FAQ Category: Lumbar Spine

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.

Spinal fusion is an important and often successful tool for treating chronic low back pain in a patient with an unstable lumbar spine. The surgeon has a wide range of surgical procedures and techniques that can be used depending on the patient’s age, general health, bone density, activity level, and the cause of the problem.

Bone grafting is needed with fusion to help stabilize the surgical site until more bone can grow in and around it to form a solid union. Natural bone material is best. It can be taken from the patient (called an autograft) or from a bone bank (allograft). Autografts for the lumbar spine are usually taken from the iliac crest, the bone you feel when you place your hands on your hips. An alternate site is the tibia (shin bone).

The advantage of autografts is that it isn’t foreign to the patient, so he or she doesn’t react to it and reject it. The disadvantage is that the donor site can become infected, swollen, and extremely painful for a long time after the surgery. Donor site problems are avoided with donated tissue from a bone bank.

There are some new approaches to spinal fusion available and under ongoing investigation. And that’s the use of bone enhancers called bone morphogenetic protein (BMP). A specific bone growth factor (rhBMP-2) has been approved by the Food and Drug Association (FDA) for limited use. This product is put on a special collagen sponge and inserted inside a tiny cage that is then placed between the vertebral bodies. The BMP stimulates bone to grow faster to help create a bridge of bone to fuse the two vertebrae together.

There are some potential problems with this approach, too. This is a biologically active substance, which the body may react to. There can be soft tissue swelling, the formation of seromas (fluid-filled cysts), and even ectopic bone formation. Ectopic means out of place, wrong place, or malpositioned. In the case of lumbar spine fusion, the rhBMP can leak outside of the intervertebral space and form bone inside the spinal canal or around the spinal nerve roots. As a result, serious neurologic problems can develop.

Your sister may want to discuss all her options with the surgeon and find out what might work best for her given her own unique circumstances. Not everyone has a bad reaction to auto- or allografts. Bone enhancers are being used by some, but not all, surgeons. Her surgeon may have a specific protocol or way he or she performs lumbar fusions. The procedure is usually very safe and effective.

Surgeons continue to look for ways to fuse the lumbar spine with the best results and fewest problems. One of the biggest problems with spinal fusion is the need for bone graft material. Bone chips taken from the patient’s hip (iliac crest) work but often leave undesirable pain, infection, and swelling at the donor site. New biologic agents might be able to speed up the fusion process and do it without the use of bone graft material.

One of those biologic agents is rhBMP-2 or recombinant human bone morphogenetic protein. rhBMP-2 is a growth factor that can be used to stimulate bone growth. Right now, rhBMP-2 has been approved by the FDA for use in spinal fusions. In its liquid form, it is placed on a sponge (called the carrier). The sponge is put inside a tiny cage that is then implanted between the two vertebrae. The disc that normally sits between the two vertebral bones has been removed first in a procedure called a discectomy. The discectomy is done to remove the damaged disc material and make room for the intervertebral cage.

In its off-label use, the procedure just described with the sponge carrier inside the cage is still used. But in addition, the surgeon puts some rhBMP-2 in the space left by the discectomy before inserting the cage (that’s the off-label use). The rhBMP is pushed up against what’s left of the disc lining (the annulus fibrosis), then the cage is set behind it. This pushes the cage back a bit from where it would normally rest without the additional rhBMP-2. The cage ends up being flush or even with the back wall of the vertebral bone.

There have been some problems with this approach. There has been some leakage of the rhBMP outside of the cage and inside the spinal canal. As a result, bone has formed where it doesn’t belong. In a few cases, bone has formed inside the spinal canal and wrapped itself around the spinal nerve root as it leaves the spinal canal. Serious neurologic problems can develop as a result of this complication.

That’s why efforts are being made to modify the procedure and see if these (rare) problems can be resolved. Those who are using rhBMP-2 in an off-label way as described here now build in protective layers using crushed bone and a layer of fibrin glue. A layer of bone is placed between the rhBMP-2 and the annular covering at the front of the empty disc space. Then the rhBMP-2 goes in and then another protective layer of bone. Next goes the cage filled with the rhBMP-2 carrier. The final layer (a special fibrin glue) is placed behind the cage. They also pay close attention to where the cage is placed. Putting it as far forward as possible (and as far away from the nerve tissue) may help reduce the problem of neural compression.

