FAQ Category: Lumbar Spine

Pubic symphysis diastasis is a disruption of the pubic bones in front of the body. It is a known complication of pregnancy and vaginal childbirth. The entire pelvis is formed by the sacrum (wedge-shaped bone at the base of the spine), the coccyx (tailbone at the bottom of the sacrum), and the hip bones. The upper (socket) portion of the hip is made up of the ilium (pelvic crest), ischium (bones you sit on), and pubis (birth canal ring).

Separation of the symphysis pubis is referred to as symphyseal diastasis. The pubis symphysis is in front of the body where the two pelvic bones come together. A disruption of the connective tissue between the two pelvic bones at the symphysis pubic can cause pelvic instability. Disruption can be defined as translation (movement of the pubis on one side up or down), widening (separation), or impaction (narrowing or overlapping of the space between the two bones).

Experts propose that normal motion in this area is up to 0.5 mm in men and up to 1.5 mm in women who aren’t pregnant. Pregnant women (or women who have had multiple births) may have up to a 3.0 mm shift. Anything beyond these guidelines may be a sign of change in alignment and considered a positive response for pelvic instability.

If X-ray tests confirm the presence of symphyseal diastasis, there are several ways to approach its treatment. Patients with mild diaphysis who don’t have any symptoms may not need treatment. In cases, of mild-to-moderate separation, careful monitoring may be all that’s required. The condition may improve over time with rest. The physician may recommend that the patient remain non weight-bearing for up to four weeks.

Sometimes a pelvic binder is recommended. Special cloth or canvas binders have been designed for use during pregnancy to help prevent the diaphysis from occurring. A pelvic binder can also be used after pregnancy to help restore a more normal anatomical position.

But for the person with pain and/or instability, conservative care may not be enough. Surgery may be needed when painful instability does not respond to nonoperative measures. Internal fixation using wires, screws, or a plate and screws may be possible. For more complicated or involved injuries, an external pelvic fixator frame with fixation pins may be used.

Reduction of the symphyseal widening with the internal or external fixation is usually done with fluoroscopic guidance. A fluoroscope is a special type of real-time X-ray that allows the surgeon to see while inserting the necessary hardware.

Anytime a woman presents with pelvic pain after childbirth, a medical evaluation is advised. Damage to any part of the pelvic ring usually means there’s disruption to another portion of the ring. It’s easy to underestimate the extent of pelvic injury after birth and delivery. Early treatment may be needed to help prevent further damage.

Your mother may be experiencing a condition called separation of the symphysis pubis. This problem is more commonly referred to as symphyseal diastasis.

The entire pelvis is formed by the sacrum (wedge-shaped bone at the base of the spine), the coccyx (tailbone at the bottom of the sacrum), and the hip bones. The upper (socket) portion of the hip is made up of the ilium (pelvic crest), ischium (bones you sit on), and pubis (birth canal ring).

The pubis symphysis is in front of the body where the two pelvic bones come together. A disruption of the connective tissue between the two pelvic bones at the symphysis pubic can cause pelvic instability.

Standing on one leg can cause disruption or movement of the pubis on one side up or down. Since this area is connected together by soft tissue, there is a certain amount of normal give. But it shouldn’t be felt or perceived in any way. The clunk your mother feels is not normal. It may be a symptom of pelvic instability.

Trauma such as a car accident, childbirth, or a fall is the most common cause of pelvic instability. In older adults with osteoporosis (brittle bones), stress fractures can occur that also lead to disruption of the symphysis pubic and pelvic instability.

The diagnosis of pelvic instability is difficult. X-rays are usually taken in the standing (on two legs) position and supine (lying on the back). But these views don’t always show pelvic instability even when it’s present.

A more accurate assessment of this particular problem is with the single-stance X-ray. The single-leg X-ray, a simple, inexpensive, diagnostic tool, can be very helpful. A significant shift in the bones can best be seen by comparing the position of the symphysis pubis when standing first on one leg and then on the other (single-stance).

A history of preceding trauma, older age, or abnormal motion in the pelvic area is reason enough to order this type of X-ray view. Damage to any part of the pelvic ring can result in disruption of any other portion of the ring. A positive single-leg stance X-ray signals the need for further evaluation.

