Shingles:Chicken Pox Re-Awakened

Chicken pox is a common and usually mild childhood disease caused by the varicella virus. The  same virus is also the cause of a very painful skin rash known as shingles in adults.  These two very different illnesses demonstrate the two missions of all viruses – to reproduce themselves and to stay alive.   Reproduction keeps the varicella virus spreading from child to child. Hibernation keeps it alive in adults, giving it another chance to reproduce. While chicken pox is usually a mild disease, shingles is painful and at times disabling.

Vaccinations

Since 1995, vaccination against the varicella virus has been very successful in reducing the number of childhood chicken pox cases.  In 2005, a vaccine designed to boost adult immunity cut the number of cases of shingles in adults in half and a vaccine about to be introduced now, in 2017, promises much better protection against shingles for older adults, especially for older adults.  Both chicken pox and shingles vaccines mark significant progress against the varicella virus, which infects 95% of unvaccinated people.

Who gets shingles

Shingles typically afflicts older people or in people with weakened immune systems. In them, the long-sleeping varicella virus has suddenly awakened, erupting in an intensely itchy, blistered rash known confined to one patch of skin, usually on the trunk, but sometimes on the head or extremities. Doctors call shingles herpes zoster, which sometimes causes confusion with the common cold sore, caused by the herpes simplex virus. Both herpes simplex and varicella viruses are members of a larger family of “alphaherpes” viruses, with similar abilities to live in peace inside the body and revive periodically.

Why name it shingles?

Shingles is a more descriptive name than herpes zoster. When fully developed and severe, the shingles rash has a rough, red, pebbled surface formed by multiple blisters packed in tight formation, often rectangular in shape. Like a roof shingle, the patch of virus- laden blisters can look like it has been laid on top of the skin. The distribution of this adult eruption of the varicella virus is very different from the random and widespread distribution of blisters in chicken pox.  The difference between rashes caused by exactly the same virus is a visual lesson in the way the varicella virus infects, reproduces, goes into hiding and reemerges.

The initial infection: chicken pox

The varicella virus enters the body through the nose or mouth. It is picked up by immune cells in the lymphatic fluid and then makes its way through the rest of the body in a trip that takes 7-10 days. Since the immune system doesn’t see the virus as much of a threat, there are often no symptoms of any illness in this period. But once the virus reaches the skin, real battle begins.  Troops of immune cells produce small red dots on the skin, then red bumps and finally blisters which rupture and release new viral particles to the air.  Mission number one, reproduction is accomplished.

The virus goes into hiding

Mission number two, staying alive, is more complicated.  While varicella viruses spread easily from ruptured blisters or via coughing and sneezing, once the viruses dry out, they die.  Dried, crusted rashes are no longer contagious. But underneath the skin, some viruses begin another journey. They travel up long thin nerve fibers that carry sensory information from the skin to the spinal cord. Their first stop is the nerve cell bodies that sit in little clumps of tissue called ganglia, just outside the spinal cord. Here, for reasons that are unknown, the viruses are allowed to integrate their genetic material into the nucleus of the cells, alongside the DNA and RNA responsible for normal protein production.

Re-awakening

For years, varicella viruses demand nothing of their host nerve cells. Then in later life, or sooner in people who have suppressed immune systems from diseases like AIDS  or treatment of diseases like cancer, the varicella virus may suddenly commandeer the protein-making machinery in the  ganglionic nerve cell. It makes multiple copies of itself, sending them back out to the skin along the same nerves by which they entered the ganglia.  The rash that appears affects only the part of the skin innervated by those nerves. The sensory nerves are arranged in “stripes” around the trunk and down the limbs, and the rash looks like a portion of that stripe.

Why the re-awakened virus causes so much pain

Pain is a central feature of shingles because the immune system attacks the virus for a second time. This time, the attack starts in the ganglia where the virus has emerged from hiding. When the immune battle against the virus begins, the nerve cells report the action to the brain, even before a skin rash appears. The unwitting patient begins to feel sharp and shooting pains, as well as numbness, tingling and itching sensations in the skin as long as two or three days before a rash appears. Occasionally fever, headache and back pain appear.  Sometimes pain remains even after the rash resolves, a distressing condition called post-herpetic neuralgia, which is often difficult to manage.

Other complications

Pain is not the only complication of shingles. Permanent damage may result from re-emergence of the virus in a sensory distribution that involves organs other than skin. Rashes that involve the eye can cause scarring the cornea, and those that involve the ear sometimes cause permanent deafness.  Shingles cannot be transmitted, but if someone who has never had chicken pox or been vaccinated against it comes in contact with blister fluid from the shingles rash, they will get chicken pox. Adult chicken pox is a far worse illness than the pediatric version.

