FAQ Category: Lumbar Spine

You may be experiencing a phenomenon seen in other spinal fusion patients. When there is a loss of motion at one segment, the segments above compensate and make up for some of the motion lost. If the X-rays show a solid fusion, you may be seeing greater physiologic motion somewhere else in the spine and probably at more than one segment. In a recent study in the northeast at multiple centers including Albert Einstein College of Medicine, Bronx-Lebanon Hospital Center, and University of Pennsylvania Department of Orthopedics, patients with one-level disc degenerative disease were treated with either fusion or a total disc replacement.

Using dynamic X-rays to measure angles and motion, they found that fusion patients came out in the end with more motion than expected. But it wasn’t from movement at the fused site. There was evidence that the spinal level above contributed greater motion. And although it wasn’t considered statistically significant, increases in motion from the second, third, and even fourth levels above the fusion site added small gains in motion that eventually made up the loss at the fused site.

This may be a positive result but we’re not sure yet. There is some concern that the increased movement also means increased transfer of load to these adjacent levels. Over time, that could result in faster degeneration of those levels, too. Other experts suggest that the more evenly distributed motion above the fused site might smooth things out without adding stress and strain on those segments.

This is an area of intense study right now. Comparisons are being made between patients receiving a total disc replacement versus a spinal fusion. Studying motion before and after surgery for both treatment approaches might help us identify which patients would benefit the most by each procedure and find ways to preserve spinal motion while maintaining normal movement patterns called spinal kinematics.

The explanation for why you have the same motion before and after a fusion may be explained by compensatory motion at adjacent levels. But this would still be a good question to ask at your next appointment. There may be some other explanation your surgeon can offer for your particular situation.

Don’t be too quick to throw the towel in on your sisters. Many studies in the United States and abroad agree on one thing: low back pain is very common in pregnant women everwhere. And those women will tell you it’s darn uncomfortable and even disabling.

How do we account for this phenomenon? There doesn’t appear to be one individual factor linked with low back pain in pregnancy. Instead, it’s likely there are multiple risk factors that increase a woman’s chances for developing low back pain during pregnancy. And some women never recover fully but continue experiencing back pain well past their pregnancies.

The most common risk factors include: 1) multiparity (multiple pregnancies), 2) obesity and inactivity, 3) previous history of low back pain during previous pregnancies or any other time, and 4) perception of poor health.

In a recent study of over 1,000 Iranian women, living in a city (urban life) and not having any help with the daily workload of motherhood added additional risk. As the old expression goes, Many hand make light work. Any help or assistance family members and friends can offer pregnant women may in fact reduce the likelihood of low back pain. Perhaps it’s true that it takes a village to raise (or maybe give birth to) a child.

Multiparity (multiple pregnancies) is a well-known risk factor for the development of low back pain that doesn’t necessarily go away when the baby is born. Other risk factors such as obesity, sedentary lifestyle (i.e., inactivity and no exercise), and a previous history of low back pain are additional risk factors for ongoing, long-term (chronic) low back pain.

Scientists aren’t exactly sure why women can’t get back to their prepregnancy back health. It’s possible (even probable) that the hormone relaxin distributed throughout the woman’s body in preparation for delivery has some permanent effects on the musculoskeletal system. Ligaments and muscle-tendon junctions relax in order to allow the bones of the low back, hips, and pelvis to shift, separate, and make a wider passage for the baby.

One of the best solutions to low back pain in this population is physical activity and exercise. Studies show this tool to be the most effective for post-partum (after pregnancy) women of all ages. Check with your doctor to make sure you don’t have something nonmechanical causing your back pain (e.g., infection, fracture, tumor).

If there’s not a serious underlying medical condition, start to increase your activity level and incorporate some exercise into each day. Even 10 minutes twice a day can make a big difference. Current research data shows that 30 minutes of daily exercise benefits overall health, not just the musculoskeletal system. Take advantage of this free treatment approach and see if it has a positive effect on your back pain.

Chronic pain such as you are experiencing is, indeed, more common than one might imagine. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) estimates approximately 50 million people in the United States are chronic pain sufferers. Chronic pain is defined as pain that lasts three or more months longer than the expected time for healing.

With this many people involved, the health care costs alone are something to motivate us to find a way to alleviate this problem. Up to 220 billion dollars are spent each year in health care costs centered around pain of this type. But even more than that, the impact on quality of life requires a response.

