FAQ Category: Lumbar Spine

Back pain is a very common complaint in our society. Doctors estimate that up to 80 percent of us will complain of back pain at some point in our life. Many people also will continue to experience back pain as it comes and goes.

Research has shown that how we feel about nonspecific back pain, that is pain without a specific cause or damage to the back, can affect how badly and how long we feel the pain. For example, some people catastrophize their pain – they make everything seem worse than it might be. Others have pain expectations, “If I do this, it will make my back hurt more.” This can extend to how you feel about the pain. If you feel helpless at controlling it, it will be harder to control, for example.

So, both of you may have a point. Your father has pain, but his attitude may be keeping him from relieving the pain somewhat.

A recent study came out analyzing the organizational and service delivery factors related to quality of care by physical therapists when treating low back pain patients. They asked these questions:

Studies consistently show that patients with low back pain (LBP) get better faster when treated by a licensed physical therapist (PT) when compared with a physical therapist assistant (PTA).

Some clinics only have PTs, whereas others have PTAs. The therapist is always the professional who evaluates the patient and establishes the plan of care (POC). The therapist supervises the assistant but is not with the patient for each treatment.

There are other variables to consider in the recovery process. First, there are many different causes of low back pain. The source of the pain could be a herniated disc, spondylolysis (slippage of the vertebrae), or sprain/strain. Outcomes can be different based on different diagnoses from episode to episode.

Secondly, patients who have other diseases or conditions may experience complications or problems in the recovery process. For example, patients with heart disease may not be able to exercise in a way that would speed up their rehab and recovery. Patients with diabetes need a careful balance between diet, exercise, and medications.

Even when treated by a licensed physical therapist, the type of clinic makes a difference. A recent study showed that high volume clinics (see many low back pain patients) are more efficient (see the patient fewer times) but not necessarily more effective (have better results).

Surgeons are studying ways to avoid the problems that can occur with bone graft harvesting. Right now, bone graft is the most common way to fuse one bone segment to another. Bone can be taken from a bone bank (donated by someone else) or directly from the patient (usually from the pelvic bone). There are potential problems with either donor source.

Researchers are developing alternative fixation systems to help stabilize the spine. Some have been in use that eliminate the need for bone graft to complete the fusion. It’s a fairly new procedure and long-term results aren’t available yet.

First, surgery is performed to take pressure off the spinal nerves. The procedure is called a decompressive laminotomy. The lamina isn’t removed entirely. Just a portion is taken out to remove pressure from the spinal canal.

Long screws are placed through the vertebrae to hold it in place. The goal isn’t to change the position of the vertebrae. Studies show that external fixation with screws keeps the segment stable over a four-year period of time.

However, the system does not prevent degeneration at the next spinal level. And there is a chance that the screws can break or come loose. Further studies are needed with larger groups of patients over a longer period of time. For now, it looks like dynamic stabilization can be used instead of the more invasive bone grafting process.

Lumbar spondylolisthesis (one vertebra slips forward over another) is a common cause of spinal stenosis (narrowing of the spinal canal). Older adults are affected most often. They experience disabling leg pain that makes standing and walking difficult. The leg pain may be accompanied by back pain as well.

Surgery is often needed if conservative (nonoperative) care doesn’t help. The surgeon removes any bone pressing on the spinal cord or spinal nerves. This procedure is called a decompression. With the removal of the supportive bone, the spine has to be stabilized somehow.

Bone chips are usually taken from the patient’s pelvis and used as graft material to fuse the spinal segment. The disadvantage of the fusion is pain at the donor site. The Dynesys system was developed to bypass the fusion.

The Dynesys is a long screw that goes through the pedicle into the vertebral body to hold it in place. The pedicle is part of the bony ring that encloses the spinal canal. This is a fairly new procedure and long-term results aren’t available yet. Results after two to four years have been published.

Partial or complete pain relief was possible for most of the patients. Walking distance improved quite a bit. Two-thirds of the group were able to stop taking pain medication.
Complications include loose or broken screws and degeneration observed at the next spinal level.

The rate of change at the adjacent vertebral level appears to be about the same as reported after spinal fusion. But there is some evidence from other studies that the degeneration isn’t caused by the dynamic stabilization process. It could very well just be a natural progression of aging.

The passive straight-leg raise (SLR) test has been a standard testing tool used by doctors, physical therapists, and chiropractors for many years. The test is done with the patient lying supine (on his or her back). The examiner lifts one leg (knee straight) to an angle between 30 and 70 degrees.