Immunity

Immunity to the chicken pox virus diminishes with age, and shingles rarely appears before the late 50s.  About one in every three people who’ve had chicken pox will get shingles;  the risk of a second episode is also about one in three and higher if pain persists more than 30-60 days. Recurrences rarely happen more than twice, indicating that the reawakened virus stimulates renewed immunity.

Avoiding the often disabling pain of an acute shingles episode and diminishing the risk of post-herpetic neuralgia are both good reasons to consider adult immunization against the chicken pox virus. Not only does the adult vaccine cut the risk of getting shingles in half, it makes cases that do occur significantly less severe. The large study that yielded these results also turned up no vaccine safety issues.   When you next think about getting a flu shot, give some consideration to prevention of shingles too.

Consciousness Unplugged*

 

Turn on the bedside lamp. Arrange the pillows. Settle in with a book in progress and open to last night’s marked page. Recognize nothing. Memory for those parts read as sleep stole over you never formed.

Go back a page or two…ahh! Here is something familiar. Start there. All is smooth for a page or two. Then the pace slows. The distance between words and meaning lengthens and a struggle to understand begins.  Time slows and suddenly the still visible words no longer symbolize anything. This second, or fraction of a second, marks the border of an elusive state in which the self stands apart, still awake and aware, but disconnected from the machinery it normally uses. Catching the sensation, without slipping into the oblivion of sleep, is like being suspended in time and separated from all the meanings automatically assigned to what is seen, heard and felt in the real world – yet the world is still here.

Sleep steamrolls the elusive state almost instantly, but, while it lasts, it is a fascinating sense of “being,” poised between two worlds. One is the world of the bedroom, the light, the book, the sheets, and the surrounding walls. The other is a world detached from the meanings of all those familiar, objective things. I suspect, but do not know for sure, that this thin little membrane between wakefulness and sleep is the target area of people who are skilled in meditation and of  contemplatives who seek a spiritual connection between themselves and something outside nature.

Imagine being able to hang in the in-between place, without succumbing to the all-powerful tide of sleep, yet to be detached from the cold, hard world of the surrounding room and also aware that you are still you. Reports from skilled seekers of enlightenment, from faithful meditation practitioners and from some of the great religious traditions of wisdom suggest that exploration of consciousness unplugged from its routine state might be rewarding.  And for some reason, physical health benefits like lower blood pressure and more even moods come back from that place.

There is real appeal, too, in  personal experience that lends credence to the idea that there is more to each of us than $5.00 worth of raw materials – that some part of us rises above the chemistry.  My Stroke of Insight, Jill Bolte Taylor’s first person description of her expansive trip through her own brain while in the middle of a stroke, rocketed around the internet not because of its neuroanatomy and physiology, but because it added to the hope that the human creature is more than an animal. The hope that the nagging sense of otherness, the need to be good and to do good things, the ability to imagine, the drive to create art and music, and the love of symmetry and beauty reflect more than random biologic events culled out of DNA by the drive to survive.

When I was a child I tried to hold myself poised in another early phase of sleep – the one in which vivid imagery parades across the inner screen – in my case it was always from left to right. The images were always complex, detailed and colorful –unrelated by any story line, and not necessarily imagery form any of my real-life experiences. Elephants decked out in magnificent jeweled saddles and the like. The trick was to not pay them too much attention, or I would be back up in wakefulness, but also to pay them just enough that I would not fall into the sleep pit.

Adulthood put an end to the drifting mode of getting into sleep. Busy days and chronic sleep deprivation made cliffs out of the previously gentle slopes surrounding the sleep pit. No more lollygagging into unconsciousness.  But I suspect those childhood experiences were the beginning of my unshakeable sense that the watcher of these fascinating states of consciousness, as well of dreams, is the deepest part of the self – a part that can be unplugged from the $5.00 body.  The partial unplugging that precedes sleep is fun. The complete unplugging that comes at the end of life? I suppose it depends on what you believe. Is there something else? Is there nothing else? No way to know for sure. But I would not like to experience a persistent, conscious sense of self in a void. That might be hell.

*this was not written for an Elks Magazine Healthline column.

Osteoarthritis – Time’s Marker

The garden-variety arthritis that afflicts millions of people is the great humbler – the nagging messenger that tells the truth about age. Joints are the junctions between bones that allow movement of the skeleton. Over time joints suffer from wear, tear and imperfect repair and the result is “osteo(bone)arthr(joint)itis(inflammation).”

