FAQ Category: Lumbar Spine

Back pain is very common, more so lower back pain than upper back pain. The explanation really involves body mechanics. It is the lower back that takes the brunt of our every day movement and work. When you bend, twist, or lift something, the stress is on the lower spine.

This isn’t to say that the upper back doesn’t work nor does it not get injured – it’s just that the lower back is the hardest working part and is, therefore, more prone to injury.

Anyone working long hours at a desk job has probably wondered if sitting so much will eventually lead to back pain. It makes sense that there might be some risk with long hours of sitting. This position puts pressure on the pubic bones, increases downward compression through the discs, and increases spinal muscle activity. And many workers seem to experience low back pain that reduces work hours and productivity.

But a recent review of all studies available makes it clear that working in a sitting position for long periods of time is not a risk factor for low back pain. Researchers from Canada scoured the literature of published studies from around the world on this topic. There were articles published from the Netherlands, Iran, Nigeria, Sweden, the USA, Finland, Greece, Belgium, England, China, Germany, and Denmark. Of the 2766 studies initially identified as possible sources of good information, only five were high-quality and therefore included in this review.

But the conclusion of those five studies was consistent: there was no link between occupational sitting and low back pain — not in nurses, not in construction workers, or anyone else for that matter. In fact, if anything, there was some evidence that sitting protects the back. That makes sense when sitting is compared with occupations that involve activities such as lifting, carrying, twisting, and bending.

Whether or not sitting results in a flexed or bent position of the hips and spine has not been the focus of research. Even if you can’t leave your desk area, it might be a good idea to stand up and stretch every 30 to 60 minutes. Give your muscles a break, swing your arms to restore blood flow and oxygen, take a deep breath, then sit back down again. You may even be able to do this while on a call when there is a short period of wait time.

Physicians know that X-rays, CT scans, and MRIs don’t really contain the rest of the story. Many patients have all kinds of changes in the lumbar spine but no symptoms — no pain, no change in sensation. There can be narrowing of the disc spaces, spinal stenosis (narrowing of the spinal canal), spinal joint arthritis, and even tiny fractures called spondylolysis but no one knows about it until X-rays or other imaging studies are done for something else.

Most of the folks who have what looks like significant changes of this type in the spine are older adults (65 years old and older). Low back pain can be a common symptom in this age group. So, how much of these changes (and which ones) are linked with back pain? That’s been the focus of many researchers for quite some time.

A recent study from Boston University School of Medicine looked at the results of CT scans as a diagnostic tool. They found that although the CT scans gave a good look at the finer details of spinal anatomy, only spinal stenosis was really associated with low back pain — and a plain X-ray can show stenosis, so CT scans aren’t needed for routine evaluation.

MRIs are able to detect changes in the water content of the bones, discs, muscles, and other soft tissues. Disc abnormalities are easily viewed with an MRI. But again, many of the degenerative age-related changes observed don’t predict or correlate with back pain. So unless the physician suspects a disc protrusion, tumor, infection, or fracture, the use of more expensive imaging studies such as MRI is not advised.

Spine research has been done on a group of patients already enrolled in the world famous Framingham heart studies. Those individuals live in Framingham, Massachusetts and participate in a lifelong study of health (especially heart health). In the process of being examined, they each have CT scans done to look for blood vessel calcification (hardening and blockage of the arteries). The imaging studies also show the structures of the spine from early age on through adult life.

Advanced imaging of a subgroup within the study (people who reported back pain in the last 12 months) showed a wide range of degenerative changes as described above. Most notable was the high incidence of disc narrowing and spinal joint arthritis observed in two-thirds of the group. The researchers then started analyzing data collected about the patients to see if there were any links between low back pain, age, gender, and body mass index with degenerative structural changes in the spine.

What they found was that only spinal stenosis was significantly associated with low back pain. Disc narrowing, facet (spinal) joint arthritis, changes in the spinal muscle size, and spondylolysis are common but were NOT directly linked with low back pain. There was an association between low-density muscles of the spine (multifidus and erector spinae) and arthritic changes observed in the facet joints. Exactly what that means remains to be determined.

