Comprehensive information about diving and undersea medicine for the non-medical diver, the non-diving physician and the specialist.
Bone and Joint Quiz
References for Dysbaric Osteonecrosis
Chronic Adverse Effects of Diving on Bone
Arthritis and Scuba Diving
Fractures and Surgery
Articles by Dr. Jolie Bookspan, PhD
No More Back Pain, Part I
Back Pain, Parts II and III
Exercises for Abs
Propulsive Lift and You
by Jolie Bookspan, PhD
Bad Discs, Sciatica and Diving
by Jolie Bookspan, PhD
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The best treatment is prevention by using the safest decompression table possible. Because of the high relationship with DCS, all DCS symptoms should be treated with Recompression and HBO.
Death of a portion of the bone that is thought to be caused by nitrogen embolization "blockage" of the blood vessels in divers. Although the definitive pathologic process is poorly understood, there are several hypotheses:
In a study of bone lesions in 281 compressed air workers done
Walder in 1969, 29% of the lesions were in the humeral head (shoulder),
16% in the femoral head (hip), 40% in the lower end of the femur(lower
thigh at the knee) and 15% in the upper tibia (knee below the knee cap).
It is a significant occupational hazard, occurring in 50% of
Japanese divers, 65% of Hawaiian fishermen and 16% of commercial and
divers in the U.K. It's relationship to compressed air is strong in
it may follow a single exposure to compressed air, may occur with no
of DCS but is usually associated with significant compressed air
The distribution of lesions differs with the type of exposure-the
lesions being more common in caisson workers than in divers. There is a
definite relationship between length of time exposed to extreme depths
and the percentage of divers with bone lesions.
The diagnosis is made by x-ray/MRI appearance and has five juxta-articular classifications and four head, neck and shaft classifications indicating early radiological signs.
Early on there is flattening of articular surfaces, thinning of
with osteophyte (spur) formation. In juxta-articular lesions without
there is dead bone and marrow separated from living bone by a line of
collagen. Microscopic cysts form, fill with necrotic material and there
is massive necrosis with replacement by cancellous bone with collapse
The treatment is less than successful, often requiring a joint replacement. Spontaneous improvement occasionally happens and some juxta-articular lesions don't progress to collapse. Other treatments include immobilization and osteotomy of the femur. Cancellous bone grafts are of little help.
The best treatment is prevention by using the safest decompression table possible. Because of the high relationship with DCS, all DCS symptoms should be treated with Recompression and HBO.
*Reference: David Elliott, Medical Seminars, 1996
Jones JP Jr, 1978 [See Related Articles] Prevention of dysbaric osteonecrosis in compressed-air workers. Clin Orthop 130, 118-128 (1978)
Lauritzen JB, 1987 [See Related Articles] Dysbaric osteonecrosis. Ugeskr Laeger 149(12), 771-773 (1987)
Kawashima M, 1978 [See Related Articles] Pathological review of osteonecrosis in divers. Clin Orthop 130, 107-117 (1978)
Wade CE, 1978 [See Related Articles] Incidence of dysbaric osteonecrosis in Hawaii's diving fishermen. Undersea Biomed Res 5(2), 137-147 (1978)
Harefuah 105(7), 162-163 (1983)
Orthop Clin North Am 16(4), 595-633 (1985)
Philos Trans R Soc Lond B Biol Sci 304(1118), 153-175 (1984)
In the late 1800's and early 1900's many people worked building tunnels and bridges using compressed air in caissons to keep the workplace dry. It is from this population that Bassoe(1911) in the United States and Bornstein and Plate (1911) in Germany were the first to report disabling hip and shoulder conditions which were associated with radiological evidence of joint degeneration. The first case in a diver was not reported for another 30 years. (Grutzmacher, 1941). This, too, presented as pain in a joint. Around 10 or more cases were reported in the literature during the next ten years and all were in divers who had sought treatment for persistent joint pain. It is not possible to draw valid conclusions from these cases because the x-rays are not always published and there was no agreed standard for radiological diagnosis. Alnor et al (1964) found 72 cases of necrosis in 131 divers and of the 65 who had been kept under observation for more than 10m years, only twenty-two of them remained free from radiological lesions. Of the 43 with lesions, 17 had symptoms and 7 were "totally unable to work".
