FAQ Category: General Spine

Chronic back and/or leg pain following spinal surgery is called failed back surgery syndrome (FBSS). Most people return to normal function and work quickly after back surgery. But in the case of FBSS, pain continues even with conservative care (pain relieving medications, physical therapy). It sounds like you’ve made the rounds of possible nonoperative care for this problem.

Finding an effective treatment for this condition has been a problem. Comparing the results of one treatment to another looking for the answer is ongoing. But we can report the results of a recent study that might help you. The study was done by Dr. Deyo (and associates), a well-known and often quoted researcher on the subject of back pain.

The topic was the cost-effectiveness of spinal cord stimulation for failed back surgery syndrome (FBSS) as compared to two other treatment methods. The group included 158 worker compensation patients diagnosed with FBSS.

This report is actually the second published paper based on data gathered and reported on earlier. The first study reported on the results of three separate treatment approaches. The three treatment groups included: 1) spinal cord stimulation, 2) pain clinic, and 3) usual care. This second look compares the costs associated with each treatment method. The most cost-effective treatment is discussed.

In the first study, the authors measured outcomes over a two-year period of time based on pain, disability, and use of opioid (narcotic) medications. They found that five per cent of the spinal cord group reached the treatment goals in these three areas. Only three per cent of the patients treated at the pain clinic met the outlined treatment goals. And 10 per cent of the group receiving usual care had a successful final outcome. Success was defined as at least a 50 per cent improvement in pain, less than daily use of opioids, and a two-point improvement on the disability score using the Roland Disability Questionnaire.

Now taking a look at the costs of each approach, it turns out that the spinal cord stimulation was the most expensive. And the added costs were not offset by better results or fewer visits to the doctor than the usual care approach.

The conclusion of this study was that usual care for failed back surgery syndrome is the most successful and least expensive course of treatment. Spinal cord stimulation was not a cost-effective approach to this problem. That being said, there are other studies that show patients who are helped by this treatment approach. The technique is always tried first before making it a permanent implant. So you may want to consider spinal cord stimulation on a trial basis and see what kind of results you get.

The procedure you mentioned (percutaneous vertebroplasty) is a common approach to the problem of vertebral compression fractures. But some of the newer research actually shows long-term results may not be any better than following a conservative treatment plan. The difference is in the immediate phase of healing — vertebroplasty does provide immediate pain relief for up to 80 per cent of the patients it is used on.

And there are the complications as you mentioned. Every effort is made to protect the patient and prevent any problems from occurring. But the fact is, complications do develop. Overall, the complication rate of percutaneous vertebroplasty is reported as 1.6 to 3.8 per cent. That is fairly low and based on meta-analyses (combining the results of many smaller studies together to see the overall complication rate).

Very severe complications like paralysis or even death are rare. One complication that may be more common is the leakage of the cement used into other areas. Studies report cement leakage in anywhere from five per cent of cases up to 87 per cent.

Leakage into the disc can cause the disc to harden and bulge thus putting pressure on the spinal cord or spinal nerve roots. Injection into the thoracic vertebra close to the heart could result in perforation of the heart itself.

Research efforts are underway to prevent cement leakage. One approach has been to look for individual patient risk factors or other variables that could be modified. If patients could be screened before surgery and identified as high risk for cement leakage, then perhaps the surgeon could do something different to change that. Or maybe patients at high risk just aren’t good candidates for this particular procedure.

A recent study from The Netherlands reported three major risk factors for cement leakage when using percutaneous vertebroplasty for osteoporotic vertebral compression fractures. First, leakage was more likely in the severe fractures. The presence of disc (cortical) disruption was another important risk factor. The surgeon doesn’t have control over either of those variables.

But the third risk factor is one surgeons can change and that is how viscous (thin or thick) the cement is. Low viscosity cements flow easily (they are less resistant to flow) so they fill in all the cracks in a bone fracture. This effect is good but the low viscosity also allows the fluid to seep into other areas. A higher viscosity cement clumps more and doesn’t spread as much so there is less leakage.

With the evidence available from this and other studies, it looks like the problem of cement leakage can be better managed. The surgeon can control the cement viscosity by selecting the cement with the best viscosity for the problem before injecting it into the bone.

three major risk factors for cement leakage when using percutaneous vertebroplasty for osteoporotic vertebral compression fractures. First, leakage was more likely in the severe fractures. The presence of disc (cortical) disruption was another important risk factor. The surgeon doesn’t have control over either of those variables.