Back pain is one of the most common pain complaints in the developed world. It’s estimated that almost everyone will complain of a back ache at least once in their life. And yes, it does seem to be more common now than it did a few generations ago.

But, is it because the generation is weaker or because it’s because the new generation is just different? The answer seems to be that it’s just different. As a desk worker, your back doesn’t get the work out every day that your dad’s back did. Although he likely lifted heavy objects and did a lot of bending and hard work, his back adapted to it over the years. Many adults in the developed world don’t have that and never had the opportunity to develop the stronger backs, including the muscles in the back and the abdomen.

Also, don’t forget that sitting also puts strain on the back, albeit in a different way. Sitting for hours on end at a desk is not a natural position for the human body, so this can cause stress, which in turn, causes pain.

Ergonomics is the science of protecting your body from injury by adapting the world around you. For example, if you stand for long hours, you may be given a small stool to rest one foot a bit higher, a more natural position. You may be given a work mat to stand on, to soften or cushion your feet, and you may be encouraged to take breaks and walk around. These are all to prevent injuries.

Ergonomics for back injury prevention works in the same way. It includes using lifting belts, learning proper lifting techniques, and being sure you get the help you need when you need it. What the ergonomics doesn’t do, is strengthen the muscles in your back and abdomen, making it easier for you to lift, bend or twist.

A good example is a study that was done on farmers, who researchers thought would have a high rate of back injuries due to the nature of their work. Surprisingly, the researchers found that there was no higher a rate of back injuries among farmers than in non-farmers. That led the researchers to believe that the farmers had built up their strength and tolerance, which allowed them to do such heavy, physical labor. The researchers also determined that because the farmers didn’t injure themselves at any higher rate, the traditional ergonomic approaches towards back injury prevention wouldn’t be effective.

This question has been studied and debated by many surgeons. There are multiple factors and variables, which make it difficult to answer yes or no to your question.

For example, spinal fusion can be done anteriorly (from the front of the body), posteriorly (from the back), or posterolaterally (at an angle between the back and side). The results of a brace or corset must be compared among these three approaches before a set of guidelines can be made.

The surgery may be with or without instrumentation (metal plate and/or screws). The use of instrumentation may or may not make a difference — but we don’t know that because there aren’t enough studies to give us convincing evidence one way or the other. The same thing could be said about the results of bracing after fusion without instrumentation.

If the goal is to provide a stabilizing effect, then it’s possible the type of support used would make a difference. And there are all types of support options. The two main choices are a molded, rigid orthosis (plastic brace) and a wrap-wround canvas corset (with or without metal stays).

When and how long to wear the support is another factor to consider. Should it be worn just at night while sleeping? All day (every day around the clock)? For four weeks? Six weeks? Longer? We simply haven’t had enough studies to examine the evidence around each of these factors.

A recent study at the Spine Institute (University Hospitals of Cleveland) compared patients after a posterior lumbar fusion both with and without bracing. They used the canvas type of corset with adjustable metal supports (stays). The stays were placed inside the corset and positioned on either side of the spine. Patients who wore the brace kept it on full-time for eight weeks (except to bathe).

After following all patients for two years, there was no difference in outcomes between the two groups.

It’s possible a different brace would have different results. This group of patients had a degenerative spinal condition. It’s possible that other diagnoses might respond more favorably to the external support. And perhaps the level of fusion (upper lumbar spine versus lower lumbar spine) makes a difference.

Success may vary depending on the goals of therapy. For example, the idea of wearing a brace to limit motion may have different results when compared with using a brace to decrease pain, increase function, or improve fusion rates.

More studies are needed to look for different subgroups of patients who may benefit from bracing after spinal fusion.

Pulmonary embolism (PE) is the lodging of a blood clot in a pulmonary artery (blood vessel that delivers blood to the lungs). The result is a blockage in the blood supply to the lung tissue.

Lung blood clots are fairly common in hospitalized patients, especially after surgery. The most important risk factor is a deep venous thrombosis (DVT) A DVT is a blood clot in the arm or leg as a result of a hip fracture or total hip replacement.

Because DVTs and PEs can be fatal, every effort is made to keep them from occurring. Blood thinners such as heparin or Coumadin are routinely used before, during, and after surgeries involving the abdomen, pelvis, prostate, hip, or knee. Compression stockings on the legs are also ordered for each patient after major surgery of any kind.