So it sounds like you may be very typical of an adult in the eighth decade of life (ages 70 to 80) and very fortunate, indeed, not to have experienced any back pain up until now. Keep up with the exercise because as every physician knows, exercise is medicine and probably the most powerful prevention tool available to everyone for free.

Chronic lower back pain is a very common problem in our society. It’s estimated that just about everyone will experience lower back pain at least once in their life, with many living with chronic pain. There are many causes for lower back pain, not all of them are preventable. That being said, many are preventable and there should be an emphasis on this.

Many jobs that require lifting and physical work do focus on proper body mechanics, in an effort to prevent back injuries. But that’s not enough because back injuries happen outside of work either while doing household chores are just having fun on the weekends. Two important risk factors for back injuries could be eliminated with certain lifestyle choices: being overweight and/or being sedentary. If you are overweight, this places a burden on the body, including the back and if you are sedentary, your muscles won’t be as strong as they could be, making it more difficult for your back to do its work properly.

The lower part of your back is meant to help support your upper body stay upright. Every time you bend at the waist, the lower back takes on the weight of he upper body and has to hold it against gravity – this means more force on the spine. Even if you are just bending to pick up a pencil, there is an unnatural force working on your back. Then, if you bend over and lift something, the lower back has your body weight plus the weight of the object you are holding.

If you want to lift correctly, reducing the risk of injuring your back, the proper way to lower yourself is by using your legs. Your thigh and leg muscles are much stronger than your back and are meant for bearing weight. By keeping your back upright, bending your knees, and then lifting, the bulk of the weight is on the legs.

Back pain seems to be the most common musculoskeletal complaint in the Western world. Doctors see more back pain than any other muscle or bone-related condition. There are many explanations as to why back pain occurs, from trauma to wear-and-tear of the spine.

Lifestyle plays a role in back pain as well. We don’t move as much as generations before us. Add to that an unhealthy lifestyle that leads to carrying too much weight, this can all equal lower back pain.

Lumbar spinal stenosis is a narrowing of the spinal canal where the spinal cord travels from the brain down to the end of the spine. The spinal cord ends around the first or second lumbar vertebrae in most people. Below that level, the cord splits off into many smaller branches called the cauda equina. Equina means horse. The cauda equina with its many separate nerves resembles a horse’s tail.

Anything that obstructs or fills in the spinal canal can cause stenosis. That could be a tumor, infection, bone fragments from a fracture, disc material from a herniated disc, or inflammatory process. The most common cause of stenosis is age-related.

Over time as the discs start to degenerate and break down, the vertebral bones compress together. This puts more load and pressure on the spinal joints. The constant rubbing of the joints together causes bone spurs to form called osteophytes. The spinal ligaments start to thicken, get caught between the bones, and push against the spinal cord.

Spinal stenosis can also develop as a result of tiny fractures in the supporting column of the bones. The main body of the vertebra shifts forward over the vertebra below it. This condition is called spondylolisthesis.

Degenerative spondylolisthesis tells us the problem has developed over time due to age-related changes. One of the most common age-related changes is osteoporosis (decreased bone density). Post-menopausal women are affected by this most often. In fact the ratio between women and men is 6:1 (for every six women with this condition, only one male is affected).

Although preventing the problem isn’t always possible, there is treatment for it that can be effective in minimizing symptoms and keeping it from progressing (getting worse). Conservative care is usually tried first. That might include bed rest, antiinflammatory medications, pain relievers, physical therapy, and steroids when necessary. If conservative care fails to help, then surgery to stabilize the spine may be the next step.

To get a better understanding of your own condition, ask your surgeon to show you the X-rays or other imaging studies and explain what’s going on in your body. With this knowledge you will be able to make reasonable decisions about your own plan of care.

Stenosis or a narrowing of the spinal canal can cause low back, buttock, and leg pain that is worse when standing up straight, standing for long periods of time, or walking. Spinal extension narrows the spinal canal even more. Patients with this problem tend to avoid that movement and end up in a forward bent posture. That bent forward position may help alleviate some of their symptoms but it puts a lot of pressure on the front part of the vertebral bodies and can result in compression fractures.

All efforts to study this problem have assured us that conservative care (without surgery) can really benefit these patients. Sometimes a simple pain reliever combined with antiinflammatory medications is enough to reduce the pain and allow the patient to resume a more normal upright position.