One thing health care professionals struggle with is how to measure the burden of pain on individual patients. What is the level of pain and duration of pain? How does this impact daily activities and/or overall function? Pain is a very subjective experience. What you might call a 10 (worst ever) level of pain on a scale of zero to 10 may feel like a three the day after an especially intense bout of pain that suddenly feels like a 20!

If we had a standardized way to measure pain, then we could be about the business of measuring change (hopefully improvement) with various treatment approaches. Efforts are underway to develop an intuitive, adaptive computer program that can quickly, easily, and accurately assess pain location, intensity, duration, frequency as well as put into practical terms how that pain is affecting function.

The first prototype for such a tool has been developed. A test pilot has been run and the results were very encouraging. The computer program takes an average of one and a half minutes to complete, whereas a typical pain survey takes about 10 minutes (sometimes longer). The dynamic computer survey was tested and found to be just as accurate as a full survey. The computerized prototype had fewer items and took much less time to complete. The scores for all four content areas (pain location, intensity, duration, and impact) were equivalent between the two tests.

This early feasibility study showed that the faster, shorter computerized method worked just as well as the longer, more cumbersome full test procedure. It is currently being used with more people in a follow-up study before it can be released for general use. For now, it’s two-thumbs up for this dynamic pain assessment system that yields an accurate picture of pain patterns and the impact of pain on function. The next step will be to conduct many studies of different treatment approaches and patient responses. With this standardized way to measure pain, it will be possible to compare the results of one treatment approach versus another in reducing the impact of pain on activity, function, and quality of life.

Spondylolisthesis is a condition in which one of the vertebral bones slips forward over the one below it. Spondylolisthesis alters the alignment of the spine. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. In older adults, degeneration of the disc and facet (spinal) joints can lead to spondylolisthesis. Spondylolisthesis from degeneration usually affects people over 50 years old. This condition occurs in African Americans more often than in whites. Women are affected more often than men.

Spinal fusion has become a very popular way to treat age-related degenerative spinal conditions like spondylolisthesis. In fact, Medicare spending for spinal fusions has gone up 100 per cent in the last 10 years. Patients get pain relief, which means they feel better and engage in more of their everyday activities. For older adults, that’s an important factor in remaining independent.

There have been some doubts raised that back surgery really changes things or does more than line the pockets of health care professionals. Experts are taking a closer look at these kinds of issues. Patients are being followed for more than a few months after surgery (some studies are tracking patients for years) to see if the final results are worth the money spent.

Surgeons are also investigating which procedure used works the best and has the fewest complications. In a recent study from Dartmouth Medical School, the results of three different methods of spinal fusion were compared. They found that patients were better off than before surgery but the final results (measured in terms of pain and physical function) were the same no matter what type of surgery was done. Fusion rates were better when metal plates and/or screws were used. But clinical function wasn’t necessarily greater or different based on fusion rates.

We can’t say whether or not the grandmother you mentioned needs a spinal fusion or will benefit from this procedure. But your concerns are important. You may want to go with her to an appointment with the surgeon and get the facts for yourself. Understanding the condition and the proposed treatment (as well as asking about alternative treatments) may help you in this matter.

A recent study was done investigating patient satisfaction with health care for chronic low back pain. They found that the majority of patients were satisfied with their care. The number of visits didn’t seem to affect satisfaction. Those who weren’t happy didn’t attribute their dissatisfaction with their health care provider. They might not have felt they got an adequate explanation of their problem, so decided to seek other opinions. That’s a problem when it comes to chronic back pain because most of the time, the reason for their pain is unknown. Seeking more diagnostic help and spending more money to do so doesn’t solve the problem.

Your physician’s advice was based on sound research that shows regular exercise and change in behavior are the most effective ways to manage low back pain that is chronic (lasts more than three months). The results of the study mentioned showed that there are some other factors linked with dissatisfaction (younger age, race (Blacks and Hispanics), no insurance, and poor mental health). You may find yourself in one of these categories. It would suggest that there are other factors that affect how you think about your back pain and why you aren’t happy with the health care advice given so far.

If your pain continues to return despite regular physical activity and exercise, you may need some specific type of exercise such as core training to stabilize the trunk and spine. A physical therapist can help you identify specific areas of need and how to address those with exercise. Sometimes having a supervised, prescribed exercise program you can follow everyday at home makes all the difference.

