Radiation and its health Effects

The radiation side effects experienced by the normal body tissues during and after radiotherapy can be loosely divided into Acute and Late effects.

Acute radiation side effects constitute the acute reaction occurring during radiation and in the immediate weeks and months following treatment.

Acute Radiation Side Effects

Radiation treatment is painless and without sensation, with the exception of some mechanical sounds produced by the treatment machine associated with the start and finish of the treatment. Many patients receiving radiation therapy will experience very little reaction, but in most the normal tissues will develop some degree of radiation reaction. This varies in amount and type, depending on the part of the body treated and the amount of normal tissue included in the radiation treatment.

The degree to which individuals experience reaction varies considerably, but this section will deal with some general principles of radiation reaction. Where large areas of a patient are treated, such as the whole abdomen or chest, the reaction experienced will be mainly of a general nature. When small areas are treated the reaction will be confined to that area of the body that is radiated and to the individual tissues included in the treatment volume. Any general reaction will be much less or absent altogether.

General Side Effect Symptoms

Radiation Nausea. The degree to which patients experience nausea following treatment is very variable. Some people will experience hardly any at all, whereas others will be troubled by nausea or vomiting during the early part of the treatment and, in some instances, throughout the treatment. If it occurs, nausea is likely to be worst from two to several hours after treatment. The patient should be encouraged to maintain fluid intake.

The following dietary steps may prove helpful:

1.Salty foods or ice cold drinks help control nausea
2.Avoid greasy foods, strong-smelling or overly sweet foods
3.Small, frequent meals eaten slowly

If insufficient, anti-nausea medication may be prescribed. In most patients nausea improves as the treatment progresses.

Hair Loss. Hair loss will only occur within the radiation field. Scalp hair will only be affected if the head receives radiation.

Fatigue / Malaise. Some degree of tiredness and lack of energy is often experienced. This will not prevent most people from working or undertaking normal duties but, in some, reduction in activities during treatment and immediately afterwards will be advised.

Low Blood Count. Reduction in certain elements of the blood is often seen following radiation therapy. This results from radiation exposure of bone marrow, and to a lesser extent, direct damage to lymphocytes in the blood stream and lymph nodes.

The white cell count will be reduced, particularly the lymphocyte count, and the number of platelets will be reduced. These drops are seldom enough to cause clinical problems, but if they are, an interruption in treatment for a few days is usually sufficient to allow recovery. Reduction in red cells does not occur to any degree in radiation treatment, but may occur from blood loss due to bleeding.

Changes in the peripheral blood count are much more marked in patients who have also received chemotherapy.

Organ Specific Side Effect Symptoms

Localized reactions will occur in any tissues exposed to radiation treatment. The acute reactions expected for different treatments will be considered later, but in general acute reactions result from radiation of skin, mucous membranes and accessory glands.

Skin. Where the skin receives a significant dose of radiation a reaction will 

develop which progresses through erythema to dry desquamation and moist desquamation. The reaction may only progress part way through these steps and healing occurs through the same steps in reverse. If desquamation has occurred, crusts will form which protect the re-epithelialisation occurring underneath and will only come away and not reform when the skin is healed underneath.

The reaction develops two or three weeks after the initiation of treatment and may take four to six weeks to heal. It is best managed by:

1. Avoiding irritation from clothing, deodorants, perfumes, heat, dust and trauma
2. Best of all, leaving the area open to the air
3. Using non-stick dressings
4. Opinions vary about moisture. If the area is bathed, dry carefully, do not rub or inflame with soaps, and dust with corn starch
5. Steroid creams may help
6. Hair loss may be temporary or permanent, depending on the amount of radiation. Hair loss only occurs in skin exposed to radiation treatment
7. Avoid direct sunlight on the treated area
8. Have patience, the reaction will heal

Mucous Membranes. Wherever mucous membranes are included in a radiation field similar reactions will be experienced: Whether in the mouth, pharynx, esophagus, trachea, bowel, bladder or rectum, mucositis may develop.

As with the skin, the mucosa is reddened at first but then may be covered with a plaque-like fibrin similar to crusting of the skin. The mucous membrane remains moist and the surface covered by fibrin until the underlying mucosa is healed, when the fibrinous plaque is lost and the reaction healed.

The symptoms resulting from the inflammation, irritation and dysfunction caused by the mucosal reaction depend on the site of the reaction. There may be discomfort and dysphagia or cough, hoarseness and tracheitis, or dysuria and frequency, or diarrhoea and abdominal cramps. The management varies from site to site, but depends on the same principles as the care of skin reaction.

1. Avoid irritation by keeping food or stools soft and preventing trauma of any kind.
2. Local analgesic mixtures, antibiotics where indicated, and steroids may help.
3. Maintain hydration by encouragement and intravenous fluids if necessary.
4. Low fibre diet for those with bowel reaction.
5. Best of all, have patience, the reaction will heal.

