Should I Get My Sciatica Relieved Surgically, Or Should I Wait?

This question is highly dependent upon many factors and needs to be carefully assessed by a medical professional. If you have a severe bulging disc in your low back that is putting debilitating pressure on your nerves, then yes selective discectomy surgery can be effective for reducing radiating low back pain.

I have pain that is radiating to both my toes.  My doctor says that I have spinal stenosis and that I need a surgery.  He is recommending a fusion and wants to take some of my hip bone to help stabilize my spine.  Isn’t this excessive?  Why doesn’t he just use some screws?

A recent study looked into this very question and found that it is slightly more cost effective to perform a noninstrumented fusion, or a fusion using a person’s own tissue to stabilize the fusion, than an instrumented fusion This cost effectiveness is taking into account the possibility of need for re-surgery, potential complications following surgery like infection, and medication changes.

What is the difference between a decompression and a laminectomy?  I am in my 70’s and have spinal stenosis and am not thrilled about the prospect of surgery.  

A laminectomy is a type of decompression surgery.  During a laminectomy, the lamina bone is removed which is typically encroaching on the nerve.  The lamina is a bone that bridges the spinous process (pokey part of your spine) and the transverse process, or the side of the vertebra.  If you are not excited about surgery and have not yet done so, physical therapy can often help to minimize symptoms if not alleviate them completely.

I am a 60-year-old male with pain shooting down the backs of both of my legs.  My MRI says that I have lumbar stenosis and my surgeon wants to operate.  What are the risks associated with this surgery?  I have heard some real horror stories.

Any surgery has associated risks.  Many of these can be avoided with proper procedures.  Overall, recent data shows the risk for sentinel events or avoidable mistakes to be .8 per 1000 cases in the U.S., so overall the risk is fairly low.  That being said however, you should have a discussion with your surgeon regarding your concerns and he can give you specifics regarding risks of your particular surgical procedure.

What is the take away from this study?

If you are someone who has a BMI of 25 and above and have chronic low back pain (12 weeks or longer, consistently) reducing your BMI may not change your pain or disabilty. You should contact a skilled health care provider for proper evaluation and assessment of your symptoms.

What can I do to decrease may chances of getting lower back pain?

In this study they found, that for the average overweight American a modest increase in activity time by 17.6 minutes a day (123 minutes a week) reduces risk of lower back pain by 32 per cent and for morbidly obese people an increase of 2.1 minutes can make substantial difference. An example would be adding more time in moderate activity (walking) into your day.

What can I do about my lower back pain and weight?

Exercise has been shown to help both conditions. Speak with your physician or a qualified clinician about your back pain and weight. They can assist you in getting started with a safe, gradual and successful exercise program.

Should I trust that my therapist or practitioner is using a high-quality, research supported methods for treating my back pain?

This is a good question to ask your physical therapist, acupuncturist, masseuse, chiropractor or selected practitioner. A rigorous evidence-based education should provide your therapist of choice with the skills, tools and the body of research to support why they are selecting each treatment. It would not be unwise to have a brief discussion on the rationale behind their treatment choice.

Why am I getting shorter with age?

The exact process to explain the shortening of your spine is speculated in the spine-related research. Two proposed explanations include a cumulative micro-trauma theory at the disc-vertebra interface that creates an inflation process and merging of the cartilage and bone. The second theory suggests a gradual tensioning of the disc pulling on the vertebra that eventually triggers a process of converting the cartilage to bone.

How quickly can I expect to lose my height?

The current research can validly extrapolate that the average middle-aged man is indeed getting shorter, but by only .13 millimeters per year on an annual average. For example, if you are 5 feet 8 inches at age 45, you could safely expect to loose less than an inch by your 60th birthday.

Does spinal manipulation help improve my low back pain?

This largely depends on how wide of a search beam you project into the years of research. For example in a recent meta-analysis by Dr. Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, found very little supportive evidence in his meta-analyses on comparative effectiveness of various manual therapies, that include spinal manipulation in his review of the existing literature. “A comparative effectiveness meta-analysis” was performed to compare the relative effectiveness of various spinal manipulation treatments (from the ancient bonesetter to the modern back cracker), medical management (READ: drugs, injections, etc), physical therapy, and exercise for acute (less than a month) and chronic (more than 3 months) nonsurgical management of low back pain.