Laminectomy is the removal of part or all of the lamina, a column of bone that helps form an arch around the spinal cord to protect it. Spinal stenosis is the narrowing of the spinal canal, the long tube where the spinal cord goes from the brain down to the end of the spine. Anything that can narrow this space can put pressure on the spinal cord or spinal nerve roots. Cutting away the lamina opens up the spinal canal and takes pressure off these neural structures.

Any new symptoms within the first days to weeks after spine surgery should be reported to the surgeon for evaluation. Sometimes patients do report increased low back pain as they start to get up and move around more. This should go away in time.

The presence of other symptoms such as fever, chills, fatigue, and headache could signal infection. Skin or wound infections are possible. In older adults, urinary tract infections and pneumonia can develop without presenting with typical signs and symptoms. Back pain isn’t a typical sign of infection but it is possible. Check with the surgeon as soon as possible. He or she will be able to let you know what to expect and what to watch out for.

More and more, patient satisfaction is becoming an acceptable outcome measure of treatment. However, when potentially addictive medications such as narcotics (e.g., Oxycontin) are involved, the physician recognizes that there are other factors to consider.

Besides the fact that these drugs can be addictive, studies show that sometimes patients don’t get better in any other way. In other words, their function doesn’t improve. They have an improved sense of well-being but it is chemically induced. Without the medication, pain intensity would lead to increasing disability.

Many physicians consider this a bandaid approach. It may make you happy for the moment, but it’s not an acceptable long-term solution. A drug-free, pain free life is the ultimate goal. That may not always be possible with chronic pain problems, but until all other options have been explored, it is not considered the answer. Every patient situation is different with unique factors and variables to consider.

At your next visit, bring up this question to your physician while being open yourself to any specific ideas he or she may have to improve your pain and overall function. Sometimes it takes a multidisciplinary approach to solve a problem like chronic low back pain. Narcotics may play a role, but it usually isn’t the only treatment.

Artificial disc replacements are gaining in popularity as studies show how well they are working. They are still used primarily for patients with degenerative disc disease, but the number and types of patients with this diagnosis who have benefited continues to expand. For example, younger patients (less than 65 years old) and younger adults with early disc degeneration from trauma or work-related repetitive motions are now getting artificial implants of this type.

Artificial disc replacements do have their own problems. Sometimes they break or migrate (move). In some cases, malposition of the implant results in uneven wear and eventual hardware failure. Bone growth around the implant is expected and helps hold the implant in place. But in some patients, ossification occurs — so much bone growth that the implant is buried and nonfunctional.

But these complications are fairly rare and short-to-medium term studies report good-to-excellent results with patient satisfaction described by a majority of patients. What we don’t know is how well would an artificial disc replacement hold up under significant trauma? This idea can be tested in the laboratory using cadavers (spinal segments preserved from humans after death). But without the dynamic effects of muscles, ligaments, and other connective or soft tissues, it’s impossible to know how a traumatic force might affect the implant.

Right now, we are relying on individual patient cases to gather information on how durable these implants are under compressive or traumatic forces. There are only a handful of reports so far but here’s what has been said about the effects of impact and trauma on disc replacements.

First, most fractures of the vertebra (spinal bone) have occurred because of failure of the disc, not the other way around. Improper or unbalanced placement of the implant causing uneven force on the endplate (cartilage between the disc and the vertebral body) can result in damage to the implant and fracture of the adjacent bone. Dislocation of the implant can have the same effect.

Only one case of traumatic injury in a patient with an artificial disc replacement has been reported. A 31-year-old manual laborer with an L4-5 Charité artificial disc fell off a roof and fractured his spine at the L3 level (third vertebral bone in the lumbar spine). The compressive load through the spine was powerful enough to cause the L3 vertebra to burst into tiny pieces. This injury is called a burst fracture. The fracture was unstable meaning that pieces of the fractured bone shifted, pushing into the spinal canal and pressing on the nerves. The accident occurred 10 months after the implant was put in the spine and while the patient was back to work full-time.

Fortunately, there was no evidence of damage to the artificial disc between the fourth and fifth lumbar vertebrae. The L4 and L5 vertebrae were also undamaged. In fact, the authors think that maybe the artificial disc actually protected the vertebrae above and below it. The surgeons involved in that case hope to follow this patient long-term to see how well the implant holds up and what effects the fusion the patient had above and below the implant might have on motion, biomechanics, and spinal stability.

