole anterior surface of vertebral column, while the posterior longitudinal ligament is attached to the posterior part of the vertebral body in the spinal canal. Intervertebral discs are well protected by the anterior and posterior longitudinal ligament. However, there is no ligament in the vertebral foramen below pedicle in the. Hence, intervertebral disc is easily come out from this weak lesion, inducing frequent intervertebral herniation that compresses the nerve root.

Spinal cord passes through the spinal canal. The ligamentum flavum attached vertically along the lamina in side. Sometimes, ligaments may become thickened or calcified with degeneration process.

The transverse and spinous process themselves are connected by ligaments and the supraspinatus ligament cover the spinous processes. Lifting heavy material abruptly with their lower back flexed forward could result in the herniated disc and/or ligaments injury.

As the disc protruded, the posterior longitudinal ligament could be bulged posteriorly, too.  Traction therapy plays an important role in reducing the herniated disc into its proper place by two mechanisms. The ligament is stretched with traction and pushes the disc inside. The negative pressure, applied by traction could suck bulging or protruded disc inside.

   The disc is shaped oval from superior view. Its external part is consisted of durable capsule, annulus fibrosus, in which gelatinous material, nucleus pulposus, is contained. It acts as shock absorber against load and permits spinal mobility.

    The vertebral disc itself does not innervated and we cannot feel pain here. (In the recent, there is a strange research that nerve was discovered in disc.) Nevertheless, when the adjacent soft tissue was irritated, it leads to neck or lower back pain. Therefore, not all herniated disc patients have neck or lower back pain.  top


Now that we have studied an outline of the vertebral anatomy, we will go into each disease now.
 

 1. Herniated intervertebral disc (Herniated nucleus pulposus, HNP):

It is the slipped disc, commonly say. Although there are differences somewhat, it can happen to occur to anyone. As you already know, it is all too common.

Sitting for a long time with their head drooped and lower back bent forward for a long time, lifting material abruptly, whiplash injury, twisting injury, etc may cause disc herniated (bulged, protruded or extruded) posteriorly or posterolaterally.
The 2 conditions of the forward bending and load on disc are essential to cause disc to be protruded. This means the life style with correct posture is important for prophylaxis.
    Then, it irritates and compresses the nerve and they feel tingling sensation, numbness, and deep pulling sensation on the dominating dermatome. Such pain is different from the feelings that we get when we have headache, stomachache, inflammation, or injuries itself.

   
Lifting luggage with their posture bended forward could cause slipped disc, but lifting more heavy one with normal lordotic posture could not. Herniated disc come mostly from incorrect posture. The posture is also important after the treatment as well. Regardless of whether the disc has been reduced with traction therapy or excised by surgery, incorrect posture could result in recurrence.

Abnormal kyphotic curve with disc protrusion and severe nerve compression.

Linear curve with disc bulging and nerve root could be irritated.

Normal lordotic curve without disc problem, no nerve root compressed.


   
People are usually sitting with their head drop and bending body forward. Normally, when one is standing or walking, the head and back naturally straightened. Therefore, disc patient is at his worst condition while sitting. The symptoms may be decreased on erect, and the most comfortable when lying down. It is exactly vice verse in the spinal stenosis. This area will be explained later.

Herniated disc will not go back to its proper place even if one takes drugs, acupuncture, attaching any agents, etc. There are many people who are willing to such futile treatments without understanding the true principle of treatment. Fortunately, there are many patients who visit hospitals and get professional care as inpatients. Likewise, for the reason of not understanding the instructions of the posture principle, some may show symptomatic improvement at the time of treatment, but the pain may return in these patients shortly after therapy. There are diseases that can be healed just by doctors treatments without knowing the therapeutic principles. On the contrary, vertebral ailments may not be healed completely without knowing the therapeutic principle by patients themselves.