If the patient experiences painful back or leg symptoms (on either side), it’s considered a positive test for compression of the sciatic nerve called sciatica. The probable cause is disc protrusion or herniation. But bone spur, tumor, or infection can also cause a positive straight-leg raise test.

The clinician relies on patient history and other clinical tests to find out more specifically what’s going on. There are other conditions that can produce or mimic sciatica such as shingles, diabetic neuropathy, abscess of the psoas muscle, and peripheral vascular disease.

As you have discovered, there isn’t agreement on the definition of a positive straight-leg raise test. There isn’t even a consensus of which structures are being stretched at each point in the range-of-motion.

Some experts feel that tension is placed on the nerve at 30 degrees of hip flexion. Others believe a positive straight-leg raise can be a protective reflex of the hamstring muscles. At least one study has shown that the nerve, nerve root, and dura (covering of the spinal cord) can be restricted causing a positive test. Stretching or tractioning the nerve over a herniated disc can (but doesn’t always) cause a positive straight-leg raise.

It may not be necessary to go any further for the moment. The current standard of care for best practice is as prescribed for you. Unless the surgeon suspects a fracture, infection, or tumor, X-rays and other more advanced imaging studies aren’t always needed.

Many times, the clinical exam and history are enough to point to a probable cause of symptoms. For example, a positive straight-leg raise test points to disc pathology. A protruding or herniated disc can put pressure on the nerve causing nerve pain down the leg called sciatica. A straight-leg raise will aggravate the nerve and reproduce the symptoms. If the pain goes down past the knee, it’s very likely nerve pain.

Conservative (nonoperative) care is the first line of treatment for most back pain. Treatment begins with a trial of nonsteroidal antiinflammatory drugs and analgesics for pain control. Chiropractic or physical therapy care has been shown effective as well.

If there has been no improvement (or your symptoms get worse) in the first six weeks, then your surgeon will want to follow up with you. Usually, at least a three-month course of nonoperative care is recommended. If unsuccessful in alleviating your symptoms, then other treatment may be tried after that.

You might be interested in a study that was conducted by the Royal Netherlands (Dutch) Army. Even though it was restricted to army soldiers, the findings can apply to other groups that employ workers involved in strenuous jobs. This could include police officers, fire fighters, and construction workers. Anyone in an occupation that involves pushing, pulling, bending, and lifting may benefit from this information.

The results of this study support findings from previous studies showing that exercise of any kind is helpful in recovering from an acute episode of LBP. Some subgroups of patients do need a specific exercise program. But to prevent acute LBP from turning into a chronic problem, the key is to get active and stay active during the recovery process.

This information is especially helpful in your setting. Chronic back pain can reduce worker productivity, run up the cost of health care, and negatively affect the injured worker’s quality of life. Disability from chronic low back pain means higher costs in terms of disability pensions and replacement costs.

And the good news is that even 10-minutes a day devoted to strength-training can make a difference. Many police and firefighter programs have gone to providing exercise equipment on site. This makes it possible for the officers to physically train for the job while on the job. It may cost a few thousand dollars to get a room with some equipment set up, but it will save money and backs in the long-run. It’s a win-win situation.

It wouldn’t hurt to ask your daughter this question. She is the best one to gauge her back pain, function, and level of ability/disability. Study after study has shown the benefit of physical activity and exercise for low back pain. There is even some evidence that exercise is the one treatment that can keep an acute back injury from becoming a chronic condition.

Physical therapists (PTs) are trained to evaluate each patient and identify a plan of care that is individual to each one’s needs. Military PTs are especially attuned to the needs of soldiers and civilians alike.

No specific exercise has been proven most effective in treating back pain. There are some subgroups of patients who seem to do better with one method over another. The therapist must look each patient over carefully and determine which treatment protocol is most likely to benefit him or her.

Your daughter will likely be carefully progressed through a series of treatments. This may include manual therapy, joint mobilization, stretching, and patient education. An exercise program of flexibility, aerobics, core-training, and strength-training will be added when she is physically ready for it. With daily care, her rehab and recovery should go very smoothly. The therapist will be able to quickly adjust the program to accomodate any changes that occur in her progress.

In spinal stenosis, there is a narrowing of the spinal canal, which surrounds the spinal cord. Anything that narrows this space can put pressure on the spinal cord causing a condition called myelopathy. Patients with lumbar pain from stenosis often have similar changes in the upper spine that have not been identified yet.

The Hoffmann sign is used by examiners assessing patients with symptoms of myelopathy (spinal cord compression). The test is done by quickly snapping or flicking the patient’s middle fingernail. The test is positive for spinal cord compression when the tip of the index finger, ring finger, and/or thumb suddenly flex in response.