But the third risk factor is one surgeons can change and that is how viscous (thin or thick) the cement is. Low viscosity cements flow easily (they are less resistant to flow) so they fill in all the cracks in a bone fracture. This effect is good but the low viscosity also allows the fluid to seep into other areas. A higher viscosity cement clumps more and doesn’t spread as much so there is less leakage.

The findings of this study highlight what surgeons have observed clinically about percutaneous vertebroplasty. Cement leakage occurs most often with severe vertebral compression fractures and when the disc has been compromised. With the evidence available from this and other studies, it looks like the problem of cement leakage can be better managed. The surgeon can control the cement viscosity by selecting the cement with the best viscosity for the problem before injecting it into the bone.

From your reading you now know that compression fractures are the most common type of fracture affecting the spine. A compression fracture of a spine bone (vertebra) causes the bone to collapse in height.

Compression fractures are most common in older adults as a result of osteoporosis (decreased bone density causing brittle bones). About 700,000 cases of compression fractures due to osteoporosis occur each year in the United States. Spine bones that are weakened from osteoporosis may become unable to support normal stress and pressure. As a result, something as simple as coughing, twisting, or lifting can cause a vertebra to fracture.

Research shows that the distribution of osteoporotic vertebral compression fractures varies. The most common vertebra affected is at the bottom of the thoracic spine where the lumbar spine begins (T12 and L1). But fractures occur anywhere from T5 to L5.

According to a recent study of 177 osteoporotic vertebral compression fractures (in 89 adults), the distribution follows a bell-shaped curve. There were five fractures at T5, 10 fractures each at T6 and T7. The number increased slightly to around 14 between T8 and 11. Then the largest number were at T12 (26 of the 177 fractures located here). At the L1 to L3 levels, there were between 20 and 26 fractures. The numbers gradually declined from 15 fractures at L3 to 11 at L4 and five at L5.

So you can see that a fracture at T5 (upper end of the thoracic spine) is less common than most other locations. The mechanism of injury (e.g., fall, twist, cough) and force placed on the bone may determine where the fracture develops. For example, a fall on the buttocks is more likely to fracture the lumbar spine than the upper thoracic vertebrae.

The person’s posture is also important. Older adults who are bent forward with their spine curved in kyphosis (forward curve) have very different load and force placed on the vertebral bodies when compared with upright posture. Likewise, a fall that results in the person hitting the back of the head and/or upper back could cause fractures higher up in the spine.

Whether it is “better” or “worse” to have a fracture at one level over another is not something that has been researched. The real factors that seem to make the most difference are the patient’s age, severity of fracture, type of fracture, and overall general health. The presence of other health care problems called comorbidities can slow down the healing process more than anything else.

Studies show that adults with osteoporosis may be six times more likely to develop scoliosis compared with someone who does not have osteoporosis. But other researchers have not been able to confirm a direct relationship between scoliosis and osteoporosis. It’s possible that age is the real underlying factor.

There are two main types of scoliosis in adults (based on cause or etiology). One is called adult idiopathic scoliosis (AIS). The other is degenerative scoliosis. Idiopathic means there is no known cause. Degenerative scoliosis is as the name suggests — a breakdown in the supportive structure of the spine that occurs as a result of the aging process.

At your mother’s age, it may be more likely that she is experiencing the degenerative type of scoliosis. And, again, by the time a woman goes through menopause and reaches her 80s, the chances of having decreased bone mineral density (osteoporosis) are pretty good.

The results of a recent study from Japan may help prove that adult scoliosis does not occur as a result of osteoporosis in postmenopausal women. They examined the medical records of 176 adult women between the ages of 26 and 82.

This study was designed to look at two separate bone density measurements: one in the lumbar spine and the other at the femoral neck (area of bone between the shaft of the thigh bone and the round bone at the top of the thigh bone). Dual energy radiograph absorptiometry or DXA scans were used to measure and compare bone mineral density at both sites.