There are two-treatment modes, conservative approaches and surgical method in herniated intervertebral disc. In more than 90% of the disc patients, surgical methods are not required and it is possible to recover with conservative approach such as bed rest and physical therapy. The old and hardened herniated discs, into which the nucleus purposes flowed from rupture of annulus fibrosus, are not cured by the conventional method. Also, one should have operation only for surgical indications such as the emergency situation where severe extruded disc compressing the spinal cord, and no response on conservative treatment.

There is no reason to have the apprehension of premature notion of having a surgery whenever one is diagnosed as having a herniated disc. Patients must rest lying down in bed for a few days during the acute phase of the herniated disc at the onset. Time is necessary for the edema and inflammation around the nerve to subside. If you endure the pain and carry on working during this period, your condition will be worsened. Drugs such as muscle relaxants, analgesics, and anti-inflammation are administered and cold pack is applied on the first day. Heat therapy such as a hot pack and continuous traction therapy might be applied from the next day.

    
Since intermittent traction therapy can give more stimuli, continuous traction treatment, in which it pulls the traction steady and continuously, is applied in acute stage. After that, the traction treatment alone can reduce the herniated disc back into their proper place in subacute or chronic herniated intervertebral discs.

When the disc is somewhat rigid, heat therapy should be preceded to relax muscles and soften the discs more. Traction treatment after such preparations can reduce the herniated disc faster and more effectively.

The MRI film obtained again during or after Airtrac treatment could differentiate whether the patient have to be operated or recovered with conservative treatment additionally the diagnosis of herniated disc.

However, there are patients whose protruded disc does not retract back with Airtrac. In this case, we have to check the method of Airtrac apply is correct. I f correct, then hot pack is applied for twenty minutes on the neck or lower back for muscle relaxation and softening the disc. And then, Airtrac is put on again and applied with more strong traction force for ten to thirty minutes. One does not require applying a hot pack or strong traction therapy every time and regular traction force is used to treat the discs after that. No symptomatic improvement or change on MRI film after Airtrac treatment as mentioned for several days or week, means surgical indication. With the comparative interpretation of the MR images before and after the traction therapy can provide more objective decision on whether surgery is indicated or not.

The disc reduced is still unstable and may protrude again on bending head or back forward. However, the disc will not be protruded and there will not be any symptoms as long as the normal lordotic posture is maintained. It is not easy to keep maintaining the desirable posture all day long. Thus, Airtrac must be put on and reduce the disc instantly as soon as the disc herniated again. One should maintain proper posture by pulling the chin and head backward, raise the head slightly upward and straighten the back with mildly strengthen abdominal muscle.

Reduction of the protruded disc is the job Airtrac does. To prevent the disc from being herniated again, they should keep the proper posture themselves. For those people who cannot maintain the proper posture well, they have to strengthen their back muscle everyday. Or Airtrac 5000 for mild traction and maintenance of support, which is developed for a long time use, has been introduced.

Thoracic vertebrae are curved backward (kyphotic). It is the condition with an angle, in which intervertebral disc can easily be protruded. However, thoracic disc herniation is rare. The reason is that the burden from upper body weight is dispersed to the rib cage, which support load instead. Since the 1st to 10th rib are united with cartilage and the 11th and 12th rib bones are floating, disc herniation can be observed occasionally below 10th thoracic spine. This discussion of thoracic discs is given for explaining the importance of muscle exercise. Strong muscle of abdomen and back can play a role like the ribcage.

   Lumbar Airtrac is designed to hanging for stretching force between ribcage (T10) and Pelvis; that could widen the intervertebral spaces from the 10th thoracic to sacrum. There is no rib in the neck or back. Thus, cervical and lumbar vertebrae get the whloe load of upper body. It is huge pressure. We have to do the neck exercises and train the back and abdominal muscles in order to disperse the loads. Furthermore, muscles must be developed to maintain the proper posture. That is the reason why there are more herniated disc cases with the moderns who lack exercises. Muscle exercise is necessary to prevent and cure herniated disc.
 

