FAQ Category: Lumbar Spine

Experts in the area of social science tell us that people who lose their jobs can suffer severe problems. They start out in a state of fearful distress that quickly becomes a despairing attitude of giving up. The loss of income makes things even worse. Chronic pain and work loss can become so tangled up, it’s hard to separate them. One condition feeds into the other. As you have discovered, pain confounds work loss. And work loss intensifies the pain.

When chronic low back pain leads to disability and loss of work, doctors may prescribe strong (narcotic) pain relievers called opioids. This is done in an effort to help people get back to work. But critics of this approach say there’s no proof that opioid use improves outcomes. In fact, there’s some evidence that opioid therapy may actually be linked with increased risk of work loss.

To test the effect of opioid use on work loss, a study was done using data from Worker’s Compensation. Two groups of Worker’s Compensation claimants were compared. Everyone included in the study had filed a Worker’s Comp claim for low back pain. One group was provided with opioid therapy. Some were taking weak (Class III or IV) opioids. Others were given strong (Class II) opioids. The opioid group was further divided into two subgroups based on whether or not they took opioids for up to 90 days or for more than 90 days. The second group had filed a Worker’s Comp claim for low back pain but no one in the group was taking opioid-based medications.

Analysis of the data collected for the two main groups showed a significant link between opioid use and work loss. Workers taking any kind of opioid were 11 to 14 times more likely to suffer work loss compared to the reference (no opioid) group. Workers using strong (Class II) opioids were six times more likely to experience chronic work loss. The time frame used for this study was 90 days or more. And the overall costs for the opioid group was much higher than for the nonopioid group.

What’s the answer to this dilemma? Well, there may not be an easy answer for all patients. Each case must be decided and followed on an individual basis. Sometimes a team approach is really needed. For example, strong pain relievers such as opioids used in combination with a rehab program can help move the focus from pain to function. For nonspecific low back pain (i.e., it’s not caused by a tumor, fracture, infection or other serious medical problem), there is evidence that spinal manipulation by a chiropractor or physical therapist can be helpful.

Working closely with your physician will help ensure you get the full benefit of the opioid while minimizing or preventing any of its potentially harmful effects. Knowing that your goal is to get back to work will be helpful in keeping you on track in recovery.

Medicare has asked for more proof that spinal arthrodesis (fusion) in older adults really helps. Until now, most of the studies reported on younger adults. And age could make a difference. We can’t just assume that the results of this procedure in younger adults would be the same in older adults. An advisory committee from the Centers for Medicare and Medicaid Services asked for conclusive evidence to support the use of spinal fusion in patients 65 years of age or older. This age-group includes the Medicare population.

A group of orthopedic surgeons from Kentucky, Minneapolis, Boston, and Georgia took up the challenge and conducted a study to help answer this question. The surgeons fused a single spinal level of 224 patients and then followed them for two years to see the results. The group was divided into two groups by age. Anyone younger than 65 years was in the first group. Patients 65 years old and older were in the second group.

In general, the patients in each group were very similar (e.g., education, occupation, alcohol use, general health) except for age. Men and women were included. The main differences were that the younger patients rated their pain higher. They were more likely to still be working and a Worker’s Compensation claim. And the older patients were more likely to have advanced spine degeneration with bone spurs, thickened spinal ligaments, and facet (spine) joint degeneration.

Results were measured using several well-known research tools. These included the Oswestry Disability Index (ODI), the Medical Outcomes Study SF-36, and the numeric rating scale for back and leg pain. X-rays and CT scans were also used to look at the fusion site and see if it was successful or not. These imaging studies showed the presence of bone bridging the vertebral segment (a sign of successful fusion) and any cracks in the bone (a sign of weakness or instability).

Everyone in both groups had significant improvements in their test scores. But the older group demonstrated a larger change in scores indicating greater improvement compared to the younger patients. Complications in the early postoperative period (first 30 days) were higher among the older adults. Half of the older group had an adverse event after surgery. This was compared to one-third of the younger group. Most of the problems were minor.