Immobilization (bed rest) is a risk factor for the formation of blood clots. But there’s no evidence that using a lumbar brace, support, or corset of any kind will lead to the formation of blood clots. It’s more likely that a combination of risk factors all present at the same time increases the risk of blood clot formation.

These can include heart disease, congestive heart failure, hypertension, or chronic obstructive pulmonary disease (COPD). Other minor risk factors also include the use of oral contraceptives, hormone replacement therapy, and tobacco use. Neurologic disability, long distance travel, and obesity are additional risk factors.

Lumbar spinal drainage using a needle to draw the cerebrospinal fluid (CSF) is a procedure done during brain surgery. The procedure is called a lumbar drain. Removing CSF helps the brain relax. But as you’ve discovered, complications such as a CSF leak can occur.

When that happens, a needle is inserted through the skin down into the thecal sac where the CSF is located. The thecal sac is made up of two separate but closely linked layers of lining called the dura mater and the arachnoid mater. The sac protects the nerve roots from pressure injury while the fluid supplies nutrients to the nerves.

Once the needle is in place, then a catheter can be inserted in place of the needle. The CSF is drained out through the catheter. The needle used to tap into the CSF is put in place using fluoroscopy. Fluoroscopy is a type of real-time X-ray that allows the surgeon to see the needle moving through the tissue. This type of X-ray improves accuracy but exposes both the patient and the surgeon to radiation.

Fluoroscopy has the added advantage of being portable. A unit can be brought to the patient’s room. The procedure can be performed at the bedside. But when several attempts to perform the procedure are not successful, then computed tomography (CT) may be helpful. The patient must be transported to the CT suite.

The CT scan allows safe and accurate placement of the needle from skin to spinal canal. Each cross-sectional slice provided by the CT image allowed the surgeon to choose the right needle angle. Measurements to gauge distances are given in millimeters. If there is any doubt about correct placement of the needle, a contrasting dye can be injected through the needle into the CSF. The dye is taken up by the CSF and confirms proper needle placement.

CT scan also shows if there have been any blood vessels punctured along with the formation of a hematoma (collection or pool of blood). Hematomas must be treated immediately to prevent further complications.

When one spouse hurts, the other spouse is usually acutely aware of it. Having the understanding and support of a loved one can help us through painful conditions. When the pain lasts longer than expected, how do partners cope? What happens when the problem becomes chronic or even permanent? And what is the effect on the relationship?

These are all important questions that social scientists are exploring. In a recent study from Canada, researchers looked at the degree to which a partner’s sensitivity to a hurting spouse affected the marriage. They looked at the supportive spouse’s sensitivity to changes in pain and disability in their pained partner.

Being able to gauge your spouse or partner’s pain level is referred to as empathic accuracy. The researchers said there were no differences between men and women in their sensitivity toward their partner’s pain. They did find several factors that influenced empathic accuracy. These included the pain patient’s facial and body expressions of pain, level of catastrophic thinking, and fear of reinjury. The supportive spouses own level of pain catastrophizing was evaluated but it was not considered a contributing factor.

The also reported that patients in pain had worse outcomes when their spouse was aware of the patient’s pain. It appeared that patients with disabling pain showed more outward signs to alert their spouse of their pain. Most spouses were able to accurately estimate the partners’ pain during the lifting tasks.

Less empathic spouses were more likely to ignore the pain partner and express anger, frustration, or irritation toward them. There have been some other experts who suggest ignoring a spouses’ pain or inaccurately assessing pain may be a way to protect the relationship.

Having a highly empathic spouse was not an advantage. Patients with chronic pain whose spouse was in tune with their pain had lower function, less social activity, and worse outcomes. The authors conclude that it’s not necessary to have an accurate idea of a spouse’s pain to have a happy marital relationship.

Lumbar disc herniations can be difficult to treat for some patients. Persistent pain can become disabling. Most surgeons advise at least a three month trial of conservative care before considering surgery.

Nonoperative care can include physical therapy and exercise, chiropractic or osteopathic care, steroid injections, and/or acupuncture. Sometimes patients find that a combination of two or more of these treatment approaches works best.