The good news is most pain originating from the muscles and joint in the
human body is self-limiting, meaning slowing down, protecting your
injury, and letting the body heal will often suffice. Research supports the notion that sixty to seventy per cent of acute low back pain settles in six weeks without any medical treatment. Chronic low back pain sufferers get better in a year without treatment 40 to 70 percent of the time. Pain whether short-term or long-term is indubitably unpleasant, so why suffer any longer than you have to if effective treatment is available.

Comparing physical therapy, chiropractic, and osteopathy, what nonsurgical treatment for chronic low back pain helps the most?

In a recent meta-analysis by Dr. Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, he determined in the comparison that getting your spine manipulated in the first six weeks has little influence on the outcome of shortening the duration of your acute pain. Five types of spinal manipulation providers (osteopaths, physical therapists, chiropractors, allopathic medical physicians, and bonesetters) were compared. Spinal manipulation by a physical therapist was found to be most effective, and most variable, in treating both acute and chronic back pain.

I am a fourth-generation of back pain sufferers. My wife’s family doesn’t seem to be bothered by this problem at all. But my brothers, uncles, father, grandfather, great grandfather (and myself) have all dealt with this issue all of our lives. Has anyone come up with a reason for this and/or a solution??

Despite spending more than 86 billion dollars a year on treatment for back pain in the United States, Americans continue to struggle with this problem. It has become a national epidemic. Twenty-five years ago, prominent medical doctors called for new ways to diagnose back pain and measure outcomes of treatment. Today, very little has changed. In fact, there is evidence to suggest that Americans with spine problems are worse than ever before.

What have we learned from these last 25 years of scientific inquiry and study? In a recent editorial, Dr. R. G. Hazard from the Department of Orthopaedics at Dartmouth Geisel School of Medicine offers some perspective on this question that may be of interest to you.

First, it should be noted that in 1987, researchers started using scientifically validated measures of low back pain and subsequent disability. And second, the focus shifted from looking for a specific pathologic reason for the back pain to an understanding of the biopsychosocial factors accompanying back pain.

Stress at home and at work, feelings of being out of control of life situations, and self-perceptions were some of the biopsychosocial aspects mentioned at that time. Along with these two new approaches came awareness that treatment at that time was driven by patient complaints, distress, and behavior.

On the medical side of things, it is clear that finding a clear and accurate diagnosis to label each patient is often impossible. Imaging studies with X-rays, CT scans, and/or MRIs are often “negative” (no findings of anything “wrong” in the bones or soft tissues). Even knowing this, physicians continue to use steroid injections, narcotic medications, and surgical procedures to address the problem of back pain.

Not only that, but when clear-cut diagnoses can be made (e.g., lumbar disc herniation), patients with this diagnosis respond differently to treatment. Finding one single approach that works for everyone just hasn’t happened. Some experts even recommend providing patients with amenu of (treatment) options and letting them pick their treatment of choice. This idea is labeled a shared decision-making model. However, results so far have not been any better than with physician-prescribed treatment.

So, where are we today? There is a shift toward emphasizing ability (function) rather than disability (limitations). Instead of focusing treatment on pain relief, rehab programs aim to improve flexibility, endurance, and strength in the presence of ongoing pain. If pain is relieved in the process, well then, so much the better.

Recovering function (daily activities) and the ability to return to work are the main goals of today’s treatment for chronic low back pain. This approach is referred to as the Goal Achievement Model for the treatment of low back pain. Efforts to reduce disability from back pain based on patient goals is a new way of thinking about the problem of back pain.

Concepts such as setting “acceptable targets” and forming “patient-based action plans” are the new words attached to current treatment ideas about chronic low back pain. Health care providers can still use the biopsychosocial model (working with patient values, attitudes, and beliefs) while the patient gets the results he or she is after. This approach has worked quite well with other health problems (mental health and chronic diseases that lead to severe disability). In time, we will see how patients with low back pain fare.

I am very unhappy with the way my doctor and my physical therapist are treating the problem of my back pain. It’s like they are in cahoots with each other. No one talks to me about my pain. It’s all about “doing more with pain” or “getting back to work despite the pain”. All I can focus on is how much it hurts and the pain is why I can’t do more. What can I say or do to get their attention and more important to me: their response?

Twenty-five years ago, the focus shifted from looking for a specific pathologic reason for low back pain to an understanding of the biopsychosocial factors accompanying back pain. By then, it was clear that finding a clear and accurate diagnosis to label each patient was often impossible. Imaging studies with X-rays, CT scans, and/or MRIs are often “negative” (no findings of anything “wrong” in the bones or soft tissues).