The structure of joints: cartilage, synovial membranes, tendons and ligaments

You have 206 bones and over 230 joints. The more movement required at a junction between bones, the more complex the joint.  In freely moveable joints the ends of the bones are covered with cartilage, a smooth, tough and pliable tissue that lacks a blood supply. In some joints there are also cushions of cartilage – menisci or discs – between the bones.   Cartilage is the weak link in joints – the part that thins out and breaks down with age. Bone stripped of cartilage slides poorly and painfully over other bone. Old, dried out discs and menisci fragment and hurt.  Inflammation and more pain accompany the body’s attempts to repair the damage.

The synovial membranes lining joints make a thick, lubricating fluid that seeps into crevasses in cartilage, where it forms reservoir pools that keep the thin film of fluid between the bones even during movement. This synovial fluid carries nutrients and waste products and depends on joint movement for its circulation.

The ligaments that connect bone to bone, and the tendons that attach the muscles to bone form the joint capsule. Tendons and ligaments are tough and gristly and have poor blood supplies. They heal slowly, repairing themselves with stiff scar tissue. Time marks its progress in these structures by making them less flexible and more prone to damage.

Joint symptoms

The pain of joint inflammation, the stiffness of ligaments and tendons, and the resulting limitation of joint movement are the cardinal symptoms of osteoarthritis.  Excessive bone formation, narrowing of joint spaces and irregularity of bony margins, seen mainly on X-rays are signs of the ailment.  In contrast to other more inflammatory joint problems, such as rheumatoid arthritis and gout, osteoarthritis produces no blood or joint fluid abnormalities.

Why are some people more affected than others by osteoarthritis?

If osteoarthritis is a result of age, then why are some people crippled at 60 and others still dancing at 90? As usual, genetic makeup counts. Some families pass arthritis down. Others pass along bowed legs and other skeletal builds that result in early joint deterioration. Osteoarthritis also creeps into joints injured long ago and into joints damaged by inflammation from infectious and immune system diseases. Obesity contributes to the load on weight-bearing joints, subjecting them to more damage.

Use joints or lose them: underactivity ages joints

While overuse at times predisposes joints to arthritis, under use is also a threat.  There is ample evidence in laboratory animals that joint immobility produces degeneration. Zookeepers have long known that elephants in captivity, deprived of their need to walk thirty miles a day in search of food, develop debilitating arthritis in their hips and feet. Joint cartilage gets nutrients from the surrounding tissues by diffusion through the joint fluids. Movement helps that diffusion, so optimal joint health depends in part on regular movement through a full range of motion.

Limited joint motion sets up a process of uneven wear that precedes arthritic change. In Eastern cultures, where squatting is frequent, thinning of cartilage in the hip joint occurs with age just as it does in the West, but hip degeneration is far less common. Squatting puts the ball-and-socket joint of the hip through the rotational movement for which it is designed, while walking and sitting in chairs requires flexion and extension in only one plane, wearing cartilage unevenly.

Treatment

Osteoarthritis develops over many years.  There is no cure. Medical treatment focuses on maintaining the mobility that pain and stiffness reduce. Reduced movement causes muscle weakness, tightens tendons and ligaments, and deprives cartilage of synovial fluid circulation. Intervening in this cycle requires relief of pain and maintenance of activity.

Anti-inflammatory agents such as aspirin and ibuprofen are helpful – but often osteoarthritis involves little real inflammation and the potential hazards of chronic use of these medications (kidney damage) have to be weighed against their pain-relieving benefits.  Ice, heat, massage and topical agents like Ben Gay are substitutes. Supplements such as glucosamine and chondroitin – the building blocks of cartilage – are thought by some to be helpful. While there is no proof of their efficacy, there is also no indication that they are harmful. External devices such as knee braces and back supports are useful for stability in exercise.

Exercise is treatment

Exercise is crucial for joints. Properly carried out, exercise strengthens muscles and maintains range of motion. Stiffness improves as a joint “warms up.”  With time, patience and the proper exercises, range of motion can be increased and symptoms greatly reduced.  Exercise promotes weight loss, which relieves the load on hips, knees, ankles and feet. Because it reduces gravitational forces, water is a wonderful medium for exercise for arthritic patients.