The amount of bone loss was similar between hip and spine. And the amount of bone loss in adult women with scoliosis was pretty much the same (no statistical difference) as women the same age who did not have scoliosis. The main finding was that it was the older women in the study who were more likely to have decreased bone mineral density.

The authors think that the results of this study may help prove that adult scoliosis does not occur as a result of osteoporosis in postmenopausal women. And along the same lines, the spinal curvature won’t get worse if osteoporosis is present. It’s more likely that advancing age is the main reason why scoliosis curves develop and/or get worse in older women.

That is a good question and one that is being studied at various centers around the world. Most recently, there was a study from Japan investigating the relationship between scoliosis and osteoporosis.

The authors were interested in finding out if women with scoliosis were more likely to develop osteoporosis as a result of having the scoliosis. Other studies have suggested a link between osteoporosis and scoliosis. Does it go both ways?

They also analyzed the data to see if osteoporosis in adult women with scoliosis affects the final results of surgery. Success of the fusion, number and type of complications, and final scoliosis curve were used as measures of surgical outcomes.

They reported that the amount of bone loss in adult women with scoliosis was pretty much the same (no statistical difference) as women the same age who did not have scoliosis. As far as the results of the spinal fusion surgery, the fusion rate was excellent (93 per cent). The complication rate was 13.6 per cent. There was not a statistically significant relationship between the presence of osteoporosis and number of complications.

The authors think that the results of this study may help prove that adult scoliosis does not occur as a result of osteoporosis in postmenopausal women. And along the same lines, the spinal curvature won’t get worse if osteoporosis is present. It’s more likely that advancing age is the main reason why scoliosis curves develop and/or get worse in older women.

They suggest that having osteoporosis will not prevent bone fusion after spinal surgery. The bottom-line is that women (especially older women who have gone through menopause) can have spinal fusion for scoliosis. The procedure is safe and unaffected by the weaker bone structure so common in this age group. Further study on a larger number of patients including men is needed.

Your surgeon is really the best one to advise you. He or she will take into consideration all your individual risk factors (age, general health, severity of scoliosis and osteoporosis, activity level, mental function and so on). Don’t hesitate to ask this question — it’s a good one!

You may be referring to bone morphogenetic protein known as BMP-2 or BMP for short. BMP is a growth factor (protein) that helps bone heal and promotes bone fusion. It reportedly helps speed up the recovery rate after spinal fusion. BMP is designed to promote bone formation by setting up an inflammatory reaction. This type of enhancer was developed to avoid problems that occur with traditional bone grafting.

There are potential complications with any surgical procedure. Wound infection, hematomas (pockets of pooled blood), blood clots, and even death can occur. Older adults, especially those with other comorbidities (other health problems) such as diabetes, heart disease, or lung conditions may be at increased risk from blood clots, stroke, and pneumonia. In rare cases, death from any of these more serious conditions can occur after surgery.

Spinal fusion has a few complications all of its own — depending on how the procedure is done. For example, fusion from the front (anterior approach) of the cervical spine (neck) can cause damage to the vocal cords. Incision and surgery from the back (posterior approach) can create injury to the spinal cord or nerves to the arms and legs leaving the spinal cord.

In the case of bone morphogenetic protein (BMP), the bone growth can be “too” successful. In other words, there can be an overgrowth of bone called ectopic bone. The extra bone can press on nerve tissue causing problems.

But according to a recent study of almost 12,000 patients the risk of complications is the same with or without BMP. The one exception occurs when BMP is used for anterior cervical spinal fusions. Wound infection and hematoma formation were the two most common problems associated with anterior cervical spinal fusion using BMP.

All other spinal fusions with and without BMP had an equal number of complications (around eight per cent for both groups). This is an important finding because if the risk of using BMP during spinal fusions is greater than the benefit, then the surgeon may not want to use BMP. Factors of this type must be taken into consideration when planning spinal fusion procedures.

The authors concluded from this study that using BMP as a bone enhancer to foster bone fusion does not increase the risk of complications. This is true EXCEPT when the procedure is an anterior cervical spine (neck) fusion. Your surgeon will advise you according to all of your own individual factors (age, general health, type of surgery). Don’t hesitate to ask him or her this question. With this information in hand, you will be better prepared to understand the procedure and clear up any other questions you might have.