Accessory Glands. The acute effects of radiation will be felt by accessory glands producing saliva and mucous for example. This leads to a degree of stickiness, leading to oral discomfort, dryness and change in taste, irritating cough and discomfort, and urinary or bowel symptoms, depending on the site of radiation.

Management consists of providing replacement lubricants such as frequent small drinks, adequate urinary and bowel fluid, cough suppressants, soothing creams or lotions and patience.

Late Radiation Side Effects

The late effects of radiation treatment develop gradually over several months or years. The changes that result may be sufficiently slight as to cause no clinical symptoms, or so rare as to present minimal risk to the individual. Nevertheless, the late changes that do occur warrant notice and care in all patients who have received radiation treatment. In those few individuals with serious late effects (generally less than 5% of patients who have received high-dose radiation) the results are often disastrous and treatment extremely difficult.

Scarring. Radiation treatment results in increased connective tissue, fibrosis and scarring often associated with atrophy of accessory tissues. This leads to some increased rigidity of tissues, less suppleness and less resistance to injury.

In addition, the walls of small blood vessels may be thickened and distorted, leading to reduction in blood supply to some tissues. This particularly leads to less ability to deal with injury or trauma such as that resulting from infection or surgery.

Any area of the body that has received radiation treatment should be treated "gently" for the rest of the patient's life.

Carcinogenicity. Radiation is one of the causes of cancer. Very rarely leukemia may result some five to twenty years after radiation exposure, due to bone marrow cells being damaged during radiation therapy. Similarly cancer can result in the area treated twenty or more years later.

The chances of either of these occurring are very small indeed.

The patient's risk of dying of the original disease, unless successfully treated, are much higher than the risk of developing cancer from the treatment.

Nevertheless, the risk is there and is one of the reasons why benign diseases are not treated by radiation unless absolutely necessary.

Genetic Effects. Exposure of the gonads to radiation increases the risk of abnormal mutations and genetic changes. Most chromosome damage from radiation results in a failure of conception and not an abnormal child. Even if both parents have been exposed to radiation, the risks of abnormal children being produced are so small as to be almost negligible. Late genetic effects in the individual are much less important than the increased risk of inducing cancer or the late vascular changes produced by radiation treatment.

IMMUNIZATION DURING CANCER TREATMENT (e.g. radiation)

1. When a child or adult has cancer and is receiving treatment which may be suppressing their immune system, such as whole body irradiation, "live" vaccines should not be given until six months after treatment is completed- "Killed" vaccines may be given although it is unclear as to their effectiveness in the immunosuppressed patient.
2. Immunosuppressed cancer patients should avoid changing diapers of infants or children for six weeks, who have recently been immunized with live (oral) polio vaccine. Immunosuppressed grand-parents are particularly at risk if they have never been immunized for polio. The risk is eliminated if the polio vaccine is given by injection (killed vaccine).
3. There is no risk from "flu" vaccines as they are not live vaccines.
4. Advice should be sought from the Infection Control Service or the Transplant Service of the Children's or Vancouver General Hospitals or family physician.
5. Travel Immunizations: The same rules apply as in 1-2 above. 

Adapted from: Healthcastle Nutrition Inc.

Acute Transverse Myelitis

Acute transverse myelitis is inflammation that affects the spinal cord across its entire width (transversely) and thus blocks transmission of nerve impulses traveling up or down the spinal cord.

In the United States, acute transverse myelitis is estimated to occur in about 1,400 people each year. Also, about 33,000 people are thought to have some type of disability due to the disorder. The entire width of one or more areas of the spinal cord, usually in the chest (thoracic area), becomes inflamed.

What triggers acute transverse myelitis is unknown, but it may result from an autoimmune reaction (when the immune system misinterprets the body's tissues as foreign and attacks them). The disorder may develop during the following:

• Multiple sclerosis (most commonly)
• Neuromyelitis optica, a disorder that can also cause visual problems and may come and go
• Certain bacterial infections (such as Lyme disease, syphilis, or tuberculosis)
• Inflammation of blood vessels (vasculitis), including lupus (systemic lupus erythematosus)
• Viral meningoencephalitis (an infection of the brain and its surrounding tissues)
• Use of certain antiparasitic or antifungal drugs
• Intravenous injection of heroin or amphetamines

It sometimes develops after mild viral infections or a vaccination.

Symptoms

Usually, symptoms begin suddenly with pain in the back and a bandlike tightness around the affected area of the body (such as the chest or abdomen). Within hours to a few days, tingling, numbness, and muscle weakness develop in the feet and move upward. Urinating becomes difficult, although some people feel an urgent need to urinate (urgency). Symptoms may worsen over several more days and may become severe, resulting in paralysis, loss of sensation, retention of urine, and loss of bladder and bowel control. The degree of disability depends on the location (level) of the inflammation in the spinal cord and the severity of the inflammation.