As with many cases of nonspecific low back pain, even when there’s a known cause (car accident), tests are negative and no known anatomical reason exists for the pain that continues past the time of healing. Many patients like you who find themselves in this situation expect a medical doctor somewhere to figure out what is wrong and fix it. They have become weak and deconditioned. Their quality of life has plummeted. They feel they have nowhere else to go.

If that’s your situation, then it’s time to take action. Many people with chronic pain have found out that they can learn to manage the pain, reduce the sense of suffering, and understand the pain, rather than fear it. But it takes a multidisciplinary program of pain management, physical therapy, cognitive behavioral therapy, counseling, and activity — not just one of these modalities at a time, but a mix of several (sometimes all) of them.

Entering a comprehensive pain-management program can give you the tools needed to get back control of your life and improve your quality of life. You may not get rid of the pain, but it will no longer dictate what you can and can’t do. You can learn how to live with your pain and remain active. It is possible to change from being a passive patient waiting for a cure that may never happen to becoming a person with improved quality of life and a desire to continue learning in spite of the pain.

Keep in mind there are certain risk factors that contribute to chronic pain. Trauma of any kind can play a role. A past (or current) history of physical or sexual abuse or trauma is a key factor. It’s estimated that as many as half of all patients with chronic back pain have some type of abuse history.

Although the pain itself might not be the result of posttraumatic stress disorder (PTSD; also known as posttraumatic stress syndrome or PTSS), the level of pain intensity and chronic duration seem to be linked with PTSD/PTSS. PTSD/PTSS seems to affect severity of symptoms, level of disability, and depth of depression. One other psychologic factor that seems to be part of the picture with chronic pain is pain catastrophizing.

Pain catastrophizing refers to a negative view of the pain experience. It is exaggerated or blown out of proportion. Sometimes it refers to a patient who actually has pain already. In other cases the person isn’t even in pain yet — he or she is still just anticipating it might happen. A person who tends to catastrophize sees things as worse than they really are. Studies show that without intervention these behaviors can lead to chronic pain and disability over time. Catastrophizing or expecting the worst to happen increases pain. Catastrophizing boosts anxiety and worry. These negative emotions stimulate neural systems that produce increased sensitivity to pain. It can become a vicious cycle.

It may be time to take stock of your situation. Review your own risk factors. Put aside thoughts that nothing will help — you’ve tried it all. Start over by seeking a multidisciplinary approach and set your course for improving and maintaining the best quality of life despite the pain. Many people have done this successfully and can help you get started as well.

Yoga is a meditative practice based on the Hindu philosophy centered on training the mental, verbal, and physical aspects of life. The discipline started in India around Hinduism, Buddhism, and Jainism. But it has spread to the western world where it is more likely to be practiced as a form of physical exercise without the philosophic or religious focus.

In the United States, the most common forms of yoga offered are Hatha yoga, Iyengar yoga, and Bikrum yoga. Hatha yoga is the style most people think of when talking about yoga or when attending a yoga class at a health club or other similar type facility in the U.S. Hatha yoga prepares the physical body for spiritual meditation.

Iyengar yoga is based on teachings from a yoga master by the same name (B. K. S. Iyengar). Mr. Iyengar has specialized in finding ways to apply yoga to many health problems. Participants in Iyengar style of yoga can use props such as bolsters, blankets, and supports to help them assume and maintain any pose that is too difficult to reach or hold without help. With careful movement and focused breathing, the postures can be achieved with practice.

Bikram yoga is a more contemporary version of yoga developed by an individual named Bikram Choudhury. Also known as hot yoga or fire yoga, this type of yoga is practiced in a room heated to 105 degrees with low humidity. A certified Bikram instructor guides the students through 26 postures and two breathing exercises during a 90-minute period of time.

Yoga can be practiced by anyone of any age and almost any physical function. Most of the time, it’s helpful if the participant can get up and down off the floor but it can be modified and done in a seated position.

The first place to start might be with your counselor. If your counselor is recommending yoga, then he or she might know where to send you in your local area. Everyone must start yoga as a beginner. You will always find more experienced students in most any yoga class. Don’t let that keep you from going. Studies show that yoga is safe and effective for adults of all ages and levels of fitness. It has been shown to reduce pain, depression, and disability while increasing function and improving mood.

You may have to try a class or two before you find what works best for you. Sometimes it’s a different form of yoga that seems important. In other cases, it has more to do with the personal style or approach of the instructor. Like any form of exercise, consistent practice is needed to gain long-term benefits.