Efforts to find ways to heal and/or restore degenerative discs have been in the mix for quite some time now. Most of the studies have been on animals such as mice, rats, rabbits, minipigs, and other small animals.

Gene therapy is one of several forms of treatment for degenerative disc disease referred to as biologic therapy. The healthy replacement gene is attached to a transportation unit called a vector (like a taxicab driver who takes you where you are going).

Most gene transfer methods use viruses as the vector. This works well to get the gene inside the cell but then the immune system starts to kill off the viral vector. The result may be illness from the virus as well as a die-off of the genes.

Gene therapy is a favored form of biologic therapy because no injection is required. Most of the other biologic therapies are injected into the disc. The injection damages the cells and sets up an inflammatory response that can make things worse instead of better.

No direct studies have been done in this area yet on humans. There are other types of biologic therapies under investigation as well. Like gene therapy, most are still being done in animals. The switch from animals to humans will only take place when the techniques have been proven safe and effective in animal studies.

Degenerative disc disease is an example of something that affects most people as they get older. Everyone is going to have a certain amount of damage to the spine. This occurs throughout a lifetime. The discs can flatten, and protrude from between the bones. In time, most people will have small tears in the outer layers of these discs.

Finding ways to repair damage to the discs is the focus of many research studies. One of the most recent directions in research has been the use of biologic therapies to restore the disc. Examples of these treatment approaches include disc cell reimplantation, stem cell implantation, disc denervation, injection of therapeutic proteins, and gene therapy.

Stem cells are the basic cells from which all other cells are formed. Attempts to inject stem cells into the disc (called stem cells implantation) so that they will form new disc cells have been limited. The internal cell environment of degenerated disc tissue is acidic and that doesn’t support new life very well. As a result, the stem cells are often quickly killed.

Stem cell studies for the treatment of degenerative disc disease have been limited with mixed results reported. Some of the newer studies are trying different ways to inject the stem cells into the cells. Others are looking for ways to keep the stem cells alive long enough to reproduce.

Efforts at stem cell implantation have been successful enough with small animals that scientists are trying to repeat the same studies on larger animals. They started with mice and rats and have moved to rabbits and minipigs (slightly larger than rabbits).

According to a recent review from orthopedic surgeons at the Thomas Jefferson University (Philadelphia), studies using stem cells on humans for degenerative disc disease have not been reported yet.

BMP stands for bone morphogenetic protein. Rh-BMP-2 is a protein that helps bone heal. BMP reportedly helps speed up the recovery rate after spinal fusion. BMP is designed to promote bone formation by setting up an inflammatory reaction. This type of enhancer was developed to avoid problems that occur with traditional bone grafting.

Original studies were very positive about the use of this product. No adverse effects were reported but most of those studies were done (or funded by) the companies that developed BMP products. Later, private researchers with no ties to the developers or manufacturers of BMP observed up to a 50 per cent increase in risk of complications specifically linked with BMP.

As it turns out, cancer is one of those risks. As a product designed to stimulate bone growth, BMP may actually trigger cell growth resulting in cancer. The complication is for sure — the biologic mechanism by which it happens remains uncertain.

Not all patients who received BMP developed cancer so there may be other factors involved. In one study using a particular BMP product, the reported rate of cancer was 3.8 per cent. This compared to a 0.89 per cent rate of new cancer growth in patients who had a fusion using their own bone graft material.

There was some speculation at the time that a higher dose of rhBMP-2 might be the problem. Or perhaps there is a specific ingredient in the BMP that is to blame. Further studies are needed to verify these theories.

If you develop any suspicious symptoms, don’t hesitate to report these to your physician. An early diagnosis of any kind of complication can help minimize negative effects of the problem.

Any surgery comes with complications otherwise known as potential adverse events in medical lingo. There can be infections, blood clots, delayed wound healing, and so on. In the case of spinal fusion, there is a whole set of possible additional problems specific to that procedure including sterility.

Here’s what can happen. Devices called implants or cages placed between two vertebrae replace the disc that was removed as part of the fusion procedure. These devices can shift out of position or sink into the bone putting pressure on nerve tissue. Accidental cutting of the nerve tissue during the operation can also occur. Damage to the spinal cord and/or spinal nerve roots can result in bladder retention of urine and retrograde ejaculation. These complications have been reported.