Diagnosis

Symptoms suggest the diagnosis. But doctors must distinguish acute transverse myelitis from other disorders that cause similar symptoms, such as Guillain-Barré syndrome, spinal cord compression, or blockage of the blood supply to the spinal cord. Magnetic resonance imaging (MRI) is done first. If MRI does not detect spinal cord compression, a spinal tap (lumbar puncture) is done to obtain a sample of spinal cord fluid. If acute transverse myelitis is present, the number of certain white blood cells and the protein level in the fluid is increased. If the disorder is advanced, MRI typically shows swelling of the spinal cord due to inflammation.

Tests, such as a chest x-ray and blood tests, are also done to look for causes. Doctors may also ask people about use of drugs.

Prognosis

Occasionally, the disorder recurs in people with multiple sclerosis or lupus. Multiple sclerosis eventually develops in about 10 to 20% of people who have transverse myelitis with no identified cause.

Generally, the more quickly the disorder progresses, the worse the outlook. Severe pain suggests worse inflammation. The outcome is split evenly:

• About one third of people recover.
• About one third continue to have some muscle weakness and urinary problems (urgency or loss of bladder control).
• About one third recover very little, remaining confined to a wheelchair or bed, continuing to have bladder and bowel problems, and requiring help with daily activities.

Treatment

If transverse myelitis is caused by another disorder, that disorder is treated.

If the cause cannot be identified, high doses of corticosteroids such as prednisone are often given to suppress the immune system, which may be involved in acute transverse myelitis. Plasma exchange—removal of a large amount of plasma (the liquid part of blood) plus plasma transfusions—may also be done. However, whether these treatments are useful is unclear.

Symptoms are treated.

Adapted from: Merck & Co. Inc.

Spinal tumor

A spinal tumor is a cancerous (malignant) or noncancerous (benign) growth that develops within or near your spinal cord or within the bones of your spine. Although back pain is the most common indication of a spinal tumor, most back pain is associated with stress, strain and aging — not with a tumor.

In most areas of your body, noncancerous tumors aren't particularly worrisome. That's not necessarily the case with your spinal cord, where a spinal tumor or a growth of any kind can impinge on your nerves, leading to pain, neurological problems and sometimes paralysis.

A spinal tumor, whether cancerous or not, can threaten life and cause permanent disability. Yet advances in spinal tumor treatment offer more options than ever before.

Symptoms

Depending on the location and type of tumor, various signs and symptoms can develop, especially as a tumor grows and impinges on your spinal cord or on the nerve roots, blood vessels or bones of your spine. Signs and symptoms may include:

• Back pain, often radiating to other parts of your body and worse at night
• Loss of sensation or muscle weakness, especially in your legs
• Difficulty walking, sometimes leading to falls
• Decreased sensitivity to pain, heat and cold
• Loss of bowel or bladder function
• Paralysis that may occur in varying degrees and in different parts of your body, depending on which nerves are compressed
• Scoliosis or other spinal deformity resulting from a large, but noncancerous tumor

Back pain, especially in the middle or lower back, is the most frequent symptom of both noncancerous and cancerous spinal tumors. The pain may be worse at night or on awakening. It also may spread beyond your spine to your hips, legs, feet or arms and may become more severe over time in spite of treatment.

Spinal tumors progress at different rates. In general, cancerous tumors grow more quickly, whereas noncancerous tumors may develop very slowly, sometimes existing for years or even decades before causing problems.

When to see a doctor
Most back pain is not the result of a spinal tumor. But because early diagnosis and treatment are important for many back problems, see your doctor about your back pain if:

• It's persistent
• It's not activity related
• It gets worse at night
• It isn't relieved by over-the-counter analgesics

Seek immediate medical attention if you experience:

• Progressive muscle weakness or numbness in your legs
• Changes in bowel or bladder function

Causes

Although scientists are learning more about the genetic and environmental factors involved in the development of many kinds of tumors, spinal tumors are still a relatively unknown quantity. Spinal tumor cells often contain a number of abnormal genes, but in many cases, researchers don't know what causes these genetic alterations. They do know that in some cases, spinal cord tumors run in families and are associated with familial cancer syndromes such as:

• Neurofibromatosis 2. In this hereditary disorder, noncancerous tumors develop on or near the nerves related to hearing, leading to progressive hearing loss in one or both ears. Some people with neurofibromatosis 2 also develop tumors in the arachnoid layer of the spinal cord or in the supporting glial cells.
• Von Hippel-Lindau disease. This rare, multisystem disorder is associated with noncancerous blood vessel tumors (hemangioblastomas) in the brain, retina and spinal cord and with other types of tumors in the kidneys or adrenal glands.

