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|NI FEATURE: TIMELESS REVERBERATIONS - COMMENTARY
|Year : 2017 | Volume
| Issue : 2 | Page : 238-239
The element fluorine and its effects on human health including its neurological manifestations
D Raja Reddy
Senior Consultant, Apollo Hospital Hyderabad, Former Head of the Department, Department of Neurosurgery and Former Director, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Web Publication||10-Mar-2017|
Dr. D Raja Reddy
Senior Consultant Neurosurgery, Apollo Hospital, Jubilee Hills, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Reddy D R. The element fluorine and its effects on human health including its neurological manifestations. Neurol India 2017;65:238-9
Fluorine is one of 118 chemical elements recorded so far. Being highly reactive, it does not occur in its free form in nature; as fluoride, it constitutes the 13th commonest element on the earth's crust. Fluorides are ubiquitous in nature and are present in everything that humans eat and drink. Hence, fluorides play a role in affecting human health. They may have both a beneficial as well as a detrimental role depending upon their optimum intake. 96-99% of fluoride retained in the body resides in the skeleton since it is a bone-seeking element like calcium and its effects are confined to the skeletal system, including the teeth. Optimum intake of fluoride reduces the incidence of dental caries and probably osteoporosis but excessive intake leads to dental and skeletal fluorosis and also neurological manifestations. The two main sources of fluorides are water (including various beverages) and food. Ninety percent of rural water supplies are based on ground water sources and these, in large parts of the country, do not have optimum levels of fluorides for a tropical country like India. In contrast, all major cities in the country get a good part of their water supply from perennial rivers that have an optimum fluoride content. Epidemiological studies have proven that malnutrition aggravates fluoride toxicity. It is well known that malnutrition is widely prevalent in rural areas of our country and it has become extremely difficult to control it. It is, therefore, obvious that fluorosis has become very prevalent in the country, is rapidly spreading and has become a major public health problem. Official reports confirm that 275 districts are affected by fluorosis in India and these are spread across 21 states. It is estimated that 66 million people living in endemic areas are at risk of contacting fluorosis and six million people are crippled because of it. The clinical manifestations of patients having fluorosis with neurological problems need to be understood so that effective methods can be instituted to treat such cases.
Etiopathogenesis of skeletal fluorosis
Skeletal changes of fluorosis include an overall increase in the bone mass, the calcification and ossification of ligaments and inter-osseous fasciae, and periosteal new bone formation with the development of exostoses on long bones and osteophytes in the spine. The effect on the vertebral column is seen as roughening of the pedicles, laminae, spinous processes and transverse processes. The osteophytes projecting into the spinal canal and inter-vertebral foraminae may press upon the cord and spinal roots, accounting for the radiculo-myelopathic features noted in chronic fluorosis.
Neurological manifestations of skeletal fluorosis
The neurological sequelae in skeletal fluorosis are mainly mechanical in nature, manifesting usually as a radiculo-myelopathy and are brought about by osteophytosis and sclerosis of the vertebral column. However, it is only in the later stages, owing to pressure on the radicular vessels in the intervertebral foraminae, that vascular complications may supervene. However, the neural toxicity attributable to fluorides is yet to be established.
Fluorosis is a relentlessly progressive chronic disease, except in traumatic cases, where neurological complications may develop suddenly.
a) Management of acute onset of spinal cord compression
Minor trauma causing major neurological manifestations, such as quadriplegia, is witnessed in patients with fluorosis. If there is no malalignment of spine in such cases, these patients may be treated conservatively. The aggressive decompression of those cases with focal compression have, however, resulted in a favorable outcome., The diagnosis of fluorosis in such cases can be made on the observation that in the T1 and T2 weighted images of magnetic resonance imaging scans, the spinal column appears as hypointense.
b) Management of neurological manifestations of fluorosis
Since the neurological manifestations of fluorosis are mechanical in nature, surgical decompression is the only answer in these cases. It is only possible in those early cases in whom the compression is confined to a small segment of the spinal column. Management of even these cases becomes difficult because of the marked fixity of the spine and rigidity of the thoracic cage leading to postoperative chest complications. The intubation during anesthesia becomes problematic and there may even be difficulty in positioning of the spine during surgery. That is why surgical decompression of the spine in a patient suffering from fluorosis becomes difficult. However, the results of surgery of the spine undertaken in a select group of cases were found to be encouraging in the case of the spinal compression being restricted to the cervical region, but is disappointing in the cases having a dorsal region compression, which might be attributed to the anatomical peculiarities of the spinal cord in that region. Lumbar compression rarely necessitates surgical decompression as the roots get accommodated easily; and, by the time they are pressed upon, other parts of the spine become affected, thus precluding surgery. In the recent years, with accurate localization of the compression, and the assessment of its extent in both vertical and axial planes by the MRI, the performance of a fiber optic intubation, the availability of rigid fixation, the presence of better facilities for operative site illumination, the introduction of specialized instrumentation during surgery for drilling and removal of the hard fluorotic bone and the institution of postoperative respiratory support, surgery has become safer and effective in alleviation of mechanical compression in fluorosis. It is, however, not known what happens to all these patients after surgery, when they go back to their endemic areas and again start to ingest high fluoride-containing water and food.
| » References|| |
Reddy DR, Skeletal fluorosis. In: Vinken PJ, Bruyn GW, editors. Handbook of Clinical Neurology. Vol. 36. Amsterdam: North Holland Publishing Co; 1979.p465-504.
Reddy DR, Ravishankar EV, Prasad V SSV, Muralidhara BN, Nayak RK, Prasad BCM, et al
. Minor trauma causing major cervical myelopathy in fluorosis. International Conference on Recent Advances in Neurotraumatology (ICRAN), Gold coast, 25-28th
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Reddy DR, Rao BD, Subramanian MV. Results of surgery in spinal compression due to skeletal fluorosis. Indian J Surg 1974;36:30-2.
Reddy DR, Prasad VS, Reddy JJ. Neuroradiology of skeletal fluorosis. Clin Neurosci Ann Acad Singapore 1993;22:493-500.