Bed rest during the worst flare-ups may be advised but in general, too much bed rest has more bad effects than benefits. Getting control of the pain, staying active, and restoring normal movement are the keys to managing this problem. And it is a matter of management because without surgery to open up those pathways, the underlying pathology won’t change.

Even if the patient has multiple levels of stenosis, if the vertebrae are in good alignment, they do well with nonoperative care. When surgery is the treatment of choice, results are not better for single level versus multiple level stenosis when stenosis is the only problem present.

There’s no reason not to try a six to 12 week course of conservative care. Medications combined with physical therapy can be effective. Surgery can always be considered later if needed. Delaying surgery for a long as possible does not affect results later. In fact, even with multilevel spinal stenosis, patients can get better with conservative management resulting in less intense symptoms and improved daily function.

Spinal fusion is a commonly used way to stabilize one or more segments of the spine in older adults. A spinal fusion procedure is also known as a spinal arthrodesis. There are several different ways to perform this operation. The simplest and most often studied technique is the posterolateral spine fusion.

Patients are placed face down (prone) on a special surgical table called a Wilson frame. This frame can be adjusted to place the spine in the exact amount of curvature (flexion or extension) needed to give the surgeon access to the spine while limiting blood loss as much as possible.

To describe the basic fusion procedure in layman’s terms, the surgeon makes the necessary incision down to the bone, then divides the fascia (connective tissue covering the muscles and spine). The muscles are cut away (enough to get to the spine). The surgeon removes the cartilage around the facet (spinal) joint and then removes enough bone along the sides to form a gutter. This depression is where the bone graft will be placed for the fusion.

Screws are used to hold the segments together (one above and one below) until the fusion takes hold. X-rays are used to make sure the screws are in the right spot for optimal stability. Once the screws are in place, additional bone is shaved or cut away, a procedure called decortication. The screws are locked together with a supporting (vertical) rod between the two segments being fused. The final step involves packing the gutters with bone graft material.

It used to be that surgeons would remove some of the patient’s own pelvic bone to use as an autograft (bone donated to oneself). But more and more, bone from a bone bank is used supplemented by newer materials that work much better. These newer graft substitutes are made up of bone marrow, bone morphogenetic proteins (growth factors), and even ceramic material.

One final X-ray is taken to make sure everything is in place where it should be before closing the incision. Patients are followed routinely to make sure the graft material fills in and stabilizes the segment. This may not describe the exact steps your surgeon will take but it may help you make sense of what you saw on the video. It might not be a bad idea to view the video again with this information in hand. And you might want to double check to make sure the film really is without narration — perhaps there is a way to turn on sound that was missing the first time around.

You may have found what is the first mention of a rare complication with X-stop devices. X-stops are spacers placed between two vertebrae to hold them apart. They are used to manage various degenerative conditions of the lumbar spine such as spinal stenosis (narrowing of the spinal canal) and disc degeneration.

The surgeon implants the X-stop between the spinous processes — not between the main bodies of the vertebrae. The device is called an X-stop because it stops the movement of spinal extension at that level. The spinous process is the bony projection off the vertebra that you feel as you run your hand down along your spine.
The device is called an X-stop because it stops the movement of spinal extension at that level.

Neurosurgeons from Italy recently published a paper reporting a fracture of the spinous process in three patients who had double-level X-stop devices. Double-level means there were two X-stops: one between the spinous processes of L3 and L4 and another between L4 and L5. The surgeons named this new type of fracture the sandwich phenomenon because the broken spinous process (L4) is sandwiched between two X-stop distractors.

Although X-stop is a fairly new treatment technique, two-level implants of this type have been used in many patients around the world without problems. The atraumatic fractures described in this report affected three men of different ages. It is considered a rare postoperative complication.

What causes a spontaneous fracture like this? That presents an unsolved puzzle. There could be some anatomic difference in these three men contributing to the fracture. But what exactly that difference is remains a mystery. There was no sign of osteoporosis (decreased bone density leading to brittle bones) that could account for the fracture. The double-level procedure was the most likely key feature.

The authors of this report suggest a possible piston effect on the spinous process. The X-stop above and below the process applied pressure to the bone with every spinal movement until it finally snapped. They concluded that despite this rare sandwich phenomenon, X-stop implants are still safe and effective.