More studies are needed to look at the differences in results of lumbar spinal fusion based on age and number of levels fused. Surgeons try to select the right procedure for each patient and the best patient (candidate) for each procedure. Choosing patients carefully for spinal fusion increases the chances of a good result. When you see an orthopedic surgeon for an evaluation, ask him or her this question. Their experience may be able to give you some additional insight that can help you with this decision.

Back pain from degenerative disc disease can be very disabling for older adults. In a recent study, orthopedic surgeons showed how a simple spinal fusion can make a big difference in patients 65 years old and older.

The surgeons fused a single spinal level of 224 patients and then followed them for two years to see the results. The group was divided into two groups by age. Anyone younger than 65 years was in the first group. Patients 65 years old and older were in the second group.

The operation performed was a single-level posterolateral lumbar arthrodesis with iliac crest bone graft. Posterolateral refers to the direction (back and side) that the fusion was done. Iliac crest bone graft comes from the top of the pelvic bone. Instrumentation (rod and screws) were used to hold the segment stable until bone filled in around the bone graft. The spinal level fused was slightly different between the two groups. The older patients’ fusion was in the L345 region. The younger patients were more likely to have a fusion at the L5-S1 level.

Everyone in both groups had significant improvements in their test scores. But the older group demonstrated a larger change in scores indicating greater improvement compared to the younger patients. Complications in the early postoperative period (first 30 days) were higher among the older adults. Half of the older group had an adverse event after surgery. This was compared to one-third of the younger group. Most of the problems were minor but some patients had a heart attack, blood clot, or infection.

The authors concluded that older adults having a single level spinal fusion for degenerative disc disease can have a marked decrease in disability and improved health-related quality of life. The substantial benefit demonstrated in this study supports the use of this procedure for adults 65 years of age and older. The procedure is not without some potential complications, but overall it is safe and effective. Improvement seemed to occur even in those patients who had some type of problem after surgery.

Five years ago (in 2004), the Food and Drug Administration (FDA) approved the lumbar CHARITÉ artificial disc. This approval was made based on a two-year trial conducted by orthopedic surgeons at 14 different clinics around the United States.

The CHARITÉ artificial disc has been around much longer than that. It was designed and tested first in Germany before it was brought to the United States. The CHARITÉ disc has three-pieces. There is a sliding core sandwiched between two metal endplates. The sliding core is plastic and the endplates are metal made from cobalt chromium. The endplates support the core. They have small teeth that hold them to the vertebrae above and below the disc space. The sliding core fits in between.

Disc replacement is meant to replace spinal arthrodesis (fusion). The main difference between spinal fusion and an artificial disc implant is motion. Fusion stops vertebral motion at the level of the fusion.

The disc implant allows continued normal motion in all directions — even including a small amount of segmental translation. Segmental translation refers to the sliding motion of one vertebral body over another. With a fusion, there is no segmental translation at the fused level. Just the right amount of translational movement is needed for normal spinal motion. Too much translation and the segment would be unstable.

Various measures were used to study the outcomes. Pain, range-of-motion, function, disability, work status, and reoperation rates are commonly evaluated before and after surgery. X-rays measure differences between flexion, extension, and translation of the vertebral segment operated on as well as the adjacent segments (above and below).

Even without a significant difference in all of the outcome measures, decreased pain and increased quality of life can result in patient satisfaction.

Five years ago (in 2004), the Food and Drug Administration (FDA) approved the CHARITÉ artificial disc. This approval was made based on a two-year trial conducted by orthopedic surgeons at 14 different clinics around the United States. The first five-year results for the same patients are now available. This is the largest and longest randomized, multicenter study of artificial discs published in the United States so far.

All patients receiving the artificial disc had severe back pain. They had all tried (and failed to improve with) six months or more of conservative (nonoperative) care. The diagnosis for everyone was degenerative disc disease. Only patients with single-level disease between L4 and S1 were included.

The patients were randomly divided into two groups. One group was treated with a spinal fusion at the affected level. The second group had the damaged disc removed and replaced with an artificial disc device.