Called 'Compression Pains' in the new U.S. Navy Diving Manual (3- 10.8). it is referred to as compression arthralgia in other texts (Edmonds and Bove). It is the result from increases in external pressure surrounding the body. These pains affect the joints and may occur in almost any diver. They have been experienced in the knees, shoulders, fingers, back, hips, neck, and ribs. Occasionally, severe low back pain or xiphisternal pain may occur (Bove). The pains are often described as deep aching pains, similar to those of Type I decompression sickness. However, the pains may be relatively sudden in onset and initially intense. These pains may be accompanied by “popping” of joints or a dry, “gritty” feeling within the joint.
Symptoms are dependent on depth, rate of compression, and individual susceptibility and usually come on at 200 fsw (60 msw), increasing with depth and aggravated by exercise. While primarily a problem encountered in saturation diving, symptoms may occur as shallow as 100 fsw at rapid compression rates, such as seen in air diving. In deep, helium saturation dives with slower compression rates, symptoms are more commonly seen deeper than 300 fsw. Deeper than 600 fsw, compression pains may occur even at very slow rates of compression. These pains may be severe enough to limit diver activity, travel rate and depths during downward excursions. Improvement is generally noted as time is spent at depth but, on occasion, these pains may last well into the decompression phase of the dive until shallower depths are reached. They can be distinguished from decompression sickness pain because they were present before decompression was started and do not increase in intensity with decreasing depth.
Mechanism of Action
The mechanism of compression pain is unknown, but is thought to result from the sudden increase in tissue gas tension surrounding the joints causing fluid shifts and interfering with joint lubrication. Edmonds describes this as a gas induced osmosis producing cavitation due to a relative imbalance between the inert gas in the blood and that in the synovial fluid and articular cartilage, causing a water shift from the joint to the higher osmolarity blood.
The symptoms usually disappear in reverse
as the diver ascends or decompressed. Unless damaged during the
at depth, the joint pain disappears, requiring no treatment. If damage
occurs at depth from load bearing exercise, then the pains on the
might be difficult to differentiate from the pain of decompression
Recompression would improve DCS pain.
In addition, the underwater environment causes a diver to be at a tremendous disadvantage due to:
- The effect the condition has on organs vital to safe diving (central nervous system, heart, lungs, ears, eyes)
- The limitation of physical ability caused by the condition; alteration of the diver/buddy relationship
- The effect on diving of medications taken for the condition
- Complex interactions between the above that require Solomonic wisdom as to the probity of diving.
Divers have to have a reasonable level of physical and physiological fitness because of the obligatory stresses of the underwater environment. They must also be free of other limitations compromising safety in the underwater milieu. For safe diving, the millions of recreational and sport divers should maintain a reasonable level of fitness, the medical requirements for sport diving not being stringent.
- the difficulty in propulsion through the surrounding water;
- through rapid heat loss to water generally colder than body temperature;
- breathing gas of compressed density;
- the diver uses an altered cardiorespiratory system from a changed environment;
- in order to prevent damage to air-containing spaces in the body, the diver has to accommodate to changes in gas volume and pressure;
- accommodation to the effects of the partial pressure of gases that can cause toxic, narcotic, stimulatory and gas solubility changes to bodily functions.
Arthritis and Scuba Diving
Risk Factors for Arthritis
Age and sex are two of the most important risk factors for the rheumatic diseases. Most of the major joint conditions show a remarkable sex difference in incidence; eg, systemic lupus erythematosus (SLE) occurs primarily in women, whereas ankylosing spondylitis (Spine) is both more frequent and more severe in males. The reasons for this are unclear. Divers of all ages will need to be aware of the few but important relationships to this widespread condition.