There aren’t very many studies directly comparing these two forms of exercise. But there are literally hundreds of studies supporting the use of ANY physical activity or exercise for your better health. Even 10 minutes of exercise twice a day has been shown to help.

In the case of chronic low back pain, there have been a few studies looking at Pilates or yoga. Six-weeks of Pilates brought about an eight per cent improvement in function (decreased disability). That’s not really very much change. The same study had a group of chronic back pain sufferers in a 10-week program of Pilates. That group had a 48 per cent improvement. Now, that’s more like it.

On the other hand, a recent study using yoga as a treatment modality for chronic back pain sufferers found the most change took place between 12 and 24 weeks. There were benefits after only six weeks. But the improvements accumulated over time.

Given your time constraints, you may want to pursue a program of lumbar stabilization through Pilates for the first six weeks and then continue on your own for the added benefit during the work-training program. From all the studies done with these two forms of exercise, it appears that consistent and persistent follow-through in either one will bring improvements in many areas — pain reduction, decreased use of pain medications, and both decreased disability and improved function.

No one doubts that patients with chronic low back pain have pain and even an underlying cause for that pain. But what to do about it can be a baffling challenge. Scientists, researchers, doctors, and physical therapists have not been able to find one individual treatment that’s most effective for chronic back pain sufferers.

The three most common causes for chronic low back pain are disc disorders (degenerative discs, disc herniation), back disorders (arthritis, spinal stenosis), and back injuries. Scientists don’t know the exact neural mechanism that sets up the pain signals. There’s some evidence that pain signals disrupt normal brain structure, processing, and function related to thinking and feeling. Until we know more and can find a way to turn those signals off without drugs, the best medicine is a focus on pain management through exercise, activity, and counseling.

Studies support the use of a multidisciplinary program of pain management, physical therapy, cognitive behavioral therapy, counseling, and activity for patients like you. Others following this approach have been able to get back to work, walk three miles a day without being limited by pain, raise a family, stay active, and remain a contributing member of society.

But just like it takes a village to raise a child, it can take a coordinated plan through a community of health care providers to provide all the tools needed to manage chronic pain. If you suffer from chronic low back pain, don’t let it have a negative impact on your quality of life and level of function. Talk to your doctor about services of this type in your community. See the American Chronic Pain Association (www.theacpa.org/) for more information concerning services, conditions and pain management issues.

Spinal fusion is still a safe and effective procedure for your condition. But based on recent studies, surgeons screen their patients more carefully before suggesting spinal fusion. And patients are more accurate information about what to expect, what could happen, and how likely it is that they might develop complications while in the hospital. This information will help both surgeons and patients weigh the pros and cons, risks and benefits of spinal fusion for this condition.

There’s more work to be done in the area of patient selection for spinal fusion. For instance, investigation is needed to show how many people leave the hospital after spinal fusion surgery but are later readmitted for one or more complications. How and why do complications occur? Does the type of fusion that is done make a difference? How about number of levels fused or type of instrumentation used in the surgery (e.g., plates, screws, pins, wires)? There is plenty of room for additional study on this topic and in finding specific ways to reduce in-hospital complication rates.

Once this type of information is available, surgeons of all kinds can work to improve conditions and reduce complications. Until that happens, each patient is viewed on a case-by-case basis. Your individual characteristics are examined carefully. Neurosurgeons have training that might assist them in more difficult or complex cases. Many times, an orthopedic surgeon and a neurosurgeon work together in the operating room on patients who need the expertise of both.

It might be possible to have a telephone conference with both your orthopedic surgeon and your neurosurgeon to discuss the details of your situation. Communication is often the key to successfully establishing a plan of care that will give you the best results with the least trauma. If that doesn’t seem possible, consider getting a third opinion with someone who can review what you have been told so far and make recommendations at this point in your process.

Lumbar spinal fusion has become more popular for degenerative conditions of the spine associated with aging. Studies show that this procedure is both safe and effective. But, as with any operation, there can be complications and problems that develop as a result of the hospitalization, surgery, and all that goes with those two things.

Sometimes it’s not clear why a particular patient developed complications. In other cases, there is a more identifiable reason. For example, patients with high blood pressure or diabetes are known to be at increased risk of problems when having orthopedic surgery such as a spinal fusion.