Various measures were used to study the outcomes. Pain, range-of-motion, function, disability, work
status, and reoperation rates were all compared between the two groups. For the most part, they found similar results in both groups. The same number of patients improved at the same time and in the same amount in both groups.

This isn’t the result they were expecting. In theory, the artificial disc replacement should produce better results than a fusion. In reality, only slightly more than half the group had improved function and that was very minimal.

There was some question raised that maybe the similarity of results was because of differences in patients in each group. But the groups were very similar in terms of race, age, weight, activity level, and work status before surgery. The only significant difference was the larger number of patients in the disc replacement group who had prior (minor) back surgery. The CHARITÉ group was also more likely to be working full-time before surgery compared with the fusion group.

Independent reviewers of the study suggested that the results weren’t really acceptable for either treatment (fusion or disc replacement). And the fact that the patients chosen for either surgery were highly selected raised some questions, too. If patients were so carefully selected but didn’t really get the hoped for results, what does that suggest?

Although the authors say the disc replacement is safe and effective for this patient population, the editors advised caution. They suggested future studies are needed to look at some of these problems and answer the difficult questions raised before giving artificial disc replacements the green light as safe and effective for long-term use.

Back pain is so common, experts predict that 80 per cent of all adults around the world will experience at least one episode sometime in their lives. Millions of hours and days are lost to work disability from back pain each year in the United States and elsewhere.

Researchers in many developed countries are busy trying to find ways to prevent episodes of back pain. An equally important study topic is getting workers back on-the-job as soon as possible and avoiding a chronic back pain problem.

In general, the prognosis is good and 80 to 90 per cent of workers are able to return to work after a very short period of rest. In fact, unless the back pain is coming from a bone fracture, tumor, or infection, they are advised to stay as active as possible. Getting back to work as quickly as possible is another goal.

Only a small number of people end up with chronic pain. Blue-collar workers who develop fear-avoidance behaviors and/or who went on sick leave during the first 90 days of pain onset have the highest risk of delayed recovery. Fear-avoidance refers to changes in motion or the development of altered movement patterns that occur as a result of fear of reinjury or the belief that certain movements will cause pain.

Just because you develop back pain, doesn’t mean you’ll lose your job or your livelihood. Working with a rehabilitation specialist such as a physical therapist can help identify patients early who are at risk of chronic pain and disability and get them back up to full speed ahead in a short period of time.

Right now, there’s no consensus (general agreement) among experts who study low back pain in an effort to prevent repeat episodes. The definition of low back pain recurrence can range anywhere from the patient’s pain returned to the patient had at least a month without back pain before the pain returned and lasted for more than 24 hours.

According to some experts, a true recurrence really means the patient recovered fully from the first episode. The new symptoms are truly considered a separate incident. But the gray area comes when trying to say just when one episode ended and a new episode began. And there’s some question as to whether features such as pain intensity, duration, or frequency should factor into the definition.

As you have discovered, persistence of pain from a first episode that never really recovered is different from recurrence. Persistence of pain occurs in someone who did not recover from the first bout of low back pain. Clear, separated pain episodes are used to distinguish recurrence from a continuation of the original pain.

According to the most recent studies, to qualify as a separate episode, back pain must occur after at least 30 painfree days after the original episode of back pain. This last parameter (i.e., pain-free for at least one month) represents the working definition of recovery.

Ask your doctor to help you sort out what parts of your clinical picture and history might support that what you experienced amounted to two separate episodes.

It can be difficult to know when an episode of back pain is just a continuation of the last bout or an actual recurrence. Defining recurrence is the topic of a recent study from Australia. The authors looked at the different ways researchers define recurrence. When trying to figure out which treatment works best for low back pain, the concept of recurrence becomes an important measuring stick.

According to the authors of this paper, a true recurrence really means the patient recovered fully from the first episode. The new symptoms are truly considered a separate incident. But the gray area comes when trying to say just when one episode ended and a new episode began. And there’s some question as to whether features such as pain intensity, duration, or frequency should factor into the definition.