    

    

    

    

    

    

    Maintain each position of exercise, while breathing naturally, for ten seconds a time and 10 to 20 times repeatedly. Such an exercises are performed 2 to 4 times a day. The amount of exercise could be gradually increased.

 

         

         

            


    
To review the treatments for the herniated intervertebral disc as above.
    It can be summarized as
       
1. Airtrac traction treatment
       
2. Maintain the proper posture
       
3. Exercise of cervical and abdominal muscles.

   If we keep these 3 promises in the indication of conservative treatment, herniated disc can be cured permanentlytop

 2. Spinal stenosis:

   
Commonly occurs after the age of 50. Each joint of our body thickens, as one gets older. The articular facet joints of spine also could be hypertrophied like finger node bigger with age. Then, intervertebral foramen becomes narrowed gradually. As the disc space is narrowed with degenerative change, intervertebral foramen becomes further narrowed.

   Thus, nerve roots could be pinched and incarcerated between bone and joints. They feel pain on standing or walking because the curve is lordosis and intervertebral foramen is narrowed on erect. Nerve does not be pressed when one bends their back forward because intervertebral foramen is somewhat widened. Resting while sitting or bending hip forward slightly (kyphotic) for a while makes symptom disappear. This is the very spinal stenosis.

   On the other hand, the herniated disc patients show the symptoms most severely during sitting position. This symptom is pathgnomonic characteristics and the differential diagnosis can be made easily

Such spinal stenosis can be treated by widening the intervertebral foramen with traction therapy that increases the disc space, and by decreasing lordosis with abdominal muscle exercise for fifteen days to three months.
In severe case that it is not responding to such a treatment and can walk less then 50 meters with pain, surgical intervention is needed.
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 3. Degenerative spondylitis, Spondylosis:
    
As one gets old, problems may occur in every joint, like the arthritis of the knee, ankle and wrist joint. It is easier to understand if we think that arthritis occurs in the spine as well. If the legs with arthritis are loaded with the body weight by standing on the floor, pain will be worsened. Similarly, if one gets up and sits, stand or walk, he/she may feel lower back pain soon. Hence, elderly people tend to lie down since there is less pain on lying down. If a person is lying down continuously, muscles in the arms, legs and trunk are weakened and atrophy occurs, making it even weaker. Then, the condition will be worsened and vicious circle ensues.

In such case, one put on Airtrac 5000 to relieve the load of upper body weight (lifting) and the pain will be disappeared immediately. It allows one to carry on the normal daily lives.

If ones waist is oversize, he/she must use Airtrac 440 or 2000 instead. If the pain disappears, one can move around without lying down all the time. Hence, muscle weakness can be prevented, and concurrent exercise of the abdominal and back muscle can change the vicious circle and improvement will follow. Regardless of age, our body has a natural capacity to heal itself. Early administration of anti-arthritic drug at the onset will also be helpful, too.   top

4. Strain, Sprain:

   
It refers to cases of and lumps (muscles), twisted (ligaments). Like the disc, when one bends ones head, bend ones back too long, or lift an object abruptly by bending ones back, or when one get a whiplash injury, the ligament or muscle can be damaged. And the herniated disc can occur, too.

If a ligament is injured, the exact center of the back, where there is a groove, is painful especially on forward bending, like one would wash his/her face. It is easy to make the diagnosis on physical examination. For ligament sprain, the lesion should be well supported and avoid the posture of kyphosis listed above. It takes several weeks to stabilize and recover. Lately, there is injection introduced that shorten the healing process of ligament.

Office work such as desk job, long driving, automobile accident, cause for insomnia, etc. can injure neck muscles. Having a stiff neck or shoulder, etc., or pressing dull pain can harden it. The mechanism of action is that if one pushes the chin forward while bending the head forward, cervical vertebrae do not stand straight upward and lean forward. The head weighing as much as 10 lb. (5kg) tends to fall forward. The back of neck muscles and shoulders and back muscles will naturally be overloaded for a long time to support not to fall forward.