A recent study was done at Stanford University to help sort out some of the possible risk factors for in-hospital complications linked with lumbar fusion. They analyzed the data on over 66,000 patients who had posterior spinal fusion. The patients were all diagnosed with one particular spinal problem called acquired spondylolisthesis. This condition is also known as degenerative spondylolisthesis.

Acquired spondylolisthesis is usually a condition seen in older adults (though it can be seen in younger individuals). Acquired means it’s something that happens to the person, rather than being a condition he or she was born with. When spondylolisthesis occurs in childhood, it is usually as a result of an injury. In older adults, degeneration of the disc and facet (spinal) joints can lead to spondylolisthesis.

Spondylolisthesis describes a condition of the spine in which one of the vertebral bones in the lumbar spine (low back) slips forward over the one below it. As the bones shift, the spinal canal opening (where the spinal cord is located) narrows. The result can be pressure on the spinal cord or peripheral nerves leaving the spinal cord in the lumbar region. Back, buttock, and leg pain are the main symptoms of this condition. Over time, leg weakness may also develop.

Complications from this procedure range from minor to major but the overall complication rate nationwide is 11 per cent. That’s pretty high but fortunately less than one per cent are life-threatening resulting in death. Hematomas (pocket of blood at the surgical site) were shown to be the main problem. These are usually fairly minor.

More serious complications included blood clots, heart attacks, kidney infections or kidney failure, and less often, neurologic problems. Patients 65 years old and older were much more likely to develop complications. Anyone with more than one medical problem was also at increased risk of post-operative complications. If your brother is 65 or older and has some significant other health problems, these two factors could explain why he had so many problems.

The natural disc is a miniature shock absorber sitting between two bones (vertebral bodies). The disc keeps the bones apart, absorb and transmit forces passed through the bones to other areas, and help keep proper alignment of the facet (spinal) joints on either side of the spine.

Anytime the disc is compressed, the facet joints are also compressed. The opposing joint surfaces get squeezed together and rub instead of sliding and gliding against each other. The result over time can be degeneration of the spinal joints. Disc replacement helps maintain the natural heighth of the spine and keep the vertebral bodies separated and supported.

Studies show that when placed with good alignment, these implants do indeed hold up better and last longer with fewer problems over time. But current artificial disc replacements on the market don’t appear to have good shock absorption. The makers of artificial disc replacements are considering ways to improve the design to help absorb compressive loading and vibration. The hope is that the implant could actually help protect the segments above and below it, rather than transfer the load to the vertebrae above and below.

Long-term studies comparing the results of artificial discs against spinal fusion are underway. In time, we will have more data to show just how these implants (and the surrounding spinal structures) hold up under normal everyday wear as well as under compressive or traumatic forces.

When it comes to the treatment of mechanical low back pain, physicians and physical therapists have taken a different approach in the last few years. Research has shown that certain subgroups of patients seem to do better with one form of treatment over another. So, efforts are being made to develop a classification system that will help identify which subgroup a patient should be placed in for the best results.

Mechanical low back pain refers to back pain that is related to the way the spine moves. Some movements or positions make it better while other movements or positions make it worse. These patterns are somewhat predictable. The response (pain is better or worse) is the same each time the movement is used or position is assumed. Mechanical pain usually involves the soft tissue structures, joints, discs, cartilage and/or bone. Another term gaining in popularity for this type of pain is nonspecific low back pain (NSLBP). Mechanical or nonspecific low back pain is not caused by tumors, infections, or fractures.

Traditional therapy for mechanical or nonspecific pain has been through a rehab approach. Patients are given reassurance of recovery, an exercise program, and advice to stay active. Bed rest is no longer recommended. Sometimes various forms of heat or cold are used. But this is a one-size-fits-all kind of approach. And many people are left unhappy with the results. They don’t really know what is causing their pain and they don’t get better.

That’s why health care professionals stopped and took a closer look at patients with low back pain and realized there may be subgroups of patients — patients with certain characteristics, histories, and clinical presentations — who could be treated in a specific way for a better outcome. It sounds like you’ve gotten in with a group of health care professionals who are as up-to-date as possible. Give it a try and see if you get the results you are hoping for. If not, then consider your options.

Based on the results of many studies over the last 10 years, physical therapists are trying to categorize low back patients into subgroups. These groups are based on patient characteristics and recognition of certain pain patterns and movement patterns.