Stress at home and at work, feelings of being out of control of life situations, and self-perceptions were some of the biopsychosocial aspects mentioned at that time. An awareness that treatment at that time was driven by patient complaints, distress, and behavior started to change things.

There was a shift toward emphasizing ability (function) rather than disability (limitations). Instead of focusing treatment on pain relief, rehab programs today aim to improve flexibility, endurance, and strength in the presence of ongoing pain. If pain is relieved, well then, so much the better. But pain relief is no longer the main treatment objective.

Recovering function (daily activities) and the ability to return to work are the main goals of today’s treatment for chronic low back pain. This approach is referred to as the Goal Achievement Model for the treatment of low back pain. Efforts to reduce disability from back pain based on patient goals is a new way of thinking about the problem of back pain.

Concepts such as setting “acceptable targets” and forming “patient-based action plans” are the new words attached to current treatment ideas about chronic low back pain. Health care providers can still use the biopsychosocial model (working with patient values, attitudes, and beliefs) while the patient gets the results he or she is after. This approach has worked quite well with other health problems (mental health and chronic diseases that lead to severe disability).

Pain can be a real deterrent to accomplishing anything from the simple task of brushing your teeth to getting a good night’s rest. Clinical and research efforts are underway in an attempt solve the dilemma of chronic low back pain. In today’s modern practice, you can expect to find yourself in a goal-oriented program that takes into consideration physical, emotional, psychologic, social, and spiritual aspects of care.

Lowering costs, meeting patient expectations, and providing successful outcomes and patient satisfaction are all important but complex factors that must be taken into consideration. Pain relief is part of that approach but only a small piece of the pie. Give this approach a fair try and see what you might be able to accomplish in the long-run rather than having a short-term focus on pain relief. It can be a challenging way to treat back pain (for the patient!) but still very effective.

It is my job at our local hospital and medical center to keep abreast of all clinical practice guidelines (CPGs) for orthopedic conditions. Most recently, I heard that the CPGs for lumbar stenosis were updated and published. Do you have a place on your website where I can access this information?

The 2006 clinical practice guidelines for degenerative lumbar spinal stenosis (DLSS) have indeed been reviewed (based on published studies up to and including July 2010) and revised. In a recent article from The Spine Journal, members from the Degenerative Lumbar Spinal Stenosis Work Group of the North American Spine Society (NASS) provided a summary of the new guidelines. This update is now considered the most recent evidence-based clinical practice guideline (CPG) on LSS.

Sixteen questions were posed and answered in the 2006 Clinical Practice Guidelines. The questions covered topics ranging from natural history of LSS to diagnosis and treatment of this condition. All questions were reviewed and responses provided in this 2013 update. The levels of evidence were indicated for each response using grades labeled A (recommended), B (suggested), C (an option), and I (insufficient evidence to recommend for or against).

The working group also provided a consensus statement when there wasn’t enough reliable evidence to provide a guideline. This consensus statement is the opinion of the group based on all currently available evidence and expert opinion. Here is a sampling of the questions and some of the updated responses:

  • What is the best working definition of degenerative lumbar spinal stenosis (DLSS)?
  • What is the natural history of symptomatic DLSS?
  • What are the most appropriate diagnostic tests for DLSS?
  • Does medical treatment improve results (compared to the “do nothing” approach)?
  • What happens in the long-term (four to 10 years) with surgical treatment compared with conservative care?

    No grades of recommendation were available for the first two sample questions. Instead, the Working Group provided consensus statements. In the case of the definition and natural history of lumbar spinal stenosis, they described the condition as follows: Degenerative lumbar spinal stenosis describes a condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal.

    The group agreed that the natural history (what happens over time) with this condition is a picture of mild to moderate symptoms (e.g., low back, buttock, and/or leg pain, difficulty walking, fatigue). About one-third to one-half of all affected adults will get better (with or without treatment).

    Physicians cannot really rely on patient history and reports of symptoms to make an accurate diagnosis. Pain that is not made worse when walking is probably not caused by stenosis. MRIs provide the best opportunity for identifying the characteristic narrowing of the spinal canal or nerve root impingement typical of lumbar spinal stenosis. Evidence to support these statements was listed as a Grade B (suggested). Evidence regarding other types of diagnostic testing (e.g., CT scans, electrodiagnostics, electromyography, motor-evoked potential) is also reviewed and updated.