It's also known that spinal cord lymphomas — cancers that affect lymphocytes, a type of immune cell — are more common in people whose immune systems are compromised by medications or disease.

Overview of the spine
Your spine provides structural support for your body while at the same time allowing flexible movement. It comprises a complex network of bones, muscles, cartilage, ligaments, joints and nerves. Of these, the vertebrae and spinal cord are the most important for an understanding of spinal tumors:

• Vertebrae. Your spine is made up of 24 small bones (vertebrae), stacked on top of one another, that enclose and protect the spinal cord and its nerve roots. The sacrum, containing five fused vertebrae, sits below the lower back. The last three tiny vertebrae, also fused together, are called the tailbone (coccyx).
• Spinal cord. Your spinal cord is a double-layered, long column of nerve fibers that carries messages to and from your brain. The inner layer of your spine contains nerve cells, blood vessels and glial cells, which are cells that support the brain. The outer layer contains nerve fibers (axons) that relay sensory information and conduct motor impulses. Wrapped around the entire spinal cord are three protective membranes (meninges). The inner membrane is called the pia mater, the middle is called the arachnoid, and the tough, outer membrane, to which the spinal nerves attach, is called the dura mater.

Types of spinal tumors
Spinal tumors are classified according to their location in the spine.

• Extradural (vertebral) tumors. Most tumors that affect the vertebrae have spread (metastasized) to the spine from another site in the body — often the prostate, breast, lung or kidney. Although the original (primary) cancer is usually diagnosed before back problems develop, back pain may be the first symptom of disease in people with metastatic spinal tumors.
  Cancerous tumors that begin in the bones of the spine are far less common. Among these are osteosarcomas (osteogenic sarcomas), the most common type of bone cancer in children, and Ewing's sarcoma, a particularly aggressive tumor that affects young adults. Multiple myeloma is a cancerous disease of the bone marrow — the spongy inner part of the bone that makes blood cells — most commonly seen in older adults.
  Noncancerous tumors, such as osteoid osteomas, osteoblastomas and hemangiomas, also can develop in the bones of the spine where they may cause long-standing pain, spinal curvature (scoliosis) and neurological problems.
  
• Intradural-extramedullary tumors. These tumors develop in the spinal cord's arachnoid membrane (meningiomas), in the nerve roots that extend out from the spinal cord (schwannomas and neurofibromas) or at the spinal cord base (filum terminale ependymomas). Meningiomas occur most often in middle-aged women. Although almost always noncancerous, meningiomas can be difficult to remove and may sometimes recur. Nerve root tumors also are generally noncancerous, although neurofibromas can become cancerous over time. Ependymomas at the end of the spinal cord are often large, and their treatment may be complicated by the extensive system of nerves in that area.
• Intramedullary tumors. These tumors begin in the supporting cells within the spinal cord. Most are either astrocytomas, which mainly affect children and adolescents, or ependymomas — the most common type of spinal cord tumor in adults. Intramedullary tumors can be either noncancerous or cancerous and, depending on their location, may cause numbness, loss of feeling, or changes in bowel and bladder function. In rare cases, tumors from other parts of the body can metastasize to the spinal cord itself.

Complications

Both noncancerous and cancerous spinal tumors can compress spinal nerves, leading to a loss of movement or sensation below the level of the tumor and sometimes to changes in bowel and bladder function. Nerve damage is often permanent, and disabilities are likely to continue even after the tumor is removed. Depending on its location, a tumor that impinges on the spinal cord itself may be life-threatening.

Preparing for your appointment

If you have symptoms that are common to spinal tumors — such as persistent, unexplained back pain, weakness or numbness in your legs, or changes in your bowel or bladder function — call your doctor promptly. After your doctor sees you, he or she may refer to you a doctor who is specially trained to diagnose and treat cancer (oncologist) or brain and spinal cord conditions (neurologist).

Here's some information to help you get ready for your appointment, and what to expect from the doctor.

What you can do

• Write down any symptoms you've been experiencing, and for how long.
• List your key medical information, including other conditions with which you've been diagnosed and the names of any prescription and over-the-counter medications you're taking.
• Note any family history of brain or spinal tumors, especially in a first-degree relative, such as a parent or sibling.
• Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Questions to ask your doctor at your initial appointment include:

• What may be causing my symptoms or condition?
• Are there any other possible causes?
• What kinds of tests do I need?
• What do you recommend for next steps in determining my diagnosis and treatment?
• Should I see a specialist?