They don’t necessarily use the specific location of pain or other symptoms to identify the underlying problem. They don’t always try to identify the soft tissues or anatomic structures involved, or diagnose the underlying pathology. Instead, they look for patients who have pain that is constant versus intermittent (comes and goes). They use movement patterns that make the pain better or worse as another way to classify patients.

Of course, treatment should always include education about posture and exercise. The difference is the way exercise is prescribed now. It’s no longer one-size-fits-all. Patients identified as falling into one of the classification groups are given exercise strategies specifically designed to find movement patterns that reduce pain while at the same time avoiding movements that bring the pain on or make the pain worse.

If your pain is not caused by a medical problem (e.g., cancer, fracture, infection), then this approach is most likely to work well for you — and it doesn’t require knowing exactly what went wrong. Most of the time, patients with mechanical pain (that’s pain brought on by certain movements or postures) doesn’t show up as anything recognizable on an X-ray, CT scan, or MRI anyway.

Spine fusion is usually done as a last resort when conservative (nonoperative) care fails to reduce painful back and/or leg symptoms from degenerative disc disease or chronic disc herniations. Usually, the surgeon removes the disc and either puts a special device in that space (called an interbody spacer) or fills the hole with bone graft material.

Even with the interbody spacer, bone graft material is inserted in and around the area to help foster bone growth and subsequent fusion. Whenever bone graft is used, there are several different choices. There are two kinds of human bone graft: allograft (bone from a donor bank) or autograft (bone taken from the patient’s pelvis). A third choice is the use of rhBMP-2 bone substitute. rhBMP-2 stands for recombinant human bone morphogenetic protein type 2, so you can see why they shortened it to rhBMP-2. This protein stimulates the body’s natural production of bone.

As you said, there are pros and cons with each one. Bone graft from a bone bank doesn’t always take. Sometimes the body recognizes it as a foreign substance and sets up an immune response against it. But it does eliminate the need for an extra incision and harvesting of bone that is required with an autograft. Donor site pain, infection, and poor wound healing are often the biggest problems following a lumbar fusion with autograft.

Bone substitutes are not without their own issues. Studies have reported up to a 35 per cent complication rate using a bone substitute in lumbar fusions. Complications include screws coming loose or placed in the wrong position, interbody cage movement called migration, and infection. Sometimes pockets of blood form called hematomas or too much bone forms, a condition called heterotopic ossification. There can also be enough disturbance in the area of the spinal nerves that results in persistent nerve pain.

Leg pain from nerve irritation is called radiculitis. It is a common complication and one that is more likely when rhBMP-2 is used without a special agent called <Duraseal. Duraseal is a water tight sealant that keeps the bone substitute from leaking into the spinal canal or around the nerve roots where it could act as an irritant. Without the Duraseal, there is also a risk of bone formation in the spinal canal, which could put pressure on the spinal cord causing pain and dysfunction.

When it’s all said and done, both ways of accomplishing fusion are safe and effective but not without potential complications. Your surgeon may have some preferences in the choice based on experience and perhaps some individual factors in your case. Be sure and find out what his or her recommendations might be.

The transforaminal lumbar interbody fusion (TLIF) technique is used to avoid the problems that come with entering the spine from the front (anterior approach. Transforaminal means the surgeon gains access to the spine from the back and side. This allows the surgeon to avoid the major blood vessels present in the front (e.g., aorta, vena cava). The surgeon makes a posterolateral incision from the back and side and removes one of the facet (spinal) joints so the disc can be taken out.

Interbody describes how the fusion is circumferential (all the way around and from front-to-back). Once the disc is removed, the two vertebrae are distracted or pulled apart gently and a special device called an interbody spacer is slid into the disc space. The spacer helps restore normal disc height, which in turn, takes pressure off the spinal nerve roots as they leave the spinal cord and pass through the opening formed by the vertebral bones.

As you know, any time the area around the spinal cord and/or spinal nerves is disrupted, problems can occur. Irritation of the nerve tissue or pressure on the nerve tissue can set up an unrelenting pain response. Irritation or pressure can develop as a result of bleeding into the area, infection, or too much bone growth. The added bone is needed for the fusion but if it extends into the space for the spinal cord or spinal nerves, the same problems with persistent pain can develop.

Further surgery may be needed to remove anything from around the nerves. There’s no guarantee that the pain will go away. For some people, it does but for others, the pain signals aren’t as easily turned off once they get started. And scientists have yet to identify individual factors that might predict which way a person will respond.