For example, does the pain have to last more than one hour to be considered a recurrence? Or two hours? Half a day or longer? Is there a minimum level of intensity that qualifies? Does it have to be at least five on a scale from zero (no pain) to 10 (most pain)? Does the location of the pain matter in the definition? Maybe when back pain is severe enough to limit activities or cause the person to seek treatment, then the incident becomes an episode.

In the end, it was recommended by the authors that a level two pain intensity on a scale from zero to 10 lasting at least 24 hours signals a new episode of low back pain. And the pain must occur after at least 30 days pain free from the last bout of back pain. This last parameter (i.e., pain-free for at least one month) represents the working definition of recovery. Pain-related disability (e.g., pain severe enough to limit activities for more than one day) should be part of the complete definition of an episode of low back pain.

Back pain from a mechanical source usually indicates a musculoskeletal problem (as opposed to a tumor, fracture or infection causing the pain). That doesn’t mean there aren’t reasons for your back pain.

Sometimes people aren’t aware of repetitive movements or poor posture that can be contributing to the problem. The wrong kind of pillow or an old, unsupportive mattress, a cramped desk space, or long hours driving in an unsupported position are all examples of factors that must be changed in order to stop the cycle of back pain – partial recovery – recurring back pain.

Usually in a self-care kind of program, patients are given a few tools to use when getting back into the swing of things. There are stretching and strengthening exercises that can help. Pacing of activities is important. It’s easy to do too much when you are feeling better — especially if you feel you have gotten behind on the days when you couldn’t complete your daily tasks.

Relaxation techniques, cognitive behavioral therapy, and use of some limited medications can be helpful. Cognitive behavioral therapy helps people work through the pain without making the situation worse. Combining relaxation training with positive atttitudes about pain help patients prevent lapses such as you are experiencing.

You may need some outside help during this transition phase from injury to recovery. A physical therapist can give you the guidance you need. The therapist will help you identify reasonable goals and ways to regain full function. Much of what you need to do can be done at home. The therapist will gear your program toward your daily activity and work demands.

Studies show that this kind of approach makes it possible for patients to avoid becoming a chronic pain patient. Full return-to-function is very possible with this method of guided, progressive self-care.

There is some evidence that psychosocial factors are part of the reason patients develop chronic pain that ends in disability. It seems that the subacute phase is when these influences have their greatest effect. Psychosocial variables refer to beliefs, moods, and coping. The subacute period of time is usuallybetween six and 12 weeks after the injury.

Behavioral medicine is a model that puts the focus on self-management of pain, slowly increasing activity, reducing fear of movement or reinjury, and changing beliefs about pain. Anatomy of the spine and physiologic function are reviewed to help patients understand their back pain.

Patients are usually given exercises and activities to complete at home. Vocational counseling and stress management are offered to those who need it. The role of attitude, emotions, and interpersonal relationships as these relate to back pain are discussed.

A different approach to back pain is called attention control condition. It sounds like this may be the type of therapy your brother is receiving. Patients receive empathy, support, and assurance from counselors who listen to them. They are encouraged to go back to the orthopedic physician or physical therapist whenever they needed help to manage their pain and speed up recovery.

There aren’t very many studies comparing these two methods. But a small pilot study from the San Diego Naval Medical Center recently published their results. Their patients were young, otherwise healthy men who had experienced their first bout of low back pain.

Recovery rates were three times higher in the behavioral medicine group than in the attention control group. More patients in the behavioral medicine group recovered at six months and were back to work full-time at their pre-back pain level of activity. Test results showed that patients in the behavioral medicine group also changed their attitudes about seeing pain as disabling.

The authors say that although this was a small study limited to military personnel, the results suggest that a behavioral approach may be a very useful way to move patients with subacute back pain toward recovery. Preventing chronic back pain from developing saves money but also saves people from suffering unnecessarily. Empathy and therapist support may be a feel good approach. But it appears that directive treatment guiding patients through rehab has better results.