The authors suggest performing the Hoffmann test on patients with low back and/or leg pain, especially when lumbar spinal stenosis is present. It is a reliable way to test for early signs of cervical myelopathy. A positive Hoffmann sign on both sides warrants imaging of the cervical spine. Anyone with evidence of cervical cord compression but no outward symptoms should be followed regularly. Routine neurologic exams every six months are advised.

Treatment of the cervical portion may not be needed. But if the person ever needs surgery, the anesthesiologist will need to know about the cervical stenosis. Position of the neck required during intubation to keep the airway open must be modified in such cases.

In the meantime, conservative care for the low back and leg pain can be started. The physician may recommend nonsteroidal antiinflammatory drugs (NSAIDs) to start. Physical therapy to help with posture, strength, and pain management may be helpful. Steroid injections have also been shown to help many patients with this condition.

If satisfactory results aren’t achieved in three to six months, then surgery may be needed. The procedure is called decompression. Pressure is taken off the spinal cord by removing bone and soft tissue pressing on the spinal cord.

And if the cervical stenosis starts to cause symptomatic myelopathy, then similar measures can be taken for the neck area.

Scar tissue in the form of adhesions and fibrosis can wrap itself around nerve tissue during the acute healing phase. This can cause increased pain and loss of function. If enough scar tissue is present, nerve impairment can be severe.

And it’s not a simple matter of going back in and removing the adhesions. If your body produces an over abundance of fibrosis, a second surgery only increases the risk of tissue tearing and nerve root injury.

Surgeons are looking for a way to keep scar tissue from forming. They have tried using a wide range of substances in the peridural (empty disc) space to prohibit fibrosis was developing. So far, no one has found anything that makes a big difference.

Most recently, a group of surgeons from Istanbul, Turkey studied the ability of mitomycin C to inhibit periepidural fibrosis. Mitomycin C is an antibiotic that has proven effective against fibrosis in glucoma and tracheal reconstruction patients. But there was no benefit in using this solution either. More studies are needed in this area.

Removing a disc or disc fragment is called discectomy. It is indicated in patients with persistent back and/or leg pain. The operation can be done with a very small incision and the aid of special surgical tools and instruments.

The hope is for a significant reduction in pain after the operation. But in a fair number of patients, pain is not improved. In fact, as in your case, the symptoms can be much worse. In 24 per cent of all cases, peridural fibrosis is the reason for failed-back surgery syndrome.

Peridural fibrosis is the formation of scar tissue in the area where the disc was removed. Scientists aren’t sure why scar tissue (and especially so much scar tissue) forms during the acute healing phase.

It could be the body reacts to intraoperative debris as if it were a foreign object. Or the pH (acid/base) levels inside the tissue may set off a series of tissue interactions. The result is an excess amount of scarring (also known as fibrosis).

Some experts have suggested that damage to the spinal muscles during the operation is a key factor. Fibroblasts from the surface of the muscles move to the open area where the disc was removed. And any type of hematoma (collection of blood) in the area can also start the process of scar tissue formation.

A recent study found that persons with calcium crystals in the joints of the coccyx can be effectively treated with either oral or injected steroids. Three out of four subjects had resolution of their pain after treatment.

Most of the time, coccydynia is caused by disc degeneration, instability, deformity of the coccyx, or trauma. Sometimes its cause is unknown. A recent report found that sudden onset coccydynia can be caused by the deposition of calcium crystals in the joints of the coccyx.

It sounds like you may have a condition called spinal stenosis. This is a common degenerative process that occurs with aging. The area inside the spinal canal gets smaller as bone spurs form and the ligaments hypertrophy (thicken). Sometimes the spinal nerves also get thicker making it more difficult to pass through the opening. Pressure on the nerves causes significant back and leg pain.

Conservative care is often advised first. Anti-inflammatory drugs, physical therapy, and steroid injections into the epidural space around the spinal cord may be tried. If improvement doesn’t occur with conservative care, then decompressive surgery to take pressure off the neural structures is next.

This is usually done by removing some or all of the bone around the nerve roots. Laminectomy to remove the lamina is still the number one surgical choice. The lamina is a column of bone that forms an arch around the spinal cord. Any bone spurs around the nerve are also scraped away. Any disc fragments are removed.

Your first surgery was successful in providing pain relief. But as many studies have shown, this condition can recur. Results deteriorate over time as the degenerative process continues or as other vertebral levels are affected.

You may be a good candidate for surgery. The surgeon will re-evaluate your situation. The presence of stenosis will be confirmed first. After taking a history and performing clinical tests, you may be scheduled for an X-rays, an MRI, or CT scans.