Questions to consider if your doctor refers you to an oncologist or neurologist include:

• Do I have a spinal tumor?
• What type of tumor do I have?
• Is the tumor noncancerous or cancerous?
• If the tumor is cancerous, how aggressive is it?
• What are the goals of treatment in my case?
• Am I a candidate for surgery? What are the risks?
• Am I a candidate for radiation? What are the risks?
• What treatment approach do you recommend?
• If the first treatment isn't successful, what will we try next?
• What is the outlook for my condition?
• Do I need a second opinion?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Thinking about your answers ahead of time will help you make the most of your appointment. A doctor who sees you for a possible spinal tumor may ask:

• What are your symptoms?
• When did you first notice these symptoms?
• Have your symptoms gotten worse over time?
• If you have pain, where does the pain seem to start?
• Does the pain spread to other parts of your body?
• Have you experienced any weakness or numbness in your legs?
• Have you had any difficulty walking?
• Have you had any problems with your bladder or bowel function?
• Have you been diagnosed with any other medical conditions?
• Are you currently taking any over-the-counter or prescription medications?
• Do you have any family history of noncancerous or cancerous spinal tumors?

Tests and diagnosis

Spinal tumors sometimes may be overlooked because they're rare and because their symptoms resemble those of more common conditions. For that reason, it's especially important that your doctor know your complete medical history and perform both physical and neurological exams. If your doctor suspects a spinal tumor, one or more of the following tests can help confirm the diagnosis and pinpoint the tumor's location:

• Spinal magnetic resonance imaging (MRI). Instead of radiation, MRI uses a powerful magnet and radio waves to produce cross-sectional images of your spine. MRI accurately shows the spinal cord and nerves and yields better pictures of bone tumors than computerized tomography (CT) scans do. A contrast agent that makes certain tissues and structures light up may be injected into a vein in your hand or forearm during the test. In addition, some medical centers use high-field-strength scanners to find small tumors that might otherwise be missed.
  You may feel claustrophobic inside the scanner or find the loud thumping sound it makes disturbing. But you're usually given earplugs to help with the noise, and some scanners are equipped with televisions or headphones. If you're very anxious, your doctor may prescribe a mild sedative.
  
• Computerized tomography (CT). This test uses a narrow beam of radiation to produce detailed, cross-sectional images of your spine. Sometimes it may be combined with an injected contrast dye to make abnormal changes in the spinal canal or spinal cord easier to see. Although not invasive, this test exposes you to more radiation than a regular X-ray does.
• Myelogram. In this test, a contrast dye is injected into your spinal column. The dye then circulates around your spinal cord and spinal nerves, which appear white on an X-ray or CT scan. Because the test poses more risks than does an MRI or conventional CT, a myelogram is usually not the first choice for diagnosis, but it may be used to help identify compressed nerves.
• Biopsy. The only way to determine whether a tumor is noncancerous or cancerous is to examine a small tissue sample (biopsy) under a microscope. If the tumor is cancerous, biopsy also helps determine the cancer's grade — information that helps determine treatment options. Grade 1 cancers are generally the least aggressive and grade 4 cancers, the most aggressive. How the sample is obtained depends on your overall health and the location of the tumor. Your doctor may use a fine needle to withdraw a small bit of tissue, or the sample may be obtained during an operation.

Treatments and drugs

Ideally, the goal in treating a spinal tumor is to eliminate the tumor completely, but this aim is complicated by the risk of permanent damage to the surrounding nerves. Doctors also must take into account your age, overall health, the type of tumor and whether it is primary or has spread to your spine.

Treatment options for most spinal tumors include:

• Monitoring. Sometimes spinal tumors are discovered before they cause symptoms — often when you're being evaluated for another condition. If small tumors are noncancerous and aren't growing or pressing on surrounding tissues, watching them carefully may be the only treatment that you need. This is especially true in older adults for whom surgery or radiation therapy may pose special risks. If you decide not to treat a spinal tumor, your doctor will recommend periodic scans to monitor the tumor's growth.
• Surgery. This is often the first step in treating tumors that can be removed with an acceptable risk of nerve damage.
  Newer techniques and instruments allow neurosurgeons to reach tumors that were once inaccessible. The high-powered microscopes used in microsurgery make it easier to distinguish tumors from healthy tissue. Doctors also can test different nerves during surgery with electrodes, thus minimizing nerve damage. In some instances, they may use sound waves to break up tumors and remove the remaining fragments.
  Even with advances in treatment, not all tumors can be removed completely. Surgical removal is the best option for many intramedullary and intradural-extramedullary tumors, yet large ependymomas at the end of the spine may be impossible to extricate from the many nerves in this area. Although noncancerous tumors in the vertebrae can usually be completely removed, metastatic tumors are less likely to be operable.
  When a tumor has spread to the spine, radiation alone is usually the treatment of choice. However, research has found that surgery combined with radiation may be more effective at preventing loss of nerve function in people who are healthy enough to tolerate an operation and who have tumors that have spread from an unknown location, have some evidence of nerve injury, have tumors resistant to radiation or have recurrent tumors that were previously irradiated.
  Recovery from spinal surgery may take weeks or months, depending on the procedure, and you may experience a temporary loss of sensation or other complications, including bleeding and damage to nerve tissue.
  