Magnetic resonance imaging (MRI) is a medical imaging technique used to look at the internal structure and function of the body. MRI provides much greater contrast between the different soft tissues of the body than computed tomography (CT) does. It is especially useful in showing changes in the brain and musculoskeletal system.

MRI does not use radiation. Instead, a powerful magnetic field constructs an image of the body. MRIs of the spine are viewed by the reader in three ways. First, the level of involvement. In the lumbar spine, most disc problems occur at the L5S1 level, but L1-2, L2-3, L3-4, or L4-5 vertebral segments can also be affected.

Second, they look at the morphology of the disc. Morphology refers to the extent of disc damage. This ranges from mild bulge (inner disc material pushes against its own outer covering) to protrusion (inner disc material pushing into the outer covering of the disc). More progressive damage leads to extrusion (inner disc material pushing through the outer disc covering) and finally, sequestration. Sequestration refers to disc fragment that breaks off and becomes a free-floating loose body in the spinal canal.

Location is the third assessment of the problem. The location of most disc problems is usually posterolateral. This means the disc pushes back toward the spinal canal and off to one side or the other. Disc protrusion can be central (straight back), lateral (just to one side), or foraminal. Foraminal describes a disc that has moved into the space where the spinal nerve root exits the spine. Lateral and foraminal discs can occur on the right or left side.

Specialists trained to read and interpret MRIs can make sense of what looks like modern art to most patients. MRIs are the gold standard in diagnosing disc problems. Studies show they are both reliable and valid. Of course, human error can occur and the person reading and interpreting the study can be wrong. This doesn’t happen very often and is usually quickly corrected when a second look is requested.

Narcotic medications called opioids come in a range of prescription strength. These subgroups are labeled by the U.S. Food and Drug Administration (FDA) as schedules II, III, and IV. Schedule II contain strong opioids such as Actiq, Dilaudid, Demerol, Morphine, and Oxycodone. You may have heard of OxyContin or Percodan — these are other names used for the same drug as Oxydodone.

Schedules III and IV are the weakest opioid including products with codeine such as Tylenol #2, #3, or #4, Lortab, Vicodin, Darvon, and Darvocet.

Opioids are administered via a pill (orally by mouth), a skin patch (called transdermal), or as a nasal spray. The specific type, formulation, and dose must be determined and prescribed by a medical doctor. Because these medications are potentially addictive, they are prescribed cautiously and monitored carefully.

If you have not had a complete workup as to the cause of (and therefore treatment for) your back pain, that’s the first step. If you have been told by your primary care physician or orthopedic surgeon that you have nonspecific back pain, then an opioid might be helpful. Nonspecific low back pain refers to pain that is caused by a mechanical problem within the musculoskeletal system (soft tissues, joints). There are no fractures, infections, or tumors causing your symptoms. Likewise, opioids are only prescribed when you have tried conservative care without success for at least three to six months.

There are many soft tissue and bony structures that make up the sacroiliac joint (SIJ). The basic joint is formed where the sacrum meets the two bones of the pelvis. The main pelvic bone (ilium) also helps form the socket for the hip joint. And the sacrum sits right underneath the last lumbar vertebra.

So, just using the bone connections as a possible source of pain doesn’t include all possible causes. There are also ligaments in the joint, around the joint (joint capsule), and the joint articular surface. Damage to any of the ligaments, muscles, or nerves in the sacroiliac joint region can contribute to pain.

And that’s another thing: pain in the sacroiliac area can be coming from someplace else like the low back area. And problems with the sacroiliac joint can refer pain to other areas such as the low back, buttock, or leg.

All of this is potentially confusing and difficult to figure out. There isn’t just one test the examiner can perform and say Aha! It’s the sacroiliac joint that’s causing the pain. Instead, they must rely on several different clinical tests. Most of these tests are provocative. This means they are designed to stretch, pull, or compress the sacroiliac joint and reproduce the symptoms.

Another diagnostic method is an intraarticular joint injection. The surgeon inserts a long, thin needle into the sacroiliac joint and injects a numbing agent and antiinflammatory drug. Since the fluid injected can leak out of the joint into the surrounding area, it’s not 100 per cent diagnostic of an intraarticular problem when the pain goes away.