Depending on your overall health and the results of the test, a treatment plan will be determined. Most likely, a course of conservative care will be tried first. Complications from surgery for stenosis can be very serious. Management with conservative therapy may be all you need.

The use of steroid injections is on the rise for lumbar disc herniation. But there’s no evidence to support this treatment. Success rates vary from 18 to 90 per cent for lumbosacral injections. More study is needed to find out why results vary so much and determine ways to improve results for all patients.

Studies do support the use of injections for sciatica more than any other diagnosis. But there’s been a big increase in the use of injections for many other problems in the Medicare population. There is some concern that injections are being over used in this age group because Medicare pays more for procedures than for other kinds of treatment.

Younger patients may be treated with lumbar disc chemonucleolysis. This is the dissolving of the disc using an injection of an enzyme such as chymopapain. It is used most effectively when the disc has protruded but is still contained within its outer covering. Chemonucleolysis works well to bridge the gap between conservative (nonoperative) care and surgery. And having this procedure doesn’t prevent the patient from having surgery if it is needed later.

There aren’t a lot of studies in this area to provide evidence of the safety of discectomy for patients who are overweight or medically obese. The newer minimally invasive surgeries have fewer complications. This approach may be best for patients with other medical problems such as obesity.

One study has been published showing good outcomes of minimally invasive lumbar discectomy in a small number of obese patients. Everyone in the study had a body mass index over 30 kg/m. BMI of 20 to 24.9 kg/m is considered normal. Obesity is defined as BMI of 30 to 40 kg/m. Anyone over 40 kg/m is considered severely or morbidly obese.

The first step is to see an orthopedic surgeon for an evaluation. Find out what are your options for conservative (nonoperative) care versus surgical management. You may be able to benefit from some medications to control inflammation and pain.

Improved symptoms could make it possible to become more active. Activity and exercise is often a successful way to manage back pain from disc problems. It may be a step-by-step process, but the results could be well worth your time and effort.

Conservative (nonoperative) care is often advised for sciatica. This is because so many studies show that after six to eight weeks, most cases of back pain radiating down the leg go away completely.

But that isn’t always the case. Sometimes people just don’t get better. Some even get worse. In the presence of severe pain or motor symptoms (muscle weakness, paralysis), surgery is indicated. And making the decision to have surgery doesn’t label you a failure.

The medical community would say that in your case (or cases like yours), the outcomes of conservative care weren’t satisfactory. That’s a signal to explore other options, including surgery. Approximately 40 per cent of patients fall into this category of crossing over from nonoperative to operative treatment. Most do so after 12 to 14 weeks of conservative care.

There’s even some research to suggest that recovery is better and faster for patients who have surgery early in the course of their sciatica (within the first two weeks after onset of symptoms). That goes against everything we’ve been told about the importance of following a prolonged course of nonoperative care before considering surgery.

So, clearly there are factors that remain unknown in predicting the success or failure of treatment for sciatica. More studies are needed to define just what these factors are and help patients navigate nonoperative care versus surgical management and the timing of both.

In Greek, the word sciatica translates to mean hip pain. But most people use this term today to mean back pain that radiates (travels) down the leg.

Lumbosacral radicular syndrome is a more accurate scientific term to describe intense leg pain from irritation of the sciatic nerve. You may also see the term sciatic neuralgia used to describe this condition. Although it’s medically more accurate, it’s not freqently used in the medical literature.

But the term syndrome is important here. Besides pain, there may be numbness, muscular weakness, and difficulty in moving or controlling the leg. All of these are symptoms, not a disease.

Most of the time, the syndrome is caused by pressure on one of the five nerve roots that form the sciatic nerve. This usually comes from a protruding or herniated disc. But it could also be caused by bone spurs, tumors, or spinal stenosis creating the same effect of compression or irriation of the nerve.

If you are seeing a physical therapist who is prescribing physical activity and exercises, then you are being cared for according to current guidelines. And these guidelines are based on scientific evidence gathered to date.

That doesn’t mean the future rehab of low back pain won’t change again. But for now, it’s clear that a successful outcome depends on staying active. Physical therapists are encouraged to use passive treatments such as heat/cold modalities, electrical stimulation, laser therapy, and so on with careful consideration and close follow-up.

Most of the time, a program of general activities and specific exercises is provided each patient on a one-to-one basis. This type of rehab program is based on the therapist’s physical assessment of each individual patient.

Other factors must be considered and evaluated such as fear-avoidance behavior or pain catastrophizing. These are behavioral issues that affect how patients perceive pain and/or movement. A specific program of behavioral counseling is needed for patients who fall into either of these groups.