• Standard radiation therapy. This may be used following an operation to eliminate the remnants of tumors that can't be completely removed or to treat inoperable tumors. It's also often the first line therapy for metastatic tumors. Radiation may also be used to relieve pain or when surgery poses too great a risk.
  Medications can help some of the side effects of radiation, such as nausea and vomiting. And depending on the type of tumor, your doctor may be able to modify your therapy to help prevent damage to surrounding tissue and improve the treatment's effectiveness. Modifications may range from simply changing the dosage of radiation you receive to using sophisticated techniques that offer better protection to healthy tissue, such as 3-D conformal radiation therapy.
  
• Stereotactic radiosurgery (SRS). This newer method, capable of delivering a high dose of precisely targeted radiation, is being studied for the treatment of spinal tumors. In SRS, doctors use computers to focus radiation beams on tumors with pinpoint accuracy, and from multiple angles. This approach has been proved effective in the treatment of brain tumors. Research is under way to determine the best technique, radiation dose and schedule for SRS in the treatment of spinal tumors.
• Chemotherapy. A standard treatment for many types of cancer, chemotherapy hasn't proved beneficial for most spinal tumors. However, there may be exceptions. Your doctor can determine whether chemotherapy might be beneficial for you, either alone or in combination with radiation therapy.
• Other drugs. Because surgery and radiation therapy as well as tumors themselves can cause inflammation inside the spinal cord, doctors sometimes prescribe corticosteroids to reduce the swelling, either following surgery or during radiation treatments. Although corticosteroids reduce inflammation, they are usually used for short periods only to avoid such serious side effects as osteoporosis, high blood pressure, diabetes and an increased susceptibility to infection.

Adapted from: Mayo Foundation for Medical Education and Research

Cervical Spondylotic Myelopathy (Spinal Cord Compression)

One of the most common neck conditions that occurs with age is cervical spondylotic myelopathy (CSM). Over time, the normal wear-and-tear effects of aging can lead to a narrowing of the spinal canal. This compresses — or squeezes — the spinal cord. CSM can cause a variety of symptoms, including pain, numbness, and weakness.

Description

The vertebral column.

Spinal cord compression is a very common neck condition affecting older people in the United States. Symptoms usually begin after the age of 50, but can occur earlier if there was an injury to the spine at a younger age.

Many people with CSM will have steady progression of their disease. Once symptoms start, they tend to continue. Typically, the disease progresses slowly over several years. In about 5% to 20% of people, CSM worsens more rapidly.

Cause

Neck pain may result from abnormalities in the soft tissues—the muscles, ligaments, and nerves—as well as in bones and joints of the spine. The most common causes of neck pain are soft-tissue abnormalities due to injury or prolonged wear and tear. In rare instances, infection or tumors may cause neck pain. In some people, neck problems may be the source of pain in the upper back, shoulders, or arms.

Inflammatory Diseases

Rheumatoid arthritis can destroy joints in the neck and cause severe stiffness and pain. Rheumatoid arthritis typically occurs in the upper neck area.

Cervical Disk Degeneration

The disk acts as a shock absorber between the bones in the neck. In cervical disk degeneration (which typically occurs in people age 40 years and older), the normal gelatin-like center of the disk degenerates and the space between the vertebrae narrows. As the disk space narrows, added stress is applied to the joints of the spine causing further wear and degenerative disease.

The cervical disk may also protrude and put pressure on the spinal cord or nerve roots when the rim of the disk weakens. This is known as a herniated cervical disk.

(Left) Side view of a healthy cervical vertebra and disk. (Right) A disk that has degenerated and collapsed.

Injury

Because the neck is so flexible and because it supports the head, it is extremely vulnerable to injury. Motor vehicle or diving accidents, contact sports, and falls may result in neck injury.

The regular use of safety belts in motor vehicles can help to prevent or minimize neck injury. A "rear end" automobile collision may result in hyperextension, a backward motion of the neck beyond normal limits, or hyperflexion, a forward motion of the neck beyond normal limits.
The most common neck injuries involve the soft tissues: the muscles and ligaments. Severe neck injuries with a fracture or dislocation of the neck may damage the spinal cord and cause paralysis.

Other Causes

Less common causes of neck pain include tumors, infections, or congenital abnormalities of the vertebrae.