Men are at risk for damage to the nerves controlling penis erection and ejaculation. With retrograde ejaculation, semen goes backwards and into the bladder instead of forward and out the penis. Not everyone recovers from this problem. In fact, only about one-third regain complete sexual function.

Retrograde ejaculation may not be life-threatening, but it is a very serious problem for those who develop this complication. Loss of sexual function and sterility (inability to have children) can adversely affect mental and emotional health as well as quality of life.

The exact rate at which this happens is not known. Studies show that urine retention after surgery is the most likely problem. Traditional bone graft spinal fusions have about a 3.6 per cent rate of urogenital problems. That is compared with a 7.9 per cent when bone substitute (called rh-BMP-2) is used. The overall breakdown as to how many of these cases are urine retention and how many are linked to retrograde ejaculation isn’t available.

If you are not having any problems urinating or getting an erection and ejaculating, you are not likely to develop any of these complications. But if you do experience any of these symptoms, see your doctor right away. There could be any number of reasons for these symptoms. Spinal fusion is just one (minor) cause.

The results of a recent study showed that major league baseball pitchers can recover from a neck or back disc herniation. It may take a while but they can even return-to-play after surgical treatment.

How did they come to this conclusion? Public records were searched for information from 1984 to 2009. They found 40 major league baseball pitchers with a history of disc herniation and then followed the results of treatment.

Everyone included in the study had surgery for the problem. They either had a spinal fusion or a disc replacement. Although return-to-play status was the defining measure of success, there were other factors assessed. How long it took to go from the last game player before injury back to the playing field was one of those measures.

According to the statistical analysis of the 40 pitchers in the study, it takes an average of about one year for players with neck herniations to fully recover fully. And players with a low back disc herniation experience an average of seven months between injury and return-to-play. That’s a full season at least for both groups. But if the injury occurs mid-season, then a seven to 12-month period of time can extend into two seasons.

What about performance for these players? By performance we are talking about pitching statistics such as earned run average, innings pitched, and walks plus hits per innings. By comparing the pitcher’s pre-injury stats to his post-injury performance, it is possible to see if his pitching performance is better-same-or-worse from preinjury to post-treatment.

A closer look at all the data showed that the biggest before and after surgery difference was in the number of innings pitched per season. In both groups (pitchers with cervical or lumbar disc herniations), players pitched fewer innings after surgery.

When those statistics were compared to players with similar injuries treated conservatively (nonoperative care), the players in the nonoperative group had better post-treatment stats. The major difference was in the number of players who were able to return-to-play in the conservative care group (far less than in the surgical group).

Major league baseball pitchers with disc herniations can indeed recover and return to sports action as good as ever. The disc injury does not necessarily mean the end of a career or even reduced performance. But expect a season or even two to go by before finding your favorite number in the dugout.

No matter what kind of surgery a person has (even the most minor procedure) comes with a list of possible risks. Those risks range from a simple skin infection to loss of limb and even loss of life. In the case of spinal surgery, there is always, always a risk of something more serious like permanent paralysis or death (which is also very permanent).

Your surgeon is being very conscientious to prepare you by counseling you. Be assured that the risk of new neurologic problems developing is fairly low (around one per cent). That means out of every 100 patients develops damage to the spinal nerve roots, cauda equina, or the spinal cord itself.

It is possible to review a client’s background and case to see who is at greatest risk and why. The “who” question was answered in a recent study reported on by the Scoliosis Research Society Morbidity and Mortality Committee.

This committee of fellowship-trained spine surgeons from many practice settings provided data on over 100,000 cases of spine surgery. The information gathered was analyzed in several different ways to get different perspectives on the problem of neurologic complications associated with spinal surgery.

Types of information collected included patient age, main diagnosis, type of surgery, types of complications, and amount of recovery. The rates of recovery were fairly high (93 per cent partial-to-full recovery) with only 4.7 per cent who had no recovery (permanent partial or complete paralysis).

Anyone requiring a revision (second) surgery was actually at the greatest risk for complications. Children had higher rates of new neurologic problems developing and especially those who required the use of instrumentation (fixation such as metal plates, rods, and screws or pins) to help fuse the spine.

Your surgeon is just doing her job in offering you counsel and education about your condition, its treatment, and the risks involved.