It sounds like whatever method was used to diagnose your pain, there is agreement as to the nature of your problem. That’s great because it isn’t always possible to clearly identify the cause and get the right treatment plan going. You’ve conquered more than half the battle just getting an accurate diagnosis!

Pain coming from the sacroiliac (SI) joint can be difficult to diagnose. That’s because the problem can be inside the joint (intraarticular) or it can be extraarticular (outside of the joint). Extraarticular structures include ligaments and muscles. And the diagnosis is made more difficult by the fact that pain coming from the SI joint can be felt in the buttock, groin, and/or leg — not just in the area of the sacroiliac joint.

There isn’t one single test that can be used as the gold standard in diagnosis. Instead, doctors use a variety of pain provocation tests and/or joint injection with a numbing agent combined with an antiinflammatory medication. Pain provocation tests stretch, compress, or contract tissue structures around the SI joint. Injection numbs or silences the pain-generating structures.

There are diagnostic criteria set out by the International Association for the Study of Pain (IASP) regarding sacroiliac joint pain. The IASP proposes that 1) SI joint pain can be identified by the location of the painful symptoms, 2) SI joint pain will be reproduced by carrying out the provocation tests, 3) And the pain will go away after injection with the numbing agent. But is this really so? There are some experts who say both sets of tests are needed. And even then, the results are not 100 per cent full-proof.

Using the location of pain as a diagnostic tool is not a valid approach. Too many patients with pain around the SI area end up with a problem originating someplace else. And too many patients with true SI joint problems have buttock, leg, or back pain (not SI joint pain).

With that out as a gold standard, two of the pain provocation tests might be helpful but they don’t really isolate exactly where the problem is coming from. For example, is it ligamentous? If so, which one(s) is involved? The same goes for muscles — is there a muscular problem and if so, which one is generating the pain signals and why? The source of pain could be the joint capsule (outside the joint) or the joint articular (cartilage) surface (inside the joint)? None of the compressive tests really sort this out carefully enough.

That leaves us with the intraarticular injection as a potential gold standard diagnostic test. But the numbing agent can leak out of the joint affecting the nearby nerves and soft tissues. Thus, the injection cannot be designated as the single most reliable and valid test for SI problems either.

Until and unless scientists can figure out how to isolate individual structures in and around the SI generating pain, it remains certain that differentiating low back from sacroiliac joint problems will be difficult. One individual diagnostic test just isn’t going to be possible. For now, it has been suggested that examiners use the provocation tests best known for their ability to recreate pain from the SI. The presence of a positive thrust test and positive compression test signal the need for further diagnostic workup with an intraarticular injection.

That brings us back to the International Association for the Study of Pain (IASP) and their criteria for the diagnosis of SI joint pain. These make a nice place to start, but there isn’t enough evidence to support them as reliable and valid diagnostic guidelines at this time.

Spine surgeons (both orthopedic and neurosurgeons) often use bracing for their patients after fusion of the neck or low back. But with today’s evidence-based practice, there’s been a question about this practice. Is it really needed? Is there any evidence to support external immobilization of this type? Or is it just a matter of doing what we’ve always done because we’ve always done it?

A study was done in Canada to see just what are the bracing patterns of spine surgeons. They looked at bracing after both cervical spine (neck) surgeries and for lumbar spine fusions. They found that when bracing was used for the lumbar spine, it was discontinued earlier with internal fixation. Internal fixation refers to the use of metal plates, rods, and/or screws to hold the spine in place during the healing/fusion process.

As far as bracing goes, surgeons reported using a canvas-material corset for lumbar spine procedures that didn’t involve fusion. Rigid bracing was used more often for fusion procedures. It didn’t appear to matter whether or not a custom-made brace was used versus an off-the-shelf model.

The results of this study show there is continued reason to doubt the need for postoperative bracing after spinal fusion. There’s no evidence that bracing really prevents motion of the fused vertebral segments. Likewise, there’s no support for the idea that bracing slows the patient down, reduces pain, or improves the fusion rate.