    Many treatments considered for lumbar spinal stenosis such as acupuncture, bracing, traction, electrical stimulation, and steroid injections are considered options (Grade C). But the evidence for or against each one is limited by insufficient research/evidence. The Working Group identified these areas as in need of further research in the future.

    Surgery can improve the symptoms and quality of life in carefully selected patients. The choice of surgical procedure (e.g., decompression alone, decompression with spinal fusion, fusion with or without instrumentation) is based on age and type and severity of symptoms. Patients with moderate to severe symptoms are considered most often for surgery based on current evidence (Grade B; suggested).

    To read the full report and review all the references, you can go to the North American Spine Society’s website at www.spine.org.

  • My 83-year-old mother was recently diagnosed with spinal stenosis. She mostly suffers from back pain and sometimes pain down her leg. In order to avoid the pain, she stays bent forward most of the time. Would a brace help her?

    Lumbar spinal stenosis in this age group is usually caused by the natural degeneration of the spine over time. The condition is described as a narrowing of the space available for the spinal cord, nerve roots, and blood vessels in the spine. The lumbar spine (low back area) is the region affected most often by this condition.

    Bending forward helps take the pressure off the neural segments (spinal cord, spinal nerve roots) but this compensatory posture has some obvious drawbacks. The use of a corset or brace has been shown to aid patients by decreasing the pain, thus making it possible to stand upright and walk unassisted. However, once the brace is removed, the benefits are gone as well. In other words, wearing a brace is not a long-term answer.

    Other types of treatment have been tried and results reported. Acupuncture, electrical stimulation, and traction are just a few examples of treatments investigated. But not everyone responds well and there is insufficient evidence to direct and guide who is most likely to respond to each treatment type.

    Surgery is advised for patients with moderate-to-severe symptoms that persist over time. But keep in mind that patients with mild-to-moderate symptoms have a 30 to 50 per cent chance of improvement over time without treatment. Symptomatic relief with short-term bracing is considered acceptable, especially if there is a chance for symptom resolution without surgery.

    I’m recently retired and looking to take up a new sport — possibly golf. I’m looking for any suggestions you might have for an “older adult” (I’m 72-years-old) that might help me stay fit without injuring myself while learning a “new game.”

    One-fourth of the 26 million golfers in the United States is over the age of 65: welcome to the ranks! Experts agree that avoiding injury among golfers begins “before the golfer ever sets foot on the course.” Prevention education is the most important way to prevent injuries from ever occurring in the first place.

    Golf-specific movement screening, performance training, and early rehabilitation for golf-related injuries are extremely important to aid in injury prevention, quick recovery after an injury, and prevent further injury or injury recurrence.

    Lumbar (low back) pain is the most common symptom in golfers who stick with the sport over a long period of time. The repetitive motion, rotation, and strain from the golf swing create pressure on the discs of the spine. The increased load and force on the spine are intense enough to damage muscles, joints, discs, and even the ribs. More than one-third (34.5 per cent) of all injuries among golfers results in low back pain.

    And in the older adult, the effects of aging decrease spine motion and the ability to handle forces placed on the spine during the golf swing. What can be done to prevent these common low back conditions in golfers? Here are a few suggestions:

  • Golfers with low back pain should be encouraged to seek help early on rather than wait and see if it goes away. Correction of swing faults, muscle imbalances, or other improper golf techniques can aid in prevention of worsening symptoms or repeated injury.
  • Breath control during swinging or putting is recognized as an important part of injury prevention in this sport.
  • Proper clubs fit to body specifications is a must for each individual player.
  • Simple things can make a difference: push the golf cart rather than pulling it, use a golf bag with dual straps rather than a single strap, and maintain proper body weight for size (being overweight is a risk factor for low back injury).

    You may want to see a sports physical therapist for some help early on in your new golf “career”. The physical therapist can assess your range-of-motion, postural alignment, movement patterns, and golf swing mechanics that need correction. Core stability training is an important part of a training or exercise program for golfers at any level (amateur to professional).

    According to one physical therapist who treats golf injuries, avoiding injury among golfers begins “before the golfer ever sets foot on the course.” Prevention education is the most important way to prevent injuries from ever occurring in the first place. You are very wise to seek counsel and advise right from the start!