Compression fractures are the most common type of fracture affecting the spine. Multiple-level vertebral compression fractures are commonly the result of osteoporosis. Spine bones weakened from osteoporosis (brittle bones) may become unable to support normal stress and pressure. As a result, something as simple as coughing, twisting, or lifting can cause a vertebra to fracture.

That’s where a balloon kyphoplasty comes in. Long needles are inserted through one or both sides of the spinal column into the fractured vertebral body. These needles guide the surgeon while drilling holes into the vertebral body. The surgeon uses a fluoroscope (special 3-D real-time X-rays) to make sure the needles and drill holes are placed in the right spot.

The surgeon then slides a hollow tube with a deflated balloon on the end through the drill hole. Inflating the balloons restores the height of the vertebral body and corrects the kyphosis deformity.

Before the procedure is complete, the surgeon injects bone cement into the hollow space formed by the balloon. The cement is injected a little bit at a time until the cavity is filled. They try to keep most of the cement in the front three-fourths of the vertebral body. This fixes the bone in its corrected size and position and supports the front part that has collapsed the most.

This procedure halts severe pain and strengthens the fractured bone. However, it also gives the advantage of improving some or all of the lost height in the vertebral body, helping prevent or correct kyphosis.

As you have just found out, this procedure can be done by inserting the needle from one side (unilateral) of the vertebral bone or from both sides (bilateral). There are potential advantages and disadvantages with both techniques.

Safety is always an issue with any spinal procedure. Inserting needles from both sides of the spine has the potential to create more problems and complications compared with a unilateral approach.

The idea of doing the procedure from both sides is that this would provide a more even lift of the collapsed vertebra. Another potential advantage of the bilateral injection is to create a large cavity to inject as much cement as possible.

On the other hand, a unilateral approach takes less time. This advantage translates into money that can be saved with shorter operative procedures. With less time required to complete the kyphoplasty, the patient is exposed to less radiation from X-rays (fluoroscopy).

A unilateral approach reduces the risk of puncturing nerves or blood vessels with the needles. Inserting one instead of two needles also reduces the chances of fracturing a bone unintentionally.

Studies show that the unilateral approach is both safe and effective. Strength of vertebral repair and stiffness are not compromised in any way. According to one recent study, all corrections made through this procedure are maintained for at least two years.

Back pain can be a very disabling problem that alters a person’s life in so many ways. As you have seen first hand, quality of life suffers. Depression is common. Suicide may be tempting. But how often do people with back pain really end their lives because of it? And how does that compare to the number of people who commit suicide who don’t have back pain?

Recently, researchers using hospital discharge records investigated suicide among people with back pain. They collected information from hospital charts for patients with and without musculoskeletal diseases and compared suicide rates. They also looked at differences in age, gender, history of mental illness, method of suicide, and alcohol and other drug abuse at the time of the suicide.

There were over 2300 suicides in patients treated at a hospital for musculoskeletal problems. The data was taken from the required hospital discharge records. Analysis of the data collected showed that men were four times more likely to complete a suicide than women.

Women who committed suicide did so most often in a nonviolent way (e.g., drug overdose). Autopsy reports were used to assess the use of alcohol or other drugs at the time of the death. The reports showed that women with back pain were more likely to be drinking when they died.

Knowing what to look for and recognizing red flag warning signs in your wife’s situation can be very helpful in identifying the risk of suicide. Getting help may begin with a return visit to the physician overseeing her care.

With your concerns about suicide, it may be time for a mental health expert to be a part of her team. Suicide assessment, counseling, and suicide prevention could make the difference for her if she has turned a corner in her own abilities to cope.

If pain control is a problem, then it may be time to try a different approach. There are many pain clinics that specialize in helping people like your wife. Patients who have lived with chronic pain can often gain better control over their symptoms with a change in medication or using other treatment tools now available.

There was a recent study from the PRIDE Research Foundation in Dallas Texas. They evaluated both the Oswestry Disability Index (ODI) and the Short Form-36 (SF-36) in relation to work retention (getting back to work).

As you probably know, when using these assessment tools, the minimum clinical important difference (MCID) is evaluated. The MCID is defined as “the smallest change or difference in results that is beneficial and leads to a change in how the patient is treated.”