This may not be exactly what your neurosurgeon does or has planned. The procedure will probably be explained to you during the pre-operative visit. Keeping this information in mind, you’ll be able to ask questions and understand first hand what will be done during your procedure.

The question of whether or not patients on Workers’ Compensation have different results after treatment for back pain has challenged the health care profession for years now. People with work-related back problems seem to have significantly worse outcomes than those patients with similar musculoskeletal conditions who aren’t on Workers’ Compensation.

A recent study was done as part of an on-going research project called Spine Patient Outcomes Research Trial or SPORT. The researchers compared Workers’ Compensation to non-Workers’ Compensation patients with back pain. Both groups were divided further by type of treatment: conservative (nonoperative) care or surgery. The results of treatment were compared at regular intervals from six weeks to two years.

The goal of a study like this is to see what effect Workers’ Compensation status has on patient outcomes. Is one treatment better than another? Do Workers’ Compensation patients have equal results to non-Workers’ Comp patients when the same treatment is applied? Patients with a lumbar disc herniation treated at 13 U.S. Spine Centers were included in the study.

Only adults who were not already considered disabled and could return to work (including unemployed patients but not retired folks, homemakers, or students) were included in the study. Conservative or usual care consisted of active physical therapy along with a home exercise program, education and counseling, and medication (anti-inflammatories). Surgery was an open incision discectomy (disc removal).

By factoring many variables into the statistical analysis, they could tell which ones were directly linked with results — in other words, which patient factors affected the final outcome. That way if something was a more important factor than Workers’ Compensation status, it would show up. They looked at clinical findings such as any neurologic signs (change in sensation, change in reflexes, muscle weakness). They included patient characteristics (smoker, other health problems, education level, income, age, sex, racial/ethnic background).

As it turned out, everyone in the study got better with treatment — that was true for both groups and both types of treatment. But a closer look at all the data also revealed that Workers’ Comp patients who had surgery didn’t have as good of results as nonWorkers’ Comp patients who had surgery. And over time, the benefit the Workers’ Comp patients showed early on deteriorated.

It’s not entirely clear why Workers’ Comp patients had worse outcomes after surgery. Despite analysis of the other factors, nothing stood out as a significant factor except Workers’ Comp status — and that was true for patients at all 13 treatment centers. It’s possible that the Workers’ Comp patients go into treatment with different expectations, ideas, and perceptions than nonWorkers’ Comp patients. Some Workers’ Comp patients may feel pushed to have surgery rather than wait for natural healing to occur in order to get back to work sooner. More study will be needed to investigate some of these ideas.

Many workers face this challenge. Should I wait for natural healing to take place? Should I play the surgery card and hope for the best? Financial incentives, work projects, and personal expectations crowd in to make the decision even more difficult.

Surgeons can’t always predict who will have a good result from surgery. Since even the most minimally invasive procedure is still invasive compared to conservative (nonoperative) care, most surgeons would advise rehab first, surgery later — and surgery only if rehab fails. That recommendation is based on many studies showing the long-term outcomes of treatment.

And there have been special studies just comparing results of treatment for Workers’ Compensation versus nonWorkers’ Compensation patients. The studies consistently show that Workers’ Comp patients don’t do as well as nonWorkers’ Comp patients. The reasons for this aren’t entirely clear yet. All indications are that the association between Workers’ Compensation status and results is a complex one.

For a decision like this, it may be best to discuss with your surgeon the risks and benefits for you of rehab versus surgery. Your choice should be based on an informed decision-making process. Using surgery as a way to get back to work faster isn’t guaranteed. Your surgeon will review all of the information about your back problem and give you a range from best case scenario to worst case scenario.

Scientists and doctors don’t know how or why acupuncture works, despite many studies. There are many theories, however. One theory, for example, is that the insertion of several needles in specific points in the body disrupts the pain messages that are sent to the brain. Another study is that the needles help stimulate the blood flow around the painful areas.

The idea of acupuncture, according to its origins, is that the human body has an energy flow. It’s believed that when this flow is disrupted, we become sick or develop some sort of pain. The energy flows through the body through pathways called meridians. There are certain points along the meridians called qi, and it is at these spots that the needles are inserted. By doing this, it is thought that the natural energy is then realigned and flows properly again.

Acupuncture is an eastern treatment that has been used for centuries. Many people feel that it helps them relieve pain or rid themselves of illness. In North America, acupuncture is considered a complementary treatment that can be used in conjunction with our traditional western medicine.