Alternative treatments and joint replacement

Acupuncture might help some people. Cortisone injections provide transient relief, but weaken tissues further. Because osteoarthritis is common and often debilitating, patients are easy targets for sales pitches guaranteeing relief. Therapies like magnets and copper bracelets and a host of pain relieving supplements beckon everywhere. At the end of the line for a joint, there is the prospect of replacement. Artificial joints restore mobility and improve life significantly for many arthritis sufferers – but they are to be approached with the care and caution. Joint replacement is a major surgical procedure in which the original joint is permanently removed.   The recovery process is arduous and the new joint surfaces are also subject to wear and tear.  Time marches on in titanium as well as in bone.

 

  Useful Websites

http://www.arthritis.org/default.asp – Arthritis Foundation homepage

http://www.rheumatology.org/public/factsheets/index.asp – American College of Rheumatology – patient education page

http://www.arthritis.com/ – Animated graphic representations of joints and arthritic processes.

Genetics in Medicine: A Game of Odds

Each of us begins life as a single cell. The chromosomes within, formed out of long chains of DNA called genes, carry all the information necessary for the formation of a human being. The entire complement of  DNA, including long segments that have no known function, must replicate itself billions of times over the course of development of the baby and the life of the individual who emerges from the womb.  If there were never any errors in the original DNA,  if there were never any errors in replication of DNA, and if genes did not turn on and off in response to environmental factors, aging would not occur and human misery would be confined to infectious diseases and trauma. Now that the human genome has been decoded, can we look forward to a disease free world and to extension of the seemingly fixed lifespan of 110-120 years? Not likely, but the focus on the genetic contribution to disease will change medicine, for better and for worse, in the years to come.

Visible genetics: the family history

Doctors have always taken a family history as part of the initial evaluation of a patient. Physical features, health and ailments that run in families are visible genetic information. Height and body shape, nose shape, bunions, baldness, premature white hair all “run in” families. So do a variety of illnesses. Family history tells the story of genes that have expressed themselves already. Laboratory analysis of an individual’s genes attempts to predict what may happen in the future.

Laboratory genetics

In a few rare illnesses such as cystic fibrosis, sickle cell disease, and some devastating neurological degenerative disorders resulting from errors in very small parts of the genetic code, the genetic information is clear cut – the individual has an abnormal gene, and they have or will eventually show signs of the disease. These diseases, along with problems of chromosome breakage or duplication such as Downs syndrome, are the object of prenatal screening tests.  For the most part, however, genetic results are statistics – the odds that a problem will eventually appear. Potentially damaging treatments applied to healthy people, based only on future odds,  is the “for worse” change that may come with the addition of genetic information in the practice of  everyday medicine.

 The problems with statistical medicine 

Statistical predictions apply to large numbers of people, not to individuals. Not all people who have a gene associated with Alzheimer’s dementia will get the disease, but since more people born with that particular gene will develop Alzheimer’s than those born without it, the gene is said to increase the risk for the Alzheimer’s disease. The prediction of a strongly hereditary trait – one associated with an 85% likelihood that some kind of illness or cancer will appear by a given age – gives the impression that the illness is almost inevitable for every member of the family. But from the standpoint of an individual within the family, the risk is always 50%.  Either they will or will not be affected.

The importance of treatment availability when disease risk is high

What does knowing that there is an increased risk of suffering a given disease do for you? If there is a treatment that prevents the evolution of the disease, and it has no adverse effects, then it would be reasonable to gamble on undergoing treatment based on worry that the disease will appear, rather than waiting to see if one is in the lucky percentage that escapes. Women who undergo removal of their breasts and or ovaries because they have a genetic trait that greatly increases risk for cancer in these organs have made this judgment.  (They also must accept the minuscule risk that breast or ovarian cancer can still occur even after surgical removal of the organs.)

In the case of the devastating brain degeneration known as Huntington’s disease (HD), people usually know they are at risk because one parent has developed the characteristic dementia and movement disorder in midlife. Because of the so called dominant inheritance pattern of HD, half of the offspring of the parent, statistically, will also be affected.  But no one knows which children carry the gene unless testing is done. Now available and definitive, the genetic test for this disease is a double-edged sword. Life is normal for the carriers of the gene until middle age. The knowledge of what is coming might convince the bearer of the gene not to reproduce, but also make living a full and happy life seem out of reach.

The role of genetics in common diseases

What about the prediction of increased susceptibility to more common diseases, such as heart disease and some cancers?  This aspect of genetic testing may help people with their motivation to lose weight, exercise, eat well and get their routine colonoscopies. Genetic analysis of cancers that have already developed is already proving helpful in the design of specific treatments for specific tumors. All tumors of lung or liver or brain are not alike and “one size fits all” treatments, the only type available in the past, will give way to individualized plans and drugs. An individual’s responses to drugs for conditions such as high blood pressure and heart disease, including both desired and to adverse effects, is also based on genetic makeup.  Personalized treatments are already increasing for these problems.