Like many people who are facing new symptoms after a successful spine surgery, you have answered your own question. Yes, you should make a follow-up appointment with the surgeon as soon as possible. It may be nothing and the symptoms could go away on their own. But delayed post-operative problems can develop. The sooner the symptoms are diagnosed and treated, the better your outcomes.

The surgeon will likely start with an X-ray to see if there are any obvious signs of trouble. The implant may have shifted causing locally increased stress forces. The result could be a stress fracture in the bones around the device. Or there could be an entirely new and different problem starting to develop. Finally, as you may be hoping — perhaps this is a temporary situation that will go away without doing anything.

The X-stop device works well to distract and separate two vertebrae in the lumbar spine. And that distraction is enough to take pressure off the spinal nerve roots. Recurrence of symptoms is a signal that something may be irritating or compressing the spinal nerve roots.

Follow your own intuition (gut feeling) and make a phone call to your surgeon today.

A transverse fracture means the break went through the sacral bone in a horizontal fashion. It can be nondisplaced (fracture has not separated) or displaced (separated or shifted apart). In severe injuries, the separated pieces of the sacrum can shift apart and then overlap one another. Any change in the normal anatomical alignment in this area can put pressure on the cauda equina (nerve tissue at the end of the spinal cord). Serious neurologic problems such as loss of sensation and/or loss of bowel and/or bladder function can develop.

Surgery is done right away when there is a need to protect the cauda equina before neurologic these problems develop or become permanent. The surgeon removes a portion of the sacrum that is pressing on the nerve tissue. This procedure is called a decompression surgery. If the fracture can’t be reduced (bone fragments put back together), then a metal plate and/or screws are used to hold it together.

Surgery isn’t always required with transverse sacral fractures. If the fracture isn’t displaced (separated) and the patient doesn’t have any neurologic damage, then conservative (nonoperative) care may be all that’s needed. But severe fractures with displacement, bony malalignment, and/or any sign of neurologic compromise warrants an immediate surgical procedure.

Some experts suggest that surgery can be preventive in a way. If the fracture looks stable but develops a large bone callus during the healing phase that presses on nerve tissue, then it would have been better to operate early on. The same thing applies if the bone fragments move after the imaging study showed they were lined up and stable.

These cases are so rare, no one knows how to predict when those complications might occur and prevent them in any other way than by doing early surgery. This is especially true when you consider that these fractures are difficult to treat and displacement of the bones only makes it that much harder to realign and stabilize them.

Despite our many advances in medicine and especially all the improved technology, we still don’t know what causes back pain for many people. And without an understanding of the cause, it is difficult to find an effective way to treat it.

We do know now that some patients have back pain coming from the facet (spinal) joint(s). Using an injected anesthetic to the facet joint’s nerve has confirmed that this area can be a pain generator. Once the nerve can no longer send signals to the spinal cord, then the pain stops. Numbing the nerve with an anesthetic agent like lidocaine is a both a diagnostic test (proves the pain is coming from that joint) and a treatment (stops the pain messages).

But the treatment isn’t always successful and doesn’t always last. Many patients do have a second or even third injection, which increases the chance of a successful outcome. There’s another treatment that can also help some patients. And that’s destroying the affected nerve with heat using radiofrequency (heat high enough to destroy the nerve tissue) Radiofrequency ablation (RFA) as it is called can relieve the pain permanently.

It’s not routinely recommended because it adds to the cost of treatment and it’s not always successful. Doctors don’t know yet which patients will respond well to RFA, so they can’t say who should definitely have this procedure. There’s some evidence that people with decreased disc height or spinal stenosis (narrowing of the spinal canal or spaces for the spinal nerve roots) get results (good pain relief) with nerve blocks and radiofrequency denervation.

This is an area that remains under close examination and study. You would be best advised to go back to your physician for a follow-up evaluation and to find out what are your treatment options. A second nerve block is definitely a possibility.

People who have back pain coming from the facet (spinal) joint(s)can be helped by a nerve block to the tiny nerves that give the joint sensation. Using an injected anesthetic to the facet joint’s nerve is used now as a diagnostic tool to confirm that this area is truly what’s causing the patient’s pain. Once the nerve can no longer send signals to the spinal cord, then the pain stops.