Studies show that patients who have surgery get better faster but the final results (one year or more later) are the same as for patients who stuck it out and waited for the body to heal itself. However, any sign that pressure on the sciatic nerve is causing permanent damage requires surgical intervention.

There are a variety of ways the surgeon may treat this problem. The simplest and most common is a discectomy (removal of the disc). Microdiscectomy is becoming the standard method used for lumbar disc herniation.

The operation is done with a surgical microscope. The surgeon makes a very small incision in the low back. This surgery is minimally invasive. It is easier to perform, prevents scarring around the nerves and joints, and helps patients recover more quickly.

Unless your condition is causing significant problems or is rapidly getting worse, most doctors will begin with nonsurgical treatment.

At first, your doctor may want your low back immobilized. Keeping the back still for a short time can calm inflammation and pain. This might include one or two days of bed rest. Lying on your back can take pressure off sore discs and nerves. However, most doctors advise against strict bed rest and prefer their patients to do ordinary activities using pain to gauge how much is too much. In rare cases in which bed rest is prescribed, it is usually used for a maximum of two days.

A back support belt is sometimes used for patients with lumbar disc herniation. The belt can help lower pressure inside the problem disc. Patients are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, their trunk muscles begin to rely on the belt and start to atrophy (shrink).

Doctors prescribe certain types of medication for patients with lumbar disc herniation. At first, you may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Severe symptoms that don’t go away may be treated with narcotic drugs, such as codeine or morphine. But narcotics should only be used for the first few days or weeks because they are addictive when used too much or improperly. Muscle relaxants may be prescribed if the low back muscles are in spasm. Pain that spreads down the leg is sometimes relieved with oral steroids taken in tapering dosages.

You may work with a physical therapist. Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A therapist can design a program to help you prevent future problems.

Most people with a herniated lumbar disc get better without surgery. As a result, doctors usually have their patients try nonoperative treatments for at least six weeks before considering surgery. But when patients simply aren’t getting better, or if the problem is becoming more severe, surgery may be the next step. Most surgeons are willing to work out a payment plan that helps patients get the care they need in a timely fashion.

Long-gone are the days when long periods of bedrest was the number one treatment choice for back pain. Now we know without a shadow of a doubt that such advice can make things worse, not better.

At the same time, doctors are prescribing far fewer muscle relaxants and narcotic painkillers. The reason is the same: research data does not support the use of these treatment methods. Back pain simply isn’t any better with (compared to without) these measures. And the potential negative side effects of medications makes this option less than desirable.

Anytime the patient reports constant and severe pain (or they simply don’t get better with conservative care), it’s a red flag of something more serious. It could be a tumor or infection. At that point, more advanced studies may be ordered (e.g., X-rays, MRIs).

But, in general, most people with low back pain who follow the stay active advice feel better and return to work and regular activities quickly.

In the last 30 years, as the Baby Boomers became adults, the management of some conditions such as low back pain (LBP) has changed. Baby Boomers were born between 1946 and 1964. Parents of Baby Boomers were more likely to expect the doctor to make all the decisions. But patients today are active consumers. This has resulted in a new concept of patient care called shared decision-making.

Today’s health care system can allow for shared decisions and a plan directed by the consumer. With all the information available on the Internet (including research results and treatment guidelines for various problems), patients can know what are the recommended guidelines for a specific disease, illness, or condition. They are in a good position to make treatment decisions for themselves.

But they can’t do this alone. They must rely on medical doctors to recognize diseases, order appropriate tests and measures, and interpret the findings. As part of the evidence-based and outcomes movement, we have new research information about many problems.

Knowing the natural history of conditions helps physicians feel confident in prescribing the proper treatment. Sometimes there’s more room for shared decision-making. For example, when the problem isn’t life-threatening, the physician can outline all the options and let the consumer decide the best approach for him or her.

But in cases of serious conditions, patients may want to rely more heavily on the physician’s knowledge of diagnosis, treatment, and prognosis. This is not to say that the patient doesn’t have choices and options. But the potential risks and/or complications of some choices may not be medically advised.

A recent study suggests that warming up for 10 minutes before playing a round of golf is important for preventing back injuries. A 60 percent decrease in golf injuries among 703 golfers was noted among those who stretched and warmed up before playing.

The authors of a recent study reviewed available literature on golf injuries. They conclude that while the modern golf swing is better for power and distance, it can be more stressful on the spine.