Genetics and aging

Genetic studies are also teasing out at least some of the pathways involved in aging. Will advances someday lead to immortality? Very unlikely, and a bad social idea anyway. But understanding the way the genes gradually fail in their the mission of cellular repair may well lead to better old age. The key will be to use the knowledge early in life. So far it looks like preventing the errors in DNA replication that contribute to the diseases of old age depends on the same old things that your grandmother might have advised – eating modest amounts real food, preferably from fresh sources in all food groups, avoiding sugar and other refined carbohydrates, drinking little alcohol, avoiding sunburn, keeping in motion, sleeping enough, and most importantly,  avoiding the biggest DNA error trigger of all – cigarette smoke.  Of equal importance is recognizing that no matter how much we know and try to prevent, life will eventually wind down. Living one’s individual allotment well and fully is as important as avoiding cancer – and may actually help genes replicate correctly.

(For readers especially interested in how the genetic code works, Francis Collins’s The Language of Life, and Matt Ridley’s Genome: The Autobiography of a Species in 23  Chapters are good starting points.)

 

Carpal Tunnel Syndrome

 

Wrist splints are common sights. You see them on cashiers and typists, on hairdressers and bank tellers. They reflect the frequency of a problem called carpal tunnel syndrome. The carpal tunnel is an anatomical structure inside the palm of the hand at its base, and the syndrome is a collection of symptoms related to the nerve that passes through the tunnel on its way from the forearm to the hand.  The nerve is the median nerve, and it is accompanied by nine tendons that connect the muscles of the forearm to the fingers.   At times, lack of space puts pressure on the median nerve, causing aching pain in the wrist, forearm and even upper arm, and numbness or tingling in the thumb, index, third and the half of the ring finger closest to the thumb. With enough pressure the thumb muscles weaken and shrink.  Any combination of these symptoms, when caused by pressure on the median nerve in the hand, adds up to carpal tunnel syndrome.

Nerves tell you they are in trouble

Pressure on nerves that run close to the surface of the body slows conduction of the electrical impulses that carry sensory information about pain, temperature, position and touch. When your foot or arm “falls asleep,” the culprit is pressure on the nerves that carry sensory information. Pressure symptoms from the median nerve in the base of the hand are so common that many people experience them transiently when they grip a steering wheel tightly over a long period of time, or pound or push with the base of the hand. Instinctively, they respond to the feeling of fingers tingling or going to sleep with re-positioning or shaking of the hand. Only when pressure is sustained do nerves become damaged enough to cause the muscles they supply to weaken. The median nerve is a common site of chronic pressure because of the anatomy of the tunnel it must pass through to the hand.

Tunnel anatomy

The roof of the carpal tunnel is an arch of bones at the base of the hand.  The floor is a horizontal span of several tendons and ligaments between the bones on the thumb side and the little finger side of the hand. The bony arch changes shape with hand movements, especially with bringing the thumb across to the little finger side, flexing the wrist and extending the wrist.

Who gets carpal tunnel syndrome?

Because the carpal tunnel is smaller in women than in men, they are more frequently affected by symptoms from pressure on the median nerve, particularly during pregnancy when hands commonly swell.  Some medical conditions like heart or kidney failure, diabetes and growth hormone producing brain tumors may cause pressure to increase in the carpal tunnel. Inflammatory conditions like rheumatoid arthritis may also bring out symptoms. While carpal tunnel syndrome seems common in people whose occupations involve repetitive hand motions or hand pressure, such as hairdressers, typists, bakers, and jackhammer operators, rigorous studies do not fault the activities alone, but the activities combined with the individual anatomic structure, and with underlying medical conditions,  if present.

The reason for those wrist splints

Since the anatomy of the hand is responsible for carpal tunnel syndrome, relief comes from maximizing the space between the ligaments and bones. When symptoms begin, the first line of treatment is a splint that keeps the wrist aligned in a neutral position – neither flexed nor extended. It also keeps the thumb from falling in toward the ring finger. The splint’s design allows for use of the fingers and thumb and it can be worn during most activities. The crucial time for keeping it on is during sleep. When we sleep our hands naturally fall into a posture of wrist and finger flexion, and some people exaggerate this pose by tucking their hands beneath them, and even unconsciously clenching them.  Hand position at night often brings carpal tunnel symptoms to light, especially aching in the forearm, and tingling in all the fingers except the pinky.