For those who are not familiar with what that means — rehab specialists need assessment tools that actually measure an important change (or amount of change) as a result of treatment. If these commonly used tests don’t give that information, then the time it takes to administer the test and calculate the results just isn’t worth it.

As it turns out, neither the Oswestry Disability Index nor the Short Form-36 measured the amount of change that would predict employment a year after treatment. More than three-fourths of the group (77 per cent) in the study did get back to work.

There were enough success stories that if the measuring tools were going to be predictive, they would have shown some type of minimum clinical important difference (MCID). But they didn’t because what they were measuring wasn’t linked with the final outcome of getting back to work.

So you may be onto something with your question — it’s a question others have asked and are actively studying. More study is needed to find a way to predict individual patient improvement that will lead to a return-to-work status as the final outcome.

There is some evidence to suggest that the longer a worker is out on disability, the less likely he or she will recover enough to return-to-work. Other factors that seem to predict work status after treatment include gender (females are less likely to get back to work) and age (older patients are more likely to take permanent disability).

Some experts suggest that it is more socially acceptable for women to stay home and not work. With older workers, work fatigue (just plain tired of working or tired of that particular job) may enter into the picture.

Also, older workers may have more degenerative changes that make it harder to get through rehab successfully. Anyone over 50 will probably need more time (longer recovery) but that doesn’t mean it’s impossible to get back to work.

Some workers must accept less than their pre-injury work status. In other words, they may reduce their hours from full-time to part-time. Or they may move into a different (modified) position with the same company.

Any of these scenarios may be temporary — in time, with continued work toward full recovery, some workers will manage to return to their desired position full-time. Your motivation to succeed is your strongest asset. Don’t let this one statistic hold you back. Such figures are averages that include people who do better and those who do worse.

There is more and more evidence to support minimally invasive procedures. Studies show that patients recover faster with less time in the hospital and fewer costs. They return to daily activities and work sooner, too. In the hands of a skilled surgeon, the procedure is safe and effective with less tissue damage, less blood loss, and less post-operative pain.

The use of a tubular retractor with minimally invasive procedures (instead of the self-retaining type of retraction used with open incision surgery) has reduced the incidence of crush injuries to the muscles, blood vessels, and nerves.

Loss of blood supply to the muscles and damage to the nerves from the self-retaining retraction often meant the patient never regained the muscle strength needed to support the spine. The result was often chronic back pain and weakness, a condition referred to as failed back surgery syndrome. This set of complications has been diminished greatly with the tubular retraction used with minimally invasive spinal surgery.

There are some drawbacks to minimally invasive surgery (MIS) and some potential complications. Surgeons who are not doing MIS say it is because the opportunity to learn this technique is limited. Intra-operative and post-operative problems are much higher when the surgeon is gaining experience. The technical difficulties can be overcome with training and practice but it takes time.

The procedure does require the use of fluoroscopy, a type of real-time X-ray. Exposure to radiation from the fluoroscopy is at low levels and fairly limited (one to four minutes). The danger is really more for the surgeon and operating room staff who are exposed with each patient.

As with any spinal surgery (whether open or via minimally invasive approaches), there is always a risk of blood clot formation, bone fracture, nerve damage, or screws going in at a wrong angle or backing out after surgery.

The American Academy of Orthopaedic Surgeons (AAOS) has recently published an instructional course lecture for spine surgeons on the subject of minimally invasive spine surgery (MISS).

They bring us all up-to-date on the current state of minimally invasive spine surgery (MISS). MISS means, it is a way to reach the spine through the skin and soft tissues without cutting through all the muscles and many tendons. Instead of a large, open incision the surgeon makes small slits in the skin and slips a tube down to the target site (usually vertebral bone or disc).

Surgical tools needed to perform any of the procedures mentioned reach the target tissue through the tube. A tiny TV camera on the end transmits real-time pictures to a screen to guide the surgeon. That sounds very simple and in a way, it is (compared to open incision and dissection or cutting through all the soft tissues).

The replacement of self-retaining retractors (used during an open procedure) by the tubular retractor (used during a minimally invasive spinal surgery) was a major turning point in spinal surgery. The self-retaining retractors pulled the soft tissue apart after incisions were made. This allowed the surgeon to gain access to the spine.