The musculoskeletal system does not "wear out"; it thrives on usage and, unlike most mechanical systems, "lasts a lifetime." The underwater 'weightlessness' lends itself nicely toward allowing this great sport of scuba to be enjoyed by many people who would otherwise not be able to participate in athletics. However, like gender, age very strongly affects the incidence, expression, and impact of musculoskeletal diseases. Some conditions only occur in childhood; others, like SLE and ankylosing spondylitis, usually start in young adults, while polymyalgia rheumatica and giant cell arteritis rarely begin in those less than 55 yr. Rheumatoid arthritis (RA), SLE, gout, and other major inflammatory rheumatic diseases are expressed differently if they begin in older patients. With minimal assistance with entrances and exits, the arthritic diver can usually manage a moderately difficult dive with ease.
Diagnosis and Assessment Important to the
Rheumatology is mainly a clinical specialty, still depending more on the skills of history-taking and examination than on special investigations. There are 2 main aspects to diagnosis: (1) differentiating the type of rheumatic disorder present and (2) assessing its impact on daily life. Diagnosis is based largely on pattern recognition --the chronology, distribution, and associated features of the disorder. The assessment of pain, disability, and handicap is often more difficult, involving investigation of patients' functional abilities, as well as their hopes, fears, needs, and aspirations. This assessment requires careful documentation in prospective divers for comparison in the case of a possible bout with decompression sickness. Most musculoskeletal disorders cause chronic pain and disability without having a great effect on life expectancy; the prevalence is therefore highest in older people. Some arthritic divers have described significant relief from pain at depth.
A few types of arthritis are treatable with specific therapy (eg, gout can be completely controlled with drugs, or Lyme disease can be treated with antibiotics), but there are no "magic bullets" for most chronic rheumatic disorders. Management principles are often similar, regardless of diagnosis, and may depend more on the patient's age and circumstances, the balance of disease processes (eg, amount of inflammation), and the outcome (severity of pain and handicap) than on the specific disease. Most arthritic divers will want to know about the effect of diving on the drugs they are taking; such as, aspirin, NSAIDs, steroids, and the numerous other medications in use for secondary (fallback) treatment of certain arthritic illnesses (gold, Cyclosporin, Immuran, etc).
Occupational therapists participate early, helping patients adjust to the situation and teaching ways to protect joints from excess stress; later, they assist in managing physical handicap, providing aids, appliances, and further education. Scuba diving can be an important part of the therapists armamentarium. Physical therapy is useful for prevention as well as for treatment, since keeping physically fit and active helps prevent musculoskeletal pain and morbidity; and, in early disease, the maintenance of muscle strength and a full range of joint motion will help prevent subsequent disability. Physiotherapy also plays a central role in rehabilitation and pain management.
Disease suppression can be achieved with hypouricemic drugs for gout, corticosteroids and immunosuppressive agents for immunologic and inflammatory diseases, and a range of miscellaneous slow-acting antirheumatic drugs for RA and the arthropathies associated with spondylitis. Specific agents are also available for many bone conditions, eg, Paget's disease. The recent development of more effective and sophisticated drug therapy for RA has been significant. Gold injections were first used in the 1930s, but we now have many similar agents, including penicillamine, hydroxychloroquine, and sulfasalazine, some of which are also active in other forms of arthritis. None of these drugs alter consciousness and therefore are not dangerous to the diver. Some blunt the immune response, however, and divers need to be aware of the increased possibility of infection in polluted and sea water.
Surgery has become important in rheumatic disease management. Synovectomy, tendon repairs, decompression, and other procedures are sometimes warranted in early inflammatory disease. In late destructive disease of any type, joint replacement, and less commonly an arthrodesis, can be performed. Joint prostheses from metal or silicone pose no problem to the diver in that they are not air containing and thus are not effected by changes in pressure.