The muscle strain is effectively relieved by stretch and support (traction treatment) than hot pack or massage. It is similar to relieve calf cramp by pulling foot dorsally.

The nerves (C1~3) originates from cervical to head and orbits upward penetrating cervical muscle and fascia. In cervical muscle strain, the nerves (C1~3) could be wrung, and they complaint headache, ophthalmic pain or visual problem. It can be relieved with stretching (traction treatment), immediately.

After the treatment with Airtrac 1000 or 3000, the cervical vertebrae must keep in straight like the posture of "Attention!" in the Army, and let the head sit calmly on top of it. It can be cured completely without overload the muscles again.

Like in the herniated disc, complete cure is difficult, because keeping good posture is neglected commonly. Without understanding the treatment principle, getting simple treatment alone will be effective merely for a time being. Patients without the knowledge of treatment are saying frequently that even hospital treatments are only effective temporarily.      top

 5. Spondylolysis, Spondylolisthesis:
    
Some may have heard that bone has a crack (Spondylolysis) or bone is out of proper alignment (Spondylolisthesis). If there are congenital or acquired defects bilaterally in the lamina, the function of keeping vertebra from slipping may be lost. And the spine could be pushed forward due to lumbar lordosis. In severe cases, a surgery, fusion, is recommended.

For the patients in the 1st and 2nd grade Spondylolisthesis, conservative treatment is applied. Muscle exercise, especially abdominal, can help them less to slipped forward. And it can be treated in the degree of not interfering the daily lives.

Airtrac 5000 and Airtrac 440 are helpful in this case. If these apparatus is put on, these symptoms will disappear. Again, at this time, one must remember the importance of long-term exercise. The frequent diseases have been covered now, There are other miscellaneous disorders, but we will omit them here.     top

    

    

    

    

    

    

 


Traction is the treatment for the underlying cause od herniated disc, with which the affected lesion can be stretched. Real ambulatory traction means lifting upper bodyweight instead of spine.

Stretch neck or lumbar (traction treatment)

Intervertebral spaces are widened and the foramina, through which nerve roots pass, are widened, too.

1. Protruded disc can be reduced by suction of negative pressure on disc. 2. Also, the protruded discs are reduced with pushing effect by straightening of bent posterior longitudinal ligament.

By stretching the lumpy muscle (strain), the stress is relieved and muscles are relaxed soon.

Traction treatment removes symptom immediately through causal treatment.

Particularly, lumbar traction treatment is not so easy because it is difficult to be hung on bone. But meaningful skeletal traction is possible between ribcage and pelvis on flank. Airtrac is designated on the focus of skeletal anatomy.

Reducing the traction force to the extent of head weight or upper body weight can make complete support. Airtrac support body regardless daily activity.   top

 

The principle of traction therapy

1. Neck traction therapy

Traction force
    When a patient is treated with traction apparatus in sitting or standing position, about 10 lb (5 kg) weight is necessary for counterbalancing the lifting of the head. If the traction treatment is applied with 30 lb (15kg) weight on the direction of head bending at about 25° ~ 30°angle, the vertebral gap begins to widen. And with 50 lb (25kg) weight, no more widening of the gap happens. Thus, for the neck traction force, 20 ~ 50 lb (10Kg~25Kg) weight is used for standing or sitting normally for the treatment. On lying down position, 10 ~ 40 lb (5kg ~20kg) weight is used for the traction force

Traction posture and Vector
    The direction of the cervical traction therapy should be one with the head declining at 25°~30° forward. However, for those patients with muscle sprains and convulsion without the stimulating symptoms of the nerve roots (radiating pain with numbness in the shoulder, arm and hand), the traction therapy is often performed at a less angle of decline or at a normal cervical vertebral posture (slightly lordotic). Nevertheless, one should never attempt the traction therapy while the head is flexed backward.