Stretching the tunnel

Stretching the base of the hand during the day is also helpful. One good stretch is accomplished by  placing the hand flat on a wall at about shoulder height, turning the body perpendicular to the wall and stepping far enough away to straighten the elbow as much as possible. Then rotate the “eye” of the elbow, its inner bend, up to face the ceiling as much as possible. Hold the stretch for up to thirty seconds at a time.

Advil doesn’t change the anatomy

Anti-inflammatory drugs like Advil can help reduce swelling of tendon sheaths if the problem with the hand is related to injury or an underlying inflammatory condition like rheumatoid arthritis, but chronic use of anti-inflammatory drugs has not been shown to help typical, uncomplicated carpal tunnel syndrome.

When conservative measures fail

If conservative measures like splinting and stretching do not resolve carpal tunnel symptoms, surgery to expand the canal is generally successful. Some surgeries are performed through a small incision, using a scope and tools inserted directly onto the tunnel to cut away the connective tissue surrounding the nerve and tendons. Other cases require an open incision in the palm.

Diagnosis

Diagnosis of carpal runnel syndrome is relatively easy from the history alone. Conservative measures can be attempted without any other tests, provided that there are no underlying medical conditions suspected to be causing the symptoms. However, if conscientiously applied conservative measures fail, or if there is muscle weakness at the time of diagnosis, then a test called a nerve conduction study and electromyogram (EMG) will almost always confirm the diagnosis. The pressure on the nerve in the carpal tunnel causes a current applied to the nerve to be delayed in its passage to the hand, easily picked up in the nerve conduction study. Tiny needles that measure activity in the palm of the hand pick up signs of loss of nerve supply to muscles.  Muscle nerve loss does not respond as well to conservative measures as sensory symptoms like numbness and tingling do, so if the EMG demonstrates muscle nerve loss, surgery is usually recommended.

 

 

A Primer on Steroids

Ask around among your friends and you will find that many of them, at one time or another, have been given “steroids” by their doctors. They have taken pills, inhaled the drugs, had injections, smeared creams on their skin, dropped liquid into their eyes, or received the drugs in an enema. They may have been treated for pain, swelling, rashes, cancer, slipped discs, vision problems, arthritis, colitis or vasculitis.  At the same time, you hear stories of athletes “doping” with “steroids” to enhance athletic performance and losing titles they won for having done so. You read ads for body building “steroids” and see the results in pictures of massively muscled men – and women. And sometimes you hear that testosterone, widely advertised for aging men, is a “steroid.” Are these all the same drugs? Yes, and no.  They are all manufactured versions of human steroid hormones.

What makes a steroid hormone?

All steroid hormones begin as molecules with the same core structure made from cholesterol. Various carbon, hydrogen and oxygen combinations added to the core make different chemical structures with different functions in the body. Those steroid hormones made in the testes and ovaries are called sex hormones. Those made in the adrenal glands are called corticosteroids and mineralocorticoids. Steroid hormones trigger a large number of different and vital chemical responses throughout the body.

Which steroids are used for which problems?

The steroids you hear about most frequently are synthetic versions of some of the adrenal glands’ corticosteroid hormones. Because they block immune system function, they are very powerful anti-inflammatory agents, commonly prescribed for allergic responses, autoimmune diseases, catastrophic situations involving trauma and shock, some cancers, and pain problems in which inflammation is thought to be the culprit. The steroids used for body building and performance enhancement are usually derivatives of the male sex hormones, or are nutritional supplements which are thought to increase the body’s own production of the male hormones.

Catabolic and anabolic effects: breaking down and building up

The first corticosteroids used in humans were animal adrenal gland extracts. They were lifesaving treatments for shock in people who had lost adrenal gland function. Incidental observations about their powerful anti-inflammatory effects propelled their widespread use and the Nobel Prize in Medicine in 1950 went to the men who elucidated their physiologic effects. With increased use, however, corticosteroids proved to have many serious long term effects because they are catabolic hormones, achieving their results by breaking down the body’s proteins and diverting them for different purposes.

The male sex steroids are anabolic hormones because they signal the body to build proteins. They have much narrower medical applications than the adrenal corticosteroids do. Anabolic steroids are useful in patients who have impaired male hormone production for reasons such as pituitary gland (the master gland) failure or testicular failure. But anabolic steroids are not medically needed in healthy people, and their use in amounts required to increase muscle mass above the body’s natural endowment courts significant risks. They are not medically available for healthy people. The male hormone testosterone is sometimes prescribed for men who have low testosterone levels later in life, with the aim of restoring libido and maintaining muscle mass, though there is some controversy about the risks versus benefits of this practice.