Clinical Approach to Arthritis as related to Diving
A complete history and physical examination are important because joint symptoms may be part of a systemic disease. Laboratory and x-ray data are usually of only supplementary help. Even mildly inflammatory or noninflammatory arthritis may be the first indication of SLE, hypertrophic pulmonary osteoarthropathy due to bronchogenic carcinoma, or a metabolic disease such as hemochromatosis. Conditions easily misinterpreted as arthritis by the patient include phlebitis, arteriosclerosis obliterans, cellulitis, edema, neuropathy, vascular compression syndromes, the stiffness of Parkinson's disease, periarticular stress fractures, myositis, and fibromyositis.Add to this the joint pains associated with "bends" or decompression illness, and you have the possibility of confusion in diagnosis. Dysbaric osteonecrosis affecting the joint cartilage can easily be mistaken for an arthritic joint.
Prominent tenderness of bones adjacent to joints and joint effusions occur in sickle cell disease and hypertrophic pulmonary osteo-arthropathy. Both sickle cell disease and pulmonary osteoarthropathy pose dangers to the diver--scuba diving being capable of causing a sickle cell crisis through hypoxia, and pulmonary disease of the extent to cause arthropathy being adverse to diving due to the possibility of barotrauma.
Physical Examination of the
Changes from previously recorded physical findings are important in differentiating pre-existing arthritis from suspected decompression sickness. A sequence of inspection, palpation, and determination of the range of motion of each involved joint area is followed. In most cases, this determines the presence of joint disease and establishes whether the joint, the adjacent structures, or both are involved. Involved joints should be compared with their uninvolved opposites or with those of the examiner. Information is recorded objectively and quantitatively; eg, by using a numbered grading system and by measuring the range of motion in degrees.
Joint motion, generally painful in joint disease, may not be painful in periarticular, bone, or soft tissue disease. Swelling is an important finding. All swollen joints should be palpated. The examiner should then "ballotte" the joint to (1) elicit the presence of fluid; (2) differentiate between simple effusion, synovial thickening, and capsule or bony enlargement; and (3) determine whether the swelling is confined to the joint or is periarticular; (4) apply pressure to check for the relief seen in DCS.
The foot and ankle: The prospective diver should test his weightbearing ability with full equipment and weight belt. Inability to handle the weight should not preclude diving, however, since suiting up can be done while sitting on the dive platform. Since weight-bearing may elucidate certain abnormalities, part of the examination should be performed with the patient standing. Since finning is such a vital part of safe diving, disorders of the foot and ankle might be adverse to diving.
The knee: Such gross deformities as swelling (eg, popliteal cysts), quadriceps muscle atrophy, and joint instability may be more obvious when the patient stands and walks, particularly with scuba gear. With the patient supine, careful palpation of the knee, especially noting the presence of joint fluid, synovial thickening, and local tenderness, helps detect arthritis.
The hip: A limp is common in patients with significant hip arthritis. It may be due to pain, shortening of the leg, flexion contracture, or muscle weakness. Loss of internal rotation, flexion, extension, or abduction can usually be demonstrated. Aseptic necrosis of the hip from barotrauma is a definite part of the differential diagnosis of hip pain.
The vertebral column: Cervical and lumbar motion should be measured. Inability to reverse the normal lumbar lordosis on flexion occurs in degenerative arthritis. Limited lumbar flexion is characteristic of ankylosing spondylitis. Neck motion can be limited either by degenerative arthritis or by ankylosing spondylitis. This can become a problem in the diver with the tank position abutting the head. The effect of movement on pain should be noted. Localized bone pain suggests such disorders as osteomyelitis, leukemia, primary or metastatic cancer, compression fracture, or herniated disk. Chest expansion should be measured, as it is typically impaired in ankylosing spondylitis. This is often associated with pulmonary emphysema, particularly dangerous to the diver. Disk disease can be aggravated by the extra weight of scuba gear causing nerve root compression and confusion as to the possibility of spinal decompression illness.