Knowing that the facet joint is a pain generator, the next question is why? Why does the joint start sending out pain signals? It’s reasonable to think that arthritic changes around the joint might set up this type of pain response. But are there other reasons like disc degeneration or spinal stenosis?

Stenosis refers to a narrowing of the spinal canal where the spinal cord is located. But it can also mean a narrowing of the intraforaminal space around the spinal nerve root as the nerve root leaves the spinal cord and travels down the leg. And a recent study has shown that stenosis might be linked with facet joint pain. Which means that blocking the nearby nerve with a local anesthetic could potentially help patients who have back pain from stenosis.

This is all preliminary right now as up until now, stenosis was actually an exclusionary factor for nerve blocks and nerve ablation (destruction) with radiofrequency (heat) treatment. To find out what might work best for you, see an orthopedic surgeon for an evaluation. There are some less invasive treatments that can help with pain relief that you might want to try first before having a nerve block. Your physician will be able to advise you given all factors of age, spine condition, general health, and any other appropriate patient characteristics.

Destroying that nerve with heat using radiofrequency denervation relieves the pain permanently.

When that happens, it’s time to go back to the drawing board. Physicians are encouraged to review the case for anything that might be missing. Taking a closer look at the patient’s personal goals, activity limitations, work issues, attitudes, and beliefs might help pinpoint the next step.

Sometimes behavioral or psychologic help is needed. Catastrophizing or dramatizing life events (including pain) can lead to more intense pain that doesn’t go away. Behavioral specialists are trained to help people literally change their minds — change the way they think because these maladaptive thoughts are contributing to the persistence in painful symptoms.

People who start avoiding certain movements or stop moving to avoid any chance the pain will start up again are experiencing something called fear avoidance behaviors. That’s another dimension to chronic back pain that must be addressed. Behavioral specialists working with physical therapists can help patients overcome this trigger for back pain.

When low back pain becomes chronic and many of these nonpharmacologic (without medication) techniques are tried but fail, then a team of specialists combine various approaches to create a multidisciplinary rehabilitation program. Medications for pain control and antidepressants may be used. A program of intense, graded activity and exercise supervised by a physical therapist is supported by behavioral counseling to help patients prepare mentally to cope with their pain and the intensity of the program.

There isn’t a one-size-fits-all approach to low back pain. But evidence from studies so far support clinical practice guidelines based on the current evidence from many studies. Patients must work with their physicians to find the program that works best for them and stick with it. When one approach doesn’t seem to fit the bill, then it may be time to try another or to combine several methods together.

A cure doesn’t always take place. Sometimes, it’s a matter of pain management. But patients can function and even regain a measure of quality of life when pain persists. Don’t give in and don’t give up. There are many alternative approaches that can help you stay active at home and at work — despite the pain.

Your desire for a nonpharmacologic (nondrug) approach to treatment is one that many people share. And for that reason, more alternative options are available than ever before. Studies show that traditional medical approaches just don’t help everyone. The goal is to find the right mix of therapies that works best for each person.

Finding a physician who is willing to devise a treatment plan tailored to your specific situation may help. If your back pain was linked with childbirth, there may be hormonal and mechanical issues to sort through. The medical doctor will be able to do some testing to see if there is an underlying medical cause for the back pain.

When there are mechanical problems in the lumbar spine or sacroiliac joint, a physical therapist can help with exercises and mobilization or manipulation to help restore normal alignment and movement. Physical therapists can often identify problems with posture, movement, and alignment that may contribute to the development and recurrence of low back pain.

An individually designed rehab program can help restore spinal alignment, normal muscle function, and motor coordination. Many therapists combine traditional approaches with other physical modalities such as yoga, Pilates, and/or relaxation techniques to aid in recovery and then maintain spinal health.

There are helpful alternatives for patients like you who are looking for noninvasive, nondrug ways to reduce painful symptoms or at least improve function when pain doesn’t change. Massage and acupuncture also seem to have some benefit in terms of enhancing healing. Long-term effects are not as likely (i.e., these techniques don’t prevent future episodes of back pain). There’s no reason to suffer when there are options that can help.