It is the opinion of some surgeons that proper surgical technique and the use of rigid internal fixation to hold the spine in place should be enough. The bone will fill in and create a solid fusion without the support of an external brace. Your surgeon will guide you regarding the use of a brace after surgery. It may depend on the condition of the bone, type of surgery done, and clinical experience of the surgeon.

That’s a question many surgeons and researchers have tried to tackle. In fact, over the last 40 years, there have been over 600 studies done on disc-related back pain. Back pain with leg pain is called radiculopathy. A more common name is sciatica. It is caused by pressure on the spinal nerve root or chemical irritation of the nerve root from the herniated disc or disc fragments.

The results suggest that as far as getting back to work as quickly as possible goes — the more conservative approach of just removing the disc fragments gives the best results. But when patients were followed for two years (or more), the incidence of reherniation was higher in this group compared with a more aggressive (complete removal) approach.

Some other disadvantages of complete disc removal include damage to the nucleus and end plate (between the disc and the next vertebra). The result can be increased back pain and a faster degeneration of the back. In the end, these patients were more likely to need more surgery later.

The surgeon will likely make this decision at the time of the surgery. Based on preoperative MRIs, he or she may have a pretty good idea of how much damage is present, how compromised the spinal nerve is, and the general health of the disc itself. A closer look during the operation will be the final factor used in making the decision.

You may have heard the expression a rose is a rose is a rose. The general suggestion is that there isn’t much difference from one rose to another — they are all the same type of flower with slightly different colors or sizes.

Well, the same expression doesn’t hold true for a disc herniation. Disc disorders have a wide range of differences that can’t be lumped all together. The three main types of disc herniation can actually be divided into disc prolapse, disc herniation, and disc sequestration.

In the case of a prolapse, the disc is bulging. The inner portion of the disc (the nucleus) is intact has migrated or moved into the outer covering called the annulus. The direction of the disc material is usually backwards toward the spinal canal. A bulge or prolapsed disc can be large enough to actually press against the nearby spinal nerve root causing back and/or leg pain.

If the nucleus breaks out of the annulus, you have a disc herniation or protrusion. To get a bit more technical, a protrusion of the disc material means the amount of tissue that is pressing backward is equal from one side to the other. The same bulge could be called an extrusion if the shape is more like a balloon with a narrow base and wider, rounder end-point.

Finally, there can be something called a sequestration. This means the disc has protruded and then a piece has actually broken off and is free to move in the spinal canal. This is a very dangerous situation as the disc fragment can press into the spinal cord causing paralysis.

Surgery to remove a disc can range from just removing any free floating fragments found during the operation to removing the entire disc. Recurrence of disc herniation or reherniation as it is sometimes called occurs when only the protruding, extruding, or sequestered part of the disc was taken out.

Some portion of the disc still remains sandwiched between the two vertebral bodies. Some surgeons leave as much of the disc behind to continue functioning as a cushion, dispersing the load and force through the spine. This helps reduce the degenerative processes in the spine at that segment but does increase the risk of a reherniation.

There are different reasons why patients with chronic low back pain need lumbar spinal fusion. Lumbar canalstenosis (narrowing of the spinal canal), degenerative disc disease, scoliosis, and instability after a previous (laminectomy) surgery are the most common problems. Laminectomy refers to the removal of a section of vertebral bone called the lamina. Cutting away the bone helps take pressure off the spinal cord or spinal nerve roots.

Most of these conditions are not the direct result of being overweight or even obese. Some of the symptoms from these conditions such as back pain can be made worse by being obese. Weight loss before surgery and quitting smoking for those who smoke are always advised. In fact, some surgeons insist on it.

Anyone with a body mass index (BMI) of 30 or higher requires careful consideration and monitoring when having surgery. A person’s BMI can be calculated using a mathematical equation of the ratio between height and weight. Anyone with a BMI of 30 kg/m2 or higher is classified as obese.