X-rays are most important in the initial evaluation of relatively localized unexplained complaints to detect possible primary or metastatic tumors, osteomyelitis, bone infarctions, periarticular calcifications, or other changes in deep structures that may escape physical examination. Erosions, cysts, and joint space narrowing can be seen in more chronic RA, gout, and osteoarthritis (OA). X-rays also are especially useful in examination of the spine. CT scans, MRI, and tomograms can help define puzzling lesions. These offer excellent baselines for future reference to the diving physician.
Other studies useful in selected patients include needle or surgical synovial biopsy, ultrasound, arthroscopy, arthrography, bone and marrow scans, electromyography, nerve conduction times, thermography, and muscle or bone biopsy.
The importance of a good physical examination of the arthritic diver has been spot-lighted as vital for differentiation of the many signs and symptoms of decompression sickness that can mimic arthritis and nerve compression. Weight-bearing has been discussed, as well as the difficulties specific to such illnesses as sickle cell disease and pulmonary osteoarthropathy.
A chronic, systemic inflammatory disorder of unknown etiology, characterized by dryness of the mouth, eyes, and other mucous membranes and often associated with rheumatic disorders sharing certain autoimmune features (eg, RA, scleroderma, and SLE) and in which lymphocyte infiltration into affected tissues is seen. The syndrome is more common than SLE (systemic lupus erythematosus) but less common than RA (rheumatoid arthritis). The effects of pressure are unknown. The condition causes keratoconjunctivitis and dry mouth, both conditions possibly inimical to the diver.
The diver with Sjogren's Syndrome should be in good physical conditioning, be in remission from the acute processes of the disease, be capable of physically managing his/her entry, exit, scuba gear and be capable of assisting a buddy with a diving problem. They should be taking no medication that would alter their ability to function or make decisions.
Pathophysiology, Symptoms, and Signs
In some, SS affects only the eyes or mouth (primary SS; sicca complex; sicca syndrome); in others, there is an associated generalized collagen-vascular disease (secondary SS).
Ocular symptoms occur when atrophy of the secretory epithelium of the lacrimal glands causes desiccation of the cornea and conjunctiva (keratoconjunctivitis sicca. In advanced cases, the cornea is severely damaged and epithelial strands hang from the corneal surface (keratitis filiformis). This would be adverse to diving.
One third of SS patients develop enlarged parotid glands that are usually firm, smooth, fluctuating in size, and mildly tender. Chronic salivary gland enlargement is rarely painful. When salivary glands atrophy, saliva diminishes, and the resulting extreme dryness of the mouth and lips (xerostomia) inhibits chewing and swallowing and promotes tooth decay and calculi formation in the salivary ducts. Taste and smell faculties may be lost. This may reduce the diver's ability to manage the mouthpiece of the regulator or snorkel.
Drying out may also develop in the skin and
mucous membranes of the nose, throat, larynx, bronchi, vulva, and
Alopecia may occur. Dryness of the respiratory tract often leads to
infections and sometimes to fatal pneumonia. Associated mucous membrane
problems could lead to difficulties equalizing the middle ears or
Knee or Hip Replacement
There should be no diving limitations or restrictions placed on diving with a knee or hip replacement, or any other metallic inserts or implants. The effects of pressure are not any specific danger for implants which do not contain compressible gases. Gas laws (Boyle's and Henry's) don't effect an implanted solid; the supposition that there is an increased chance of gas bubble formation in scar tissue or areas of deranged blood supply has no firm basis in man or animal studies.
Main limitations would be purely those imposed by rehabilitation from surgery, i.e., ability to walk around with heavy gear prior to entry and climb ladders (or shore) for exits. All wounds should be completely healed and the diver should have been released by the surgeon for full weight-bearing activities. Physical conditioning should have been accomplished.
One should be able to dive the usual limits of sport diving without any restrictions.
Diving After Knee or Hip Reconstruction
Much depends on the original cause of disability. Generally, the guidelines for the new diver are much more stringent than for an experienced diver who is returning from an injury. The sport diver should have no problem as long as there is good range of motion and the diver is able to bear weight.