Powerful drugs with powerful side effects

Side effects of adrenal corticosteroids are related to the dose, delivery mechanism and especially to length of time used.  With oral and intravenous delivery, changes in glucose metabolism shift the pattern of fat storage in the body to the trunk, the neck and the face, producing the characteristic “moon facies” of someone treated with steroids over long periods of time, in relatively high does. Skin thins. Muscles shrink. Bones lose calcium and may fracture. Cataracts commonly develop. Insomnia and sometimes a form of mania signal brain effects. Suppression of the immune system, the source of the powerful anti-inflammatory effects of the corticosteroids, allows some infections to blossom. And very soon after steroid treatment starts, the adrenal glands begin to curb their own production of steroids, making stopping the drugs dangerous unless they are slowly tapered, a process that sometimes takes months.

Injections of corticosteroids into painful, presumably inflamed areas cause breakdown of the collagen structure of in connective tissue. Injections directly into tendons can cause enough degeneration at the site to lead to tendon rupture, causing some orthopedists to ban steroid injections anywhere near the Achilles tendon. Steroid inhalation for asthma and chronic obstructive lung disease is similar to topical use for skin problems – very effective at relieving inflammation, and not associated with much absorption into the body, so not as likely to produce adverse effects.

Some of the side effects of anabolic, male hormone steroids are related to their androgenic properties – the ability to produce and enhance male characteristics, and at the same time to shut down the body’s own production of testosterone in the testicles. Female users have deepened voices and develop acne and facial hair, but lose scalp hair. Males develop decreased sperm counts and shrunken testicles and also get acne and lose scalp hair (remember how many bald cyclists there were in the Tour de France during the height of the doping scandals?) But the most dangerous side effects are not visible: they include heart disease, liver cancer, anger, aggression and irritability and depression, as well as abnormalities in liver and kidney function.

Exercise caution in legitimate use of steroids and avoid illegitimate use

Alternate day dosing schedules for corticosteroids may help prevent side effects, as will the development of newer, more targeted versions of the drugs. But steroids should always be approached with caution, and used with great care. The most important things for doctors and patients to consider are the certainty of the diagnosis and likelihood that the condition will improve with less risky treatment. For instance, if orthopedic pain comes from muscular imbalance and not from inflammation, steroid injections will not help. If the condition being treated – say a bad case of poison ivy – will resolve with other types of care, steroid risks are unnecessary. Always remember that some severe steroid side effects can occur with just a few weeks use.

Sidebar: Case History illustrating Risk/Benefit Judgment in Corticosteroid Use

A 60 y.o. woman undergoes successful surgery for a benign brain tumor, but awakens with a paralyzed facial nerve, a well-known and feared complication of surgery in this type of tumor.  She has a severely drooping mouth and lower eyelid. High dose steroids over the next week reduce the swelling in the nerve, resolving the facial nerve paralysis. But the treatment also causes degeneration of the tops of the hip bones – a well-known steroid complication called aseptic necrosis. She then needs two hip replacements. Was the side effect worth the treatment result? In this case, most people would say yes. But if the steroid treatment had been for something that would have resolved with other treatment, the hip complication would have been much harder to accept.

Your Discs Are Bulging—Does it Matter?

Have you been told that you have bulging, degenerated discs in your spine? If so, you are not alone. Millions of Americans undergo X-rays, CT scans, and MRI scans of their backs and necks each year and receive the same news. As a result, multiple millions of dollars are spent on medications, physical therapies, surgical procedures, and spinal manipulations in an effort to treat back pain. The people undergoing all this diagnosis and treatment might imagine that other, luckier people have normal spinal discs, but they might be surprised to learn that bulging discs are so common that they may be considered a normal part of aging. Most often, they cause no symptoms or problems, and it pays to be cautious about embarking on courses of investigation and treatment based simply on these “degenerative changes.” But it also pays to know when and why discs do cause trouble.

What and where are spinal discs?

The spine is a column of thick, circular bones—also called vertebral bodies—that in terms of anatomy is divided into three major sections: the cervical (neck) spine, thoracic (mid-back) spine, and lumbar (lower back) spine. The vertebral bodies have flat tops and bottoms, and they sit atop one another, separated by discs that cushion the spine and allow for the compression, rotation, and bending of the entire spinal column. The arches of bone on the back sides of each of the vertebral bodies line up with each other to form a bony tunnel, which surrounds the spinal cord and the nerves that connect it to the body. Pairs of these nerves exit from the sides of this canal below each vertebral body.