Symptoms

The spinal cord is the cable of nerves that send and receive signals from the body. When the spinal cord is slowly compressed, people may develop symptoms such as:

• Tingling and numbness
• Weakness: trouble lifting objects, dropping things
• Difficulty walking (loss of balance), wide-based gait
• Coordination problems/clumsiness: handwriting, buttoning clothes, and feeding oneself can become difficult
• Neck pain and stiffness

Doctor Examination

After discussing your symptoms and medical history, your doctor will examine your neck. He or she will look for:

• Abnormal reflexes: usually overactive (hyper-reflexia)
• Weakness: usually in the arms more than in the legs
• Numbness: mostly in the arms and hands
• Atrophy: muscles deteriorate and shrink

Tests

This MRI image shows bulging disks pressing on the spinal cord.

Other tests which may help your doctor confirm your diagnosis include:

X-rays

These studies are useful to look at the alignment of your neck.

Magnetic resonance imaging (MRI).

These studies can create better images of soft tissues. They can be used to look for compression of the spinal cord.

Myelogram

Your doctor may order this special type of computed tomography (CT) scan. CT scans allow better detailed cross-section images showing bone spurs and the size of the spinal canal. In a myelogram, color dye is injected before the scan to better outline the spinal cord.

Treatment

Nonsurgical Treatment

Some people get relief from symptoms without surgery. The most common nonsurgical treatment options include:

Soft Collars. Soft collars allow the muscles of the neck to rest and limit neck motion. This can help decrease pinching of nerve roots with movement. Soft collars should only be worn for short periods of time, because long-term wear can decrease the strength of neck muscles.
Exercise. Improving neck strength and flexibility with simple exercises may lessen discomfort.
Nonsteroidal anti-inflammatory medications (NSAIDs). Drugs like aspirin and ibuprofen can reduce swelling and painful symptoms.
Epidural steroid injections. Cortisone is a powerful anti-inflammatory. Cortisone injections in the "epidural space" can decrease swelling as well as pain, although they are not often used in CSM.
Chiropractic manipulation. Manipulation is never used if a patient has spinal cord compression.

Surgical Treatment

Whether to have surgery or not is a complex decision made between you and your doctor.

Adapted from: American Academy of Orthopaedic Surgeons

Scoliosis- Facts, Treatment, Coping/Support Options

Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. While scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown. 

Most cases of scoliosis are mild, but severe scoliosis can be disabling. An especially severe spinal curve can reduce the amount of space within the chest, making it difficult for the lungs to function properly.

Children who have mild scoliosis are monitored closely, usually with X-rays, to see if the curve is getting worse. In many cases, no treatment is necessary. Some children will need to wear a brace to stop the curve from worsening. Others may need surgery to straighten severe cases of scoliosis.

Symptoms

Signs and symptoms of scoliosis may include:

• Uneven shoulders
• One shoulder blade that appears more prominent than the other
• Uneven waist
• One hip higher than the other

If a scoliosis curve gets worse, the spine will also rotate or twist, in addition to curving side to side. This causes the ribs on one side of the body to stick out farther than on the other side. Severe scoliosis can cause back pain and difficulty breathing.

When to seek medical advice
Go to your doctor if you notice signs or symptoms of scoliosis in your child. Mild curves can develop without the parent or child knowing it because they appear gradually and usually don't cause pain.

Causes

Doctors don't know what causes the most common type of scoliosis — although it appears to involve hereditary factors because the disorder tends to run in families. Experimental testing is being done to determine if blood tests can determine the risk that scoliosis will get worse in a given individual. This type of testing is likely to be more common in the future.

Less common types of scoliosis may be caused by:

• Neuromuscular conditions, such as cerebral palsy or muscular dystrophy
• Birth defects affecting the development of the spine
• Wear-and-tear arthritis in the spine
• Having one leg longer than the other

Risk factors

Risk factors for developing the most common type of scoliosis include:

• Age. Signs and symptoms typically begin during the growth spurt that occurs just prior to puberty.
• Sex. Although both boys and girls develop mild scoliosis at about the same rate, girls have a much higher risk of the curve worsening and requiring treatment.
• Family history. Scoliosis tends to run in families.

Complications

While most people with scoliosis have a mild form of the disorder, scoliosis may sometimes cause complications, including:

• Lung and heart damage. In severe scoliosis, the rib cage may press against the lungs and heart, making it more difficult to breathe and harder for the heart to pump. In very severe scoliosis, damage to the lungs and the heart can occur. Anytime breathing is compromised, the risk of lung infections and pneumonia increases.
• Back problems. Adults who had scoliosis as children are more likely to have chronic back pain than are people in the general population. Also, people with untreated scoliosis may develop arthritis of the spine.

Preparing for your appointment

Your child's doctor may check for scoliosis at routine well-child visits. Many schools also have screening programs for scoliosis. Physical examinations prior to sports participation often detect scoliosis. If your child has a positive screen for scoliosis at school, see your doctor to confirm the condition.