Whether acupuncture is useless is impossible to say ahead of time. Several studies have been done assessing the effectiveness of acupuncture and while some results are only lukewarm, others find that acupuncture not only helps relieve pain, but decreases the need for more invasive treatments from conventional treatments.

Low back pain usually falls under one of several different types of pain. Nociceptive back pain is a common pain pattern. Identifying which type or types of pain are present is key to choosing the right treatment. Physicians must be able to distinguish one type of pain from another. The real challenge comes when patients have more than one type of pain at the same time.

Nociceptive back pain occurs when an anatomical structure in the spine is stimulated by mechanical or chemical means. Mechanical stimulation comes in the form of compression, misalignment, or deformity. Studies using chemical stimulation have injected a dye into the joint. The added fluid in the joint expands the soft tissues and puts pressure on the nerve endings inside and/or around the joint causing pain.

Studies of nociceptive pain have used normal subjects and targeted spinal ligaments, spinal joints, discs, sacroiliac joints, and back muscles. By stimulating each of these areas individually, scientists have been able to identify responses used by patients to describe nociceptive pain as dull and/or aching.

Allodynia is a medical term for pain caused by a stimulus that normally doesn’t cause pain. For example, gentle pressure or a light touch results in moderate to severe pain. Mild hot or cold temperatures in contact with the skin can cause allodynia. Pain felt with gentle brushing the skin can also be referred to as allodynia.

The presence of allodynia as a symptom signals damage to a nerve. There is no allodynia with nociceptive pain. These are two separate types of pain caused by two separate problems.

Mechanical stimulation of the disc (touching the disc or pressure on the disc) can cause back pain but not leg pain. Pain down the leg is a sign that the spinal nerve root is being compressed or irritated as it leaves the spinal cord. A herniated disc can cause this type of spinal nerve root compression. A damaged disc can also release chemicals that irritate the spinal nerve roots.

But very often, the back pain is a separate problem from the leg pain. Removing the disc removes the compression and irritation on the spinal nerve root. Suddenly the shooting pain down the leg is gone. But when the back pain remains, it’s a sure sign that something else is going on.

And that something else could be anything affecting the spinal ligaments, spinal joints, tendons, muscles, or other soft tissue structures in the spine. Finding the cause of the separate back pain can be difficult. Imaging studies such as X-rays, MRIs, ultrasonography, and CT scans may not show any changes in the soft tissue structures that point to the underlying problem.

Scientists are working hard to unravel the complexities of the nervous system — especially as it relates to back pain that doesn’t go away easily or with a variety of treatment approaches. Surgeons try to avoid operating if there’s a large chance that the surgery won’t yield the desired results (pain relief).

Physicians must carefully evaluate each patient individually. The goal is to determine the type of pain patterns present and their cause(s) before selecting the most appropriate and successful treatment.

A recently published review of all studies done on bone graft substitutes might help answer your question. The authors of the review looked at the literature already published looking on bone substitutes for lumbar fusion. They limited their search to articles in English. They included studies that used either an anterior (from the front of the spine) surgical approach or posterior (from the back of the spine) surgical approach.

Data collected from the studies included operating time, blood loss, length of hospital stay, surgical approach, and type of fusion material. Results were measured and compared using these factors as well as X-rays evaluating the fusion site. Patient pain, function, and disability were measured using a popular and well-known tool called the Oswestry Disability Index (ODI).

A total of 17 studies made the cut based on the standards set for good quality research methods, the use of English, and fusion for lumbar degenerative osteoarthritis. Most of the focus was on bone graft substitutes. These materials made from bone are called recombinant human bone morphogenetic proteins (rhBMP). There are two types of recombinant BMPs available: rhBMP-2 and rhBMP-7. Some of the studies investigated the results of other bone graft substitutes such as demineralized bone matrix DBM), platelet gels, and activated or autologous growth factor (AGF).

Each of these bone graft materials are prepared and used in a slightly different way to achieve the desired results. BMP-2 is mixed in water and placed on a collagen sponge then placed in a fusion cage between two vertebral bodies (where the disc used to be located). BMP-7 is mixed in a saline (salt) solution and combined with collagen then painted around the sides of the bones to be fused together. Collagen is the basic building material of all soft tissues and bone.