Spinal discs are a lot like flattened cream-filled doughnuts, with a soft center called the nucleus pulposus and a tougher perimeter called the annulus. Each annulus is attached to the ligaments that run the length of the spine and hold it together. Every day, gravity squeezes so much water out of each disc that an average adult shrinks by more than one-half inch between morning and night. As a disc loses water and flattens, it may protrude beyond the edges of the vertebral bodies located above and below it. Under these conditions, the ligaments bounding the disc tend to bow outward to accommodate the flattening, and the result is the classic “bulging” discs often seen on back scans. Is such bulging a cause of pain?

When bulging becomes cracking and herniation

Judging by the number of people who have bulging discs and no pain, the answer to this question is, not very often. But discs can cause pain if they are damaged. Cracks can develop in the back part of the annulus, especially in the lower neck and lower back, and are sometimes caused by sudden movement or excessive loading of the neck or back or sometimes with no readily identifiable cause. Risk factors for the development of cracks include age, smoking, and heavy weight lifting. When cracks form in the annulus, nerve fibers send out distress signals which feel like deep back pain that sometimes radiates down the legs. Symptoms usually improve over a period of six to eight weeks, but if the tear is extensive enough, it may open a path for part of the soft nucleus pulposus of the disc to work its way through, becoming a so-called herniated or “slipped” disc.

Location determines  symptoms

Extruded far enough, a herniated disc bulges straight backward into the bony tunnel that houses the spinal cord or off to either side, where it squeezes into the narrow canal that should hold only a spinal nerve root passing out to the body. Depending on the location and the extent of the disc herniation, pain in the back or neck might be accompanied by a set of neurological symptoms including numbness, tingling, and a sense of weakness in an arm or a leg. Symptoms may improve over time with no treatment or with relatively modest treatments, like physical therapy or cortisone injections, as the disc shrinks. But there is potential for the worsening of symptoms, so careful physical evaluation and follow-up are important.

More than 95 percent of disc problems occur in the lumbar spine. Here, as in the neck, discs tend to slip off to the side, compressing single nerves and causing pain to run down a leg or arm or weakness in corresponding muscles. Definite loss of strength in a muscle group controlled by the nerve under pressure most often calls for surgery to decompress the nerve. Sometimes scans indicate that a fragment of disc has broken off and lodged itself under a nerve. Unlike nonfragmented disc herniations, which may gradually shrink and relieve symptoms, symptoms caused by fragmented discs tend to be persistent unless the fragment is removed.

Disc herniation in the upper spine

When discs slip straight back into the central spinal canal, symptoms can range from none to neurological deficits that require immediate decompression surgery. Serious central disc herniations are uncommon in the neck and quite rare in the thoracic spine but in both locations may cause symptoms from the spinal cord itself that include pain, balance problems, weakness in the legs, and an inability to control the bladder.

Disc herniation in the lumbar spine

In the lumbar spine, because the spinal cord does not reach down this far, central disc herniations put pressure on the so-called cauda equine, or “horse’s tail” of nerves that travel down the spinal canal from the spinal cord to their exit points at different lumbar levels. Symptoms here often consist of a confusing array of pain, numbness around the groin and legs in a pattern that traces an area where a saddle would make contact with the body, leg weakness, fecal incontinence, and trouble initiating urination. This combination of symptoms requires immediate surgical decompression.

Surgery or not?

While surgery for severe symptoms is an easy decision and while many disc removals are done with microsurgical techniques and small incisions and are less invasive than in the past, the decision to try to improve back pain alone by operating on a bulging disc is not as easy. To improve the likelihood of good results, studies like disc injections are sometimes done. The dye used helps visualize the disc, and, if the injection reproduces the patient’s pain, confidence that the disc is the source of the back pain increases. Injections can be helpful in determining which of several bulging discs might be the source of pain.

Caution in the decision

Disc removal for pain alone or for pain combined with sensory symptoms that come and go should be approached with caution. First, every attempt should be made to improve the strength of the muscles that support and move the spine, to improve overall posture, and to lose excess weight that the spine is asked to support. Back and neck pain arise from many different structures—muscles, ligaments, tendons, bones, and nerves—and can improve dramatically with improved strength, flexibility, and posture—bulging discs or not.

 

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