To become a commercial diver, the candidate must have excellent mobility and dexterity and must be in a robust physical condition in order to meet the demands of the proposed work. For personal safety and that of others, all joints must have a normal full range of mobility.
The knee and hip are especially susceptible to dysbaric osteonecrosis and this must be kept in mind with the injury. Differentiating between residual x-ray findings and osteonecrosis may be difficult.
As far as commercial diving is concerned, it
all depends on the examiner and the medical guidelines of the company
the type of work. Baseline radiologic studies are required and
by the orthopedic surgeon, that will go a long way to persuading the
doctors to allow return to work.
Disqualification of divers with
injuries, surgery and inflammations should be considered during the
of an incompletely healed fracture, sprain, ligamentous injury or
process for several reasons;
----the loss of mobility and dexterity with a cast
----the possible alteration in the uptake of inert gas at the site of injury resulting in delayed healing and inability to climb into boats
----other aspects of diving requiring mobility and strength.
----the possibility of wound infection from marine organisms
----the possibility of reinjury to a fracture resulting in non-union, or disruption of a surgical repair.
Divers with acute bone or joint injury or
should not return to diving until:
----the injury has healed and there is a full range of motion and strength. ----residual pain should not be present to impair the diver's ability to perform in emergencies.
----in addition, there should be no pain patterns that could be confused with a decompression accident.
----they have the OK to return to diving from their physician.
Consideration should be given to the particular arrangements of diving gear, straps and equipment and what effect this will have on weight-bearing and the possibility of further injury to other underlying structures.
Diving After a Fracture
Healed fractures generally are thought not to impose any restrictions on diving. Generally, a fracture should be properly healed in 4-6 weeks barring complications. However, there is the theoretical caveat that there is an increased risk of bubble formation in regions of bone where there has been some disruption of blood supply - leaving an increased or decreased vascularity. There have been no studies to prove or disprove these cautionaries, however.
There are a couple of other factors that
1. There is significant pressure applied to the arms and legs in exiting the water climbing back into boats from weight-bearing from the heavy scuba gear. You might want to arrange with the divemaster for assistance in donning and removing your gear in the water.
2. There is significant loss of muscle strength and sometimes actual muscle atrophy with a fracture and disuse.
Finally - you should discuss this with your orthopedist for any comment that he/she might have regarding your return to diving in 5 weeks.
Moisture weakens plaster and damp padding next to the skin can cause irritation. Use two layers of plastic or purchase waterproof shields to keep your splint or cast dry while you shower or bathe.
Waterproof cast construction uses a
cast liner made of Gore-Tex (W. L. Gore and Associates, Inc, Flagstaff,
Arizona) to replace the traditional stockinette and cast padding. The
liner repels water and permits evaporation, allowing bathing, swimming,
sweating, and hydrotherapy without any special drying of the cast or
The liner material is available in rolls of 2-, 3-, and 4-in. width and
is applied directly to the patient's skin. Fiberglass casting tape is
wrapped around the waterproof liner.
It is the theoretical possibility that there might be an increased risk of bubbling in a fracture site due to the altered blood supply. If this were the case, you might find decreased healing of your fracture after diving. Consequently, it would be wise to heed the advice of your physician before diving at all with an incompletely healed fracture.
In addition, you will encounter logistical difficulties in gearing up, water entry and exit and locomotion in the water that could be risky to you and others on the dive boat.
You should be able to return to diving after complete healing of your incisions and satisfactory rehabilitation as determined by your operating surgeon. We cannot give you specific time intervals as this differs widely between individuals and is highly variable.
Healed nerve and tendon release operations generally are thought not to impose any restrictions on diving. However, there is the theoretical caveat that there might be an increased risk of bubble formation in regions of surgery where there has been some disruption of blood supply - leaving an increased or decreased vascularity. There have been no studies to prove or disprove these cautionaries, however.
Careful recording of neurological deficits should be accomplished before diving.