Morbidly obese is a separate category for those individuals who are 20 per cent or more above the optimal weight for their height and body type. Their BMIs can exceed 40 kg/m2. Patients with a lower BMI (35 to 40 kg/m2) can also be considered morbidly obese if they have one or more significant comorbidities. Comorbidity refers to other health problems such as diabetes, heart disease, high blood pressure, asthma, sleep disorders, and so on.

The surgeon must go into the lumbar spinal fusion procedure with the knowledge that obese patients have a greater risk of postoperative complications. However, there is some evidence that these problems may not be related to body size as much as the number of segments being fused. Fusion of one or two vertebrae isn’t nearly as risky as five or six segments being fused. Overall results may be better if the obese or morbidly obese patient has bariatric surgery first before spinal surgery.

Patients who find themselves in your position often wonder if this kind of decision is really justified. Are patients really at increased risk for problems during and after surgery just because they are obese? Is there any evidence to support this kind of guideline?

In fact, there are many factors to consider. For example, there can be difficulties getting a clear airway to allow the patient to breathe while being anesthetized. Folds of fat and flabby soft tissue collapse against the airway preventing intubation (placement of a breathing tube down the trachea).

It can be equally difficult to gain access to a blood vessel to start an intravenous (IV) line. Positioning the patient can be a tremendous challenge. For example, pressure on the belly can cause greater blood loss. Whenever possible, the patient is placed in such a way that the abdomen hangs free. Even more serious is the fact that studies have confirmed the link between obesity and the increased incidence of complications (including death) during and after the surgery.

There was a recent study done at the Henry Ford Hospital in Detroit showing that obese patients who had lumbar fusion surgery really didn’t lose weight after the operation. One caveat to the study was the fact that no effort was made to help patients lose weight. They were not counseled about weight loss or enrolled in an exercise program following the surgery.

You may still want to pursue the surgical approach in order to reduce your pain and improve your quality of life. It may be possible to find a surgeon willing to take high-risk patients. It will be important for you to fully understand the possible risks for yourself in terms of complications that can occur during and after the surgery.

One other option is to have bariatric surgery (e.g., stomach banding or gastric bypass) first. Lose weight. Then reconsider back surgery. You should be aware that low back pain and chronic depression are risk factors for a poor outcome after bariatric surgery as well. Some surgeons will not consider you a good candidate for bariatric surgery because of your history of low back pain.

Tumors of the sacrum are rare but can create serious problems. They can be benign or malignant. They may be primary, which means they develop first right in the sacrum. Osteosarcoma of the sacrum is a primary bone tumor. It didn’t metastasize from someplace else to the sacrum — it started right in the bone.

Surgery to remove the tumor isn’t always possible right away. The tumor can be too large or too enmeshed with other structures to remove it easily. Radiation may be used first to shrink as much of the tumor as possible.

Tumors that are advanced by the time they are diagnosed make surgery difficult and complex. Removing the tumor, a procedure called resection, isn’t always a straightforward process. The anatomy of the pelvic and sacral areas is a challenge. Bowel, bladder, and sexual function are easily disrupted by any changes in this area. The patient’s preoperative health can also make a difference (e.g., diabetes, high blood pressure, heart disease).

For those patients who can have surgery, multiple procedures may be needed to reconstruct vital bowel and bladder structures. Removal of the entire sacrum (called sacrectomy) can be a major undertaking, especially if the sacroiliac joints are compromised by the tumor. This anatomical area provides support, stability, and biomechanical function for the entire lower body.

It sounds like your brother-in-law is scheduled for a hemi-sacrectomy (removal of half the sacrum). Most likely, the surgeon won’t just take the bone out and leave the patient with half a sacrum. Usually for such a large area removed, bone from a bone bank is transplanted to replace the missing piece.

Sometimes metal plates, screws, or pins are needed to hold everything together until the bone can fuse itself in place. Patients can regain walking skills again. In fact, studies show that between 57 and 84 per cent of patients who have sacral amputation followed by radiation therapy are able to get up and walk again. There is a long period of recovery and rehab before this can be accomplished.