Treatment time
    On the traction force with 15kg weight, on the forward decline at 25°. Pull for 7 seconds and relax it for 5 seconds, repeat the procedure for 25 minutes, Then, the vertebral gap is widened maximally. Thus, normally, 20 minute traction therapy is appropriate.

Continual or intermittent traction
    It is mainly decided on the patients convenience, and intermittent traction is not recommended during an acute phase. Continual traction is performed.

Misc.
    When one receives a traction treatment, the patient must relax the neck at a comfortable setting. Prior heat treatment such as a hot pack right before the traction therapy can be helpful.
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2. Back traction therapy

Traction force
    
The posterior aspect of the vertebrae where there are nerve roots, it is maximum at the traction force of 25kg weight. When the traction force of 50kg weight is used, anterior and posterior aspects of the vertebral gaps are widened. Then a patient is treated while sitting or standing position, the traction force corresponding to 1/2 of the patients own body weight is used for lifting the upper body, and the traction force corresponding to 1/4 of the patients own body weight is used for the actual traction treatment.
    Normally, when one is being treated while standing or sitting with Airtrac ™ 2000 and 440, the patient is treated with the traction force equivalent to the 1/2 to 1 times the weight of the patient himself.

Traction posture and vector
    The traction therapy has been designed to operate at a slight forward decline of the back.
    Airtrac; 440 is more effective to get the treatment lying down. At that time, it is recommended to put wide sitting pad 5~10Cm or an object at the hip or feet, and Raise both knees. This is to adjust the direction of the traction force.

Treatment time
    Fifteen minutes will widen about 91% of the vertebral space.
    Normally, about 20 minutes of traction therapy is provided.

Others,
    When a patient receives the traction therapy, he or she must relax at comfortable setting. Prior heat treatment such as a hot pack right before the traction therapy can be helpful. If the traction treatment alone is not sufficient, prior heat therapy can be applied, relaxing lumbar muscles and soften the cartilage tissues of the discs. It permits smooth and effective application of the traction therapy. top
 

--- Summary --- (Function and treatment principle)

    Airtrac; is a portable personal traction treatment apparatus with which one can perform frame traction treatment. It will relieve much pain for the patients suffering from herniated intervertebral disc, muscle sprain, spinal stenosis, degenerative spondylitis, etc., and will be quite helpful in the treatment.
    Vertebral column comprises 7 cervical, 12 thoracic, 5 lumbar vertebrae, and the sacrum and coccyx. In each of the vertebrae intervertebral discs are positioned. They play a role in shock absorption of pressuring weight and allowing vertebral joint movements. The disorder, which is difficult to avoid for upright standing human beings, can be herniated intervertebral disc.
    For the reason of the structure above, a disc can be damaged or protruded posteriorly by long standing or sitting while bending the back or head, lifting a heavy object, and by sudden excessive turning of waist (back). In severe cases, discs Annulus Fibrosus can be destroyed and the nucleus pulposus can be flowed out of it. When it is hardened, surgical procedure is unavoidable. However, in most cases, intervertebral discs are swollen like full-belly, pressing and stimulating the nerve roots in the posterolateral region of the vertebrae. The neck and back are painful. There is numbness in the shoulder, arm, hand, hip, leg, feet, which are innervated by the nerve roots, and in severe cases, sensory abnormality and motor activity reduction, etc. are manifested.
    Consequently, the treatments of herniated intervertebral disc are for relieving the pressure on the disc through the traction therapy, and for reducing the disc back into its proper perspective. One must maintain the vertebral gap (space) at a certain level.  And a proper posture as mentioned above should be maintained for the discs that tend to protrude out again even after the traction therapy, so that they are extended anterior to the vertebral body where there are no nerve roots, making it sure that the nerve roots are not stimulated ever again.
    When the cartilage tissues and the discs become stabilized after several weeks, it will be cured completely without any disturbance to daily lives.
Furthermore, it is important that we maintain a proper posture for the vertebrae and disperse the loads vertebrae takes by making an everyday habit of exercising the back and abdominal muscles.
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