Most people are surprised when they hear the average costs incurred by even the simplest of surgeries. According to a study at Johns Hopkins Medical School, a well-known institution in Baltimore, Maryland, the cost of conservative care to help prevent surgery averages out at around $4700 per patient. That’s for a single-level lumbar disc herniation treated without surgery.

If you calculate the cost of removing one disc surgically, then we’re talking about $5,000. That’s the surgeon’s fee for a minimally invasive procedure such as you describe. Since most patients go through at least six weeks (up to three months) of conservative care, the surgical cost must be added to the conservative care costs bringing the total to around $10,000.

In reality, with all the other costs of hospitalization, anesthesia, operating room, and post-operative care, the average bill comes to about $42,500.00. But sometimes patients end up with severe pain from spine degeneration at the site of the disc removal. Then they need further surgery with a possible spinal fusion. That can be a cool half-million dollars per patient.

Substantial health care costs aren’t the norm for single-level discectomy but this Johns Hopkins patient and cost analysis shows it happens in about nine per cent of the cases at their institution. Most patients who have a microdiscectomy procedure for a herniated disc have a very successful outcome and no further treatment is needed. For those who develop back pain later, conservative care seems to clear up any problems. But in a small number of patients, significant health care costs are incurred when additional surgery is needed.

Before going any further, you might want to get a rough estimate of proposed costs, fees, and charges from the surgeon, anesthesiologist, and hospital. Ask what your chances are for a good recovery and what your risks are for complications that could add additional fees. You may have to work out a billing plan that works for you before scheduling this procedure.

No one will argue that the costs of health care can exceed even the wildest guess sometimes. A simple discectomy is simple in that a small incision is used but the technology and training that makes that possible is anything but simple.

A new real-time X-ray machine called fluoroscopy is used to guide the surgeon during the procedure. Because only a tiny incision is made, once inside the spine, an operative microscope is used to navigate surgical tools and instruments through the bone to the disc space.

All of this is done in an operating room staffed by nurses, surgical techs, the surgeon, and the anesthesiologist. Each one of those people expects to get paid for the work they do. The equipment must be paid for and updated often. Medications, surgical supplies, and postoperative care are additional expenses. And that doesn’t factor in your missed wages for being off work before, during, and after the procedure.

That’s why every effort is made to help patients recover with a conservative plan of care. Epidural steroid injections (ESIs) are used to reduce inflammation around the nerve root and thereby relieve pain. Physical therapy is important to correct posture(s) that might be contributing to the problem. The therapist will guide the patient in restoring normal movement patterns. Special techniques can be used to release anything keeping the affected nerve(s) from sliding and gliding along as they should.

It sounds like you understand your diagnosis but need some help explaining the surgical procedures and approaches used when treating this problem. As you probably know, L4-L5 describes the segment of your lumbar spine that is involved. Spondylolisthesis is a term to mean vertebral slippage. Spondyl = vertebra and olisthesis = slip. Because of a fracture in the supporting column of the vertebral bone, the main vertebral body has slipped forward away from the back half of the vertebra.

The result is a pulling, traction pressure on the nerve tissue and neurologic symptoms. X-rays taken from a side view show characteristic changes that identify this condition. Nerve tissue is highly sensitive so a shift of this type usually causes significant low back and/or leg pain. The pain is worse when extending the spine because the shift in the bone is the greatest in this position. Forward flexion moves the vertebra back toward a more neutral position, which takes pressure off the spinal nerves. When rest, improved postural alignment, and exercises don’t help, then surgery to stabilize the segment may be needed.

Fusion is the most successful surgery. But there are different ways to do a spinal fusion. Different techniques can be used along with different approaches. For example, an anterior approach means the surgery is done from the front, posterior approach from the back, and lateral or transforaminal from the side. Often a combination of two different directions gives the surgeon the angle needed to avoid tissue trauma and potential problems or complications. Interbody fusion means they remove the disc and replace it with a metal cage filled with bone chips. Screws are often used to hold everything together and in place until healing and complete fusion occurs.

Surgeons have been using various fusion techniques for many years now. Research and study have improved fusion techniques. Many procedures can be done with minimally invasive methods to spare spinal muscles and prevent major complications such as bleeding or nerve damage. The goal is to use the least invasive procedure possible while getting the most stable long-term results for each patient.