What you can do
Before the appointment, write a list that includes:

• Detailed descriptions of your child's signs and symptoms, if any are present
• Information about medical problems your child has had in the past
• Information about the medical problems that tend to run in your family
• Questions you want to ask the doctor

What to expect from your doctor
The doctor will initially take a detailed medical history and may ask questions about recent growth. During the physical exam, your doctor may have your child stand and then bend forward from the waist, with arms hanging loosely, to see if one side of the rib cage is more prominent than the other.

Your doctor may also perform a neurological exam to check for:

• Muscle weakness
• Numbness
• Abnormal reflexes

Tests and diagnosis

Plain X-rays can confirm the diagnosis of scoliosis and reveal the severity of the spinal curvature. If a doctor suspects that an underlying condition — such as a tumor — is causing the scoliosis, he or she may recommend additional imaging tests, including:

• Magnetic resonance imaging (MRI). MRI uses radio waves and a strong magnetic field to produce very detailed images of bones and soft tissues.
• Computerized tomography (CT). CT scans combine X-rays taken from many different directions to produce more-detailed images than do plain X-rays.
• Bone scan. Bone scans involve the injection of a radioactive material, which travels to the parts of your bones that are injured or healing.

Treatments and drugs

Most children with scoliosis have mild curves and probably won't need treatment with a brace or surgery. Children who have mild scoliosis may need checkups every four to six months to see if there have been changes in the curvature of their spines.

While there are guidelines for mild, moderate and severe curves, the decision to begin treatment is always made on an individual basis. Factors to be considered include:

• Sex. Girls have a much higher risk of progression than do boys.
• Severity of curve. Larger curves are more likely to worsen with time.
• Curve pattern. Double curves, also known as S-shaped curves, tend to worsen more often than do C-shaped curves.
• Location of curve. Curves located in the center (thoracic) section of the spine worsen more often than do curves in the upper or lower sections of the spine.
• Bone maturity. If a child's bones have stopped growing, the risk of curve progression is low. That also means that braces have the most effect in children whose bones are still growing.

Braces
If your child's bones are still growing and he or she has moderate scoliosis, your doctor may recommend a brace. Wearing a brace won't cure scoliosis, or reverse the curve, but it usually prevents further progression of the curve.

Most braces are worn day and night. A brace's effectiveness increases with the number of hours a day it's worn. Children who wear braces can usually participate in most activities and have few restrictions. If necessary, kids can take off the brace to participate in sports or other physical activities.

Braces are discontinued after the bones stop growing. This typically occurs:

• About two years after girls begin to menstruate
• When boys need to shave daily

Braces are of two main types:

• Underarm or low-profile brace. This type of brace is made of modern plastic materials and is contoured to conform to the body. Also called a thoracolumbosacral orthosis (TLSO), this close-fitting brace is almost invisible under the clothes, as it fits under the arms and around the rib cage, lower back and hips. Underarm braces are not helpful for curves in the upper spine.
• Milwaukee brace. This full-torso brace has a neck ring with rests for the chin and for the back of the head. The brace has a flat bar in the front and two flat bars in the back. Because they are more cumbersome, Milwaukee braces usually are used only in situations where an underarm brace won't help.

Surgery
Severe scoliosis typically progresses with time, so your doctor might suggest scoliosis surgery — called spinal fusion — to reduce the severity of the spinal curve and to prevent it from getting worse.

Spinal fusion surgery connects two or more of the bones in your spine (vertebrae) together with new bone. Surgeons may use metal rods, hooks, screws or wires to hold that part of the spine straight and still while the bone heals. The process is similar to what occurs when a broken bone heals.

Complications may include bleeding, infection, pain, nerve damage or failure of the bone to heal. Rarely, another surgery is needed if the first one fails to correct the problem.

Lifestyle and home remedies

Although physical therapy exercises can't stop scoliosis, general exercise or participating in sports may have the benefit of improving overall health and well-being.

Alternative medicine

Studies indicate that the following treatments for scoliosis are ineffective:

• Chiropractic manipulation
• Electrical stimulation of muscles
• Biofeedback

Coping and support

Coping with scoliosis is difficult for a young person in an already complicated stage of life. Teens are bombarded with physical changes and emotional and social challenges. With the added diagnosis of scoliosis, anger, insecurity and fear may occur.

A strong supportive peer group can have a significant impact on a child's or teen's acceptance of scoliosis, bracing or surgical treatment. Encourage your child to talk to his or her friends and ask for their support.

Consider joining a support group for parents and kids with scoliosis. Support group members can provide advice, relay real-life experiences and help you connect with others facing similar challenges.

Adapted from: Mayo Foundation for Medical Education and Research