But the force of the self-retaining type of retraction caused crush injuries to the muscles, blood vessels, and nerves. Replacement with the tubular retractor changed all that. Loss of blood supply to the muscles and damage to the nerves often meant the patient never regained the muscle strength needed to support the spine. The result was often chronic back pain and weakness, a condition referred to as failed back surgery syndrome.

Studies show that even at the cellular level, the goals of minimally invasive spinal surgery (to reduce soft tissue injury and speed recovery) are met. Blood studies show that all levels of biomarkers for tissue injury return to normal much faster after minimally invasive surgery.

According to this course lecture on minimally invasive spinal surgery, the technique is replacing the traditional open incision approach. There is more and more evidence to support minimally invasive procedures.

Studies show that patients recover faster with less time in the hospital and fewer costs. They return to daily activities and work sooner, too. In the hands of a skilled surgeon, the procedure is safe and effective with less tissue damage, less blood loss, and less post-operative pain.

It’s likely that your mother has age-related spinal fractures from osteoporosis. Osteoporosis is a very common disorder affecting the skeleton. In a patient with osteoporosis, the bones begin losing their minerals and support beams, leaving the skeleton brittle and prone to fractures.

In the U.S., 10 million individuals are estimated to already have the disease and almost 34 million more have low bone mass, placing them at increased risk for osteoporosis. Of the 10 million Americans affected by osteoporosis, eight million are women and two million are men. Most of them over age 65

Maintaining bone mass gets more difficult as we get older. Age makes building bone mass more difficult. In women, the loss of estrogen at menopause can cause the bones to lose density very rapidly.

The bone cells responsible for building new bone are called osteoblasts. Stimulating the creation of osteoblasts helps your body build bone and improve bone density. The bone cells involved in degeneration of the bones are called osteoclasts. Interfering with the action of the osteoclasts can slow down bone loss.

That’s where calcitonin comes in. Calcitonin is a non-sex, non-steroid hormone. Calcitonin binds to osteoclasts (the bone cells that reabsorb bone). It decreases osteoclast numbers and activity levels. The end result is that it prevents bone from melting away. It doesn’t build up missing bone but it at least keeps the bone that’s there from being broken down and reabsorbed.

Calcitonin is available in a nasal spray and should be used for osteoporotic spinal fractures within five days of the injury. Calcitonin has been shown to relieve pain when tested in four different positions (e.g., in bed, sitting, standing, and walking).

Since your mother has had a recent (acute) spinal fracture, the use of calcitonin is advised. In fact, studies show that the use of calcitonin early after vertebral compression fractures can significantly reduce pain if used in the first five days of the fracture event.

Improving and even eliminating pain helps patients get back up on their feet, moving and active. The simple act of getting out of bed and moving can help prevent many, many other problems associated with spinal fractures.

This is a hard question to answer because there are so many levels of consideration. We’ll try and cover as many as possible to help you sort through all that has happened. First (and maybe a shock to you) but there really isn’t sufficient evidence to support the current policy we all follow regarding the need to stabilize the head and neck after a traumatic injury.

In fact, there have even been studies that show better outcomes when patients were NOT immobilized in a neck collar and strapped to a rigid back board. In those cited studies, trauma patients who were treated in the manner we have come to expect (and as you described) had worse results.

All that aside, the battlefield has its own unique circumstances to consider. Once a soldier is down on the battlefield, the nearest service member or combat medic attempts to get him or her as far from the front line action as possible. If under enemy attack or fire, it may not be possible to protect the spinal cord from further injury. The hard cold fact is that the risk of death outweighs the risk of spinal cord injury. And keep in mind, not only are these folks often still under attack, there is often more than one comrade down and in need of care.

Resources are limited on the battlefield. There may not be enough backboards and protective neck guards to go around. Medics learn how to evaluate each injured soldier for risk of spinal cord injury. Red flags suggesting a need for immobilization include altered consciousness (e.g., amnesia), unconscious state, or paralysis (even if only temporary). Type of injury can also raise a warning flag. Soldiers involved in explosion or blast, fall from height, ejection from vehicle, or vehicle rollover are assessed carefully for the need to immobilize.

None of this information takes away the wonder and “what ifs” that many people (patients and their families) experience after a traumatic injury of this type. Your positive attitude is essential in going forward in this difficult situation.