Rib fractures can be very painful, decrease respiratory excursions and if severe, can cause lung puncture with the resultant pneumothorax. A diver is also possibly placed at risk for increased decompression effects at the fracture site with slowed healing of the fracture. Best advice is not to dive during the period of healing (four to six weeks).
Rib braces and ACE bandages are the only
treatment. In rare cases of fractures in severely traumatized people
markedly reduced respiratory reserve - nerve blocks can be done for
relief and improved respiration.
Diving With Unoperated Disc Disease
Diving with un-operated herniated disc disease is thought by some authorities to constitute a contra-indication to scuba diving. However, post surgical and healed vertebral fusions generally are thought not to impose any restrictions on diving. In addition, there is the theoretical caveat that there is an increased risk of bubble formation in regions of bone where there has been some disruption of blood supply - leaving an increased or decreased vascularity. There have been no studies to prove or disprove these cautionaries, however.
Cervical disc problems causing radicular neuropathy should not dive until this has been surgically repaired. It would be our feeling that if you dive, you should discuss this with your surgeon in terms of weight-bearing, climbing and the hyperextended neck position that is required with scuba diving.
You would be wise to have a neurological examination carefully recorded and with you on your dives for comparison reference in case of a decompression accident.
Lumbar herniated discs without protrusion can and do dive - however, there is a definite risk of acute herniation with the lifting activity and strain of getting back into the boat. Acute herniation can mimic a decompression accident.
Return to Diving Post-surgical
There are no set guidelines that govern the return to diving after disc surgery. This will depend to a great extent on the type of surgery, presence or absence of complications, whether or not a fusion has been done and if there have been any complicating factors, such as a wound infection or residual symptoms.
Generally, a person may return to diving in three months with the OK of the operating surgeon.
There is an absolute contraindication to diving after disc surgery that has failed and results in spinal stenosis. If there is major residua or deficit after the surgery--one probably should not dive. There is a relative contra-indication to diving after having a herniated disc repaired below L1-2 and a repaired cervical disc from the anterior approach--both should wait at least 3 months and then dive only if there are no residua.
There are those who theorize that the possibility of Neurological DCS would be more likely with bubble formation at the site of the disruption of the vasculature in the operative area. No man studies bear this out. Some feel that back surgery and previous DCS of the spine are possibly predisposing factors in the formation of spinal DCS. (Caroline Fife, MD).
Fred Bove, MD ("Diving Medicine"--Bove and Davis) feels that there is clear evidence that minimizing bubble formation is essential for safe diving and to avoid long-term damage to the central nervous system. This goal can be achieved by conservative diving that reduces the total exposure to nitrogen under pressure.
Retrospective studies of diving accidents have indicated that the threshold depth is arbitrarily 86 feet. If you have had successful surgery without residua (neurological findings) you can dive (sport, not commercial).
People with compression fractures with nerve root or spinal deficit residua, even if episodic, should not dive until the problem is repaired by spinal fixation. Symptoms of numbness and pain are mimicked by decompression sickness and pose problems in differentiation after a dive. The chances of even more scar tissue developing postoperatively are great. Weight bearing and donning gear on the surface can be real problems to the affected diver, even though it is stated that once in the water they are more comfortable due to the loss of gravity effects.
DAN feels that diving should be postponed until the back is surgically stabilized. With significant symptoms, it wouldn't take much to become paraplegic--and then the diver would be in a jam. Ironically, if the diver were paraplegic and stable--then we could make some arrangement for him to dive --but that's certainly not what we want!
A diver has to carry his equipment on land (boat) and be able to perform hard physical work on occasions. Weight-bearing with grade 3 spondylolisthesis can certainly lead to nerve root compression, resulting in severe pain, paralysis and loss of function. In addition to causing its own difficulties, this can mask neurological symptoms caused by decompression illness. Until surgically repaired, significant spondylolisthesis would be disqualifying; a three month post operative period should be allowed and no diving at all if there are significant residua.
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