It is well known that lumbar intervertebral discs degenerate with normal aging. In a recent study, aging was correlated with disc degeneration at multiple levels, from L1/2 to L4/5. In this same study, as well as others, authors are finding risk factors such as weight and high cholesterol may also lead to disc degeneration. These are factors that can be modified with lifestyle changes.

Doctors, particularly family doctors or general practitioners, are trained to look for more than just one thing in their patients. A patient may come to them with one problem, but may actually have others that are equally important or their other problem may be causing the one that they’re telling the doctor about.

Many situations with chronic pain may have other issues that have either caused them or is causing the pain to continue. For this reason, your doctor is likely probing to see if this is the case with you. It’s been found that people with certain types of chronic back pain can be helped by reducing other problems, such as depression or fear of worsening back pain.

The best thing to do in your situation is to ask your doctor why she is asking you these questions. Good open communication between the doctor and you is the best way to get the best possible treatment.

Satisfaction surveys are well-known in the consumer industry. You try a product and fill out a questionnaire about what you liked, disliked, and whether or not you would buy that item.

As a commodity, quality-of-life is a little more difficult (but not impossible) to quantify and measure. For example, satisfaction surveys for orthopedic patients might include statements like:

Of course this decision is a subjective one. What constitutes quality of life (QOL) for one person may not be the same for someone else. Most people agree that chronic, constant, and/or intense pain can reduce your ability to do things and decrease enjoyment in life.

How much improvement is enough to make it worth having the operation? That question was posed by researchers at the Kenton D. Leatherman Spine Center in Kentucky. They surveyed patients with various degenerative spine diseases before and after lumbar spinal arthrodesis (fusion).

The questionnaires they used were standard self-report instruments well-known in the health care field. Analyzing the data, they were able to come up with a minimum score that would represent improvement needed to show a benefit from the surgery. This was referred to as the clinical benefit threshold. A specific score for each survey was determined to be the clinical benefit threshold.

Using a magnitude of change doesn’t help patients decide whether or not to have the surgery. But it does help point out major improvements afterwards that might not otherwise be recognized.

The Spine Patient Outcomes Research Trial (SPORT) may have some information to shed on this topic. A group of researchers from Dartmouth Medical School used the data from this multicenter study to compare outcomes of treatment based on the level of herniation.

They reviewed the charts of patients with a known disc herniation at three separate levels: L2-3, L45, and L5-S1. They found that herniation location and level did make a difference in treatment results.

This may have to do with the amount of space in the spinal canal as the spinal cord moves down the spine. The diameter of the spinal canal is smaller at the upper levels. Surgery to remove the disc in the upper lumbar spine seems to have a greater treatment effect than for lower levels.

The direction of the herniation may also make a difference. Discs in the upper lumbar spine are more likely to protrude to the side close to the spinal nerves. It may be easier to remove the disc in this location compared to lower lumbar disc herniation, which is more likely to occur in the posterolateral (back and to the side) direction.

Nonoperative (conservative) care is always advised before considering surgery. The main exception to this guideline is if you are experiencing considerable muscle weakness (or paralysis). This would indicate more severe (and possibly permanent) damage to the spinal cord or spinal nerves. In such cases, surgery to take the pressure off the neural tissue is advised.

Lumbar spine herniation usually cause back and leg pain. But the exact location of the symptoms and accompanying neurologic deficits may change depending on which lumbar level is affected.

For example, sciatica (pain down the back of the leg to the foot) is more likely the result of a lower disc level such as L5 and S1. Anterior (front of the) thigh pain is more common with upper lumbar disc herniations (L2-L3).

You’ll probably need a medical evaluation to help sort out your symptoms. The doctor will take your personal and familly history. This information along with your clinical presentation (signs and symptoms) and results of clinical tests will determine the need for further tests and measures.

When there is a question of disc problems, the physician will carry out some specific neurologic tests. This will likely include reflex testing, muscle testing, and sensory testing to identify the level involved. Lab values, X-rays, and more advanced imaging may be ordered as well.

An early diagnosis can help prevent complications and problems that can occur when treatment or intervention is delayed. If you’ve had your symptoms for awhile and/or if they are getting worse, an appointment with your primary care physician is advised.