When everything was studied and analyzed, they found that the rhBMP-2 had the best results. Patients receiving the rhBMP-2 bone graft substitute had more stable unions/fusions when compared with rhBMP-7, demineralized bone matrix (DBM), platelet gels, and growth factors. There was less blood loss and shorter operating times with the rhBMP-2. rhBMP-2 outperformed rhBMP-7 in all areas except change in function as measured by the Oswestry Index.

The conclusion of this systematic review of bone graft substitutes for lumbar fusion was that rhBMP is a useful alternative to donor bone or bone harvested from the patient. It is safe and cost-effective. The cost savings come from fewer complications during and after surgery with less blood loss, shorter operating times, and fewer infections. More studies are really needed before any final conclusions can be made.

For some time now, physical therapists have been trying to find better ways to treat patients with low back pain. By better we mean more effective treatment with successful results. And successful refers to getting relief from pain that doesn’t come back.

Manual therapy is one technique that studies support as an effective way to treat back pain when it first develops. Manual therapy refers to a hands-on treatment given by physical therapists to reduce back pain and improve function. Manual therapy techniques vary but include thrust and nonthrust manipulation of the spinal joints. The difference between thrust and nonthrust manipulation is the speed or velocity of the force directed through the joint.

Studies have shown that patients who have four out of five predictive factors will respond well to treatment with spinal manipulation. Those five factors include duration of current pain is less than 16 days, pain can go down the leg but no farther than the knee joint, reduced motion at one (or more) spinal segments, low scores on the fear-avoidance behavior (FAB) scale, and at least 35 degrees of internal rotational motion of one hip.

Those predictive factors actually form what’s called a clinical prediction rule (CPR). Anyone who passes the clinical prediction rule with at least four predictors present will likely benefit from a thrust manipulation technique. It sounds like that’s the treatment you are receiving.

Whether one technique works better than another is being investigated. At least one study showed no difference in results from being on your back versus on your side. There was a definite difference between using a thrust technique virus a nonthrust technique. Patients receiving the thrust manipulation (in either a sidelying or supine position) had equally good results and much better than patients receiving a nonthrust manual therapy technique.

However, anytime a patient has concerns about how a treatment is delivered, it’s always best to ask your therapist for an explanation. Ultimately, you’ll be able to tell if one treatment technique changes how you are feeling and functioning. Pay attention to your symptoms and let your therapist know what you observe that might help direct treatment choices.

Experts agree based on repeated studies that strengthening and stabilization exercises work! They strengthen the trunk (abdomen and spine) and go a long way toward preventing back pain and relapses from previous back pain episodes.

Many people rely on the Pilates program to develop core stability. But as you have noticed, there are dozens of different exercises to choose from. Since the muscles that constitute the core include the abdominal muscles and deep muscles of the spine, there are a few exercises that can serve as important ways to work on stabilizing the spine. These include abdominal hollowing, hip bridges, arm and leg extensions while on hands and knees, and side-support exercises.

Abdominal hollowing is done while lying on your back and drawing your abdomen in toward your spine or the floor as far as possible. Hip bridging is done while on your back with your feet flat on the floor. The pelvis is lifted toward the ceiling (bottom up off the floor) and held in place before lowering to the floor and starting again.

Arm and leg extensions done while on the hands and knees involve lifting the left arm forward and right leg behind you. The shoulders, back, and pelvis are supposed to stay flat. To accomplish this, you must contract your abdominal muscles and hold. Side-support exercises are done while on your side, legs and feet together and body lifted off the floor. You will be propped up on your forearm to get into this position.

In all of these exercises, you will be contracting and holding the necessary core muscles. Paying attention to the abdominal muscles and maintaining good posture throughout the exercises by contracting and holding the abdominal muscles is a key to success in strengthening the core. Remember to breath throughout the exercises even while holding your stomach in.

Most experts agree that unless you have had an injury or traumatic event that could have caused a spinal fracture, it’s best to keep moving and stay active. Since you say you woke up with this pain, think back to yesterday or the day before to identify any possible causes. If you were involved in some type of trauma, you may need to see your doctor for an examination.

But if there’s no known cause and you can move about, then it is best to do so. Should your symptoms persist or get worse, call your doctor and let him or her advise you. If you develop a high fever with skin rashes, nausea and vomiting, or other general symptoms, a visit to your physician may be warranted.

Every patient who ever experienced a sudden onset of neck or back pain wonders the same thing. How long is this going to last? How soon will I be able to get back to work? Despite 1000s of studies addressing neck and back pain, no one has found a way to consistently predict the long-term outcome of spinal pain. Many have tried!

There have been efforts to use patient responses to testing and treatment as a guidepost. For example, some examiners test patients by using repeated motions in one direction (flexion, extension, rotation, sidebending) to see what happens to the pain. If it is consistently present in one direction and lessened in another direction, this is referred to as directional preference. You would be advised to avoid those movements that hurt and stay within the range-of-motion that is pain free.

Another testing concept called centralization has been used to predict response to treatment. Centralization refers to neck pain that goes down the arm or back pain that goes down the leg moving or retreating to a central location in the spine. Some experts think this is a sign that treatment will be successful using exercises and movement that cause centralization to occur.

But the bottom-line is that patients don’t all consistently respond the same way to these test measures. So it’s been difficult, if not impossible, to come up with a way to predict who will get better, how soon, and/or what specific exercise or movement works best to speed up the process.

Caring for low back pain is expensive. The people who are living with the pain frequently can’t work and must end up on disability for a while or even take early retirement. In fact, this is something that adds significantly to the cost.

There are many options available to people who have low back pain. Not all treatments are appropriate for everyone and not all treatments work for everyone. While doctors may be able to tell a patient which options aren’t open to him or her, a doctor may not be able to tell if a treatment will work or not. This means, while one patient may go and pay for a series of spinal manipulations and feel pain relief, the next person may go for the same treatment but not get any relief, meaning he may have to try another option.

Chronic pain, particularly low back pain, is difficult to treat as there often is something specific to target. If cost is an issue, people like your brother-in-law could research or ask the doctor which treatments are historically the most effective and what their costs are. Then, a decision could be made by looking at the possible benefit versus cost.

Dealing with chronic pain can be an expensive endeavor. If you must keep an eye on what the costs are, speak with your doctor about what options you have. If he or she feels that physiotherapy is an option for you, perhaps you can do some investigating to see where the physio is available at a cost that is more reasonable for you. On the other hand, if your doctor gives you a few options, then you may be able to decide which one seems best for you and take the cost into consideration.

Being afraid of re-injuring yourself is not uncommon. You know how it feels to have a sore back and you want to make sure you don’t hurt it again. Unfortunately, as you’ve learned, this can backfire on you and the more your worry and try to protect your back, the worse it can actually make it.

It may be worth visiting your doctor and discussing your concerns. There are some programs that help people learn how to deal with their fears, lowering their pain.

Cauda equina syndrome is the name of a disorder that affects the cauda equina, the nerve roots, of the lumbar (lower) spine. These nerves become compressed because of trauma, infection, or narrowing of the spinal canal, for the most part.

Symptoms include difficulty controlling your bowels or bladder, experiencing sexual difficulties, odd sensations in the saddle area (the part that would normally come in contact with a saddle if you were riding a horse), and pain or altered sensation in the legs, right down to the feet in some people.

Sometimes, surgery isn’t needed, but many times it is and it should be done as soon as possible before permanent damage sets in.

Cauda equina syndrome is pressure on the cauda equina, the nerve roots in the lower, or lumbar, back. This pressure could be from a back injury, but it also can happen if the spinal canal narrows, also called stenosis. This can be caused by an injury that your father may not recall or by diseases or tumors in the spine.

Morphine is an opioid, a narcotic. It’s one of the controlled drugs that has the potential of being addictive. Until a decade or so ago, opioids were only really used in the United States for acute pain (such as after surgery) or for cancer pain. After the government relaxed the rules and allowed doctors to prescribe it for chronic pain, some doctors began using it for patients with severe chronic back pain.

Unfortunately, although it seemed that this would be a good solution, there is no proof that opioids actually help pain like chronic back pain. Studies over the past years have failed to find any benefit to taking the opioids and they don’t seem to help workers return to work any quicker than other methods of pain relief. This is likely why your doctor is reluctant to prescribe morphine to you.

Increasing a dosage of a medication doesn’t necessarily mean that a person has become addicted to it. The human body has an amazing ability to adapt and sometimes, adaptation means getting used to or tolerating a certain dosage of medication. What can happen is that the pain level of someone taking an opioid, or narcotic, may be relieved at one point, but as the body becomes used to the medication, it no longer does the job and higher doses are needed.

In your mother’s case, it is possible that the medication she is taking is not really the right one for her. If she is still having pain, it may be a good idea for her to speak with her doctor about other pain relieving options.