FAQ Category: Lumbar Spine

The last 15 years of research has brought a change in the way patients with chronic low back pain (CLBP) are categorized and treated. In a landmark study back in 1994, a well-known physical therapist (Anthony Delitto, University of Pittsburgh, School of Physical Therapy) identified subgroups of low back pain patients. When treated based on their unique characteristics, more of these patients returned to work and reported less disability compared with patients in a standard treatment program.

That report set into motion a series of studies classifying low back pain patients based on a variety of factors. Some of these included fear of movement, intensity of pain, and self-efficacy (belief in oneself). Other areas investigated also included pain present during specific exercises and catastrophizing (believing the worst will happen).

In a more recent study, patients were subgrouped based on their lifting patterns during a repetitive lifting task. This type of classification system is based on physical functioning of patients with CLBP.

The researchers (once again from the University of Pittsburgh but this time from the engineering department) were able to show that the rehab program for patients with chronic low back pain might need to be tweaked based on this new information. Finding ways to improve patient self-efficacy (self-confidence) and change patients’ pain perception are the next steps.

Much work continues in the area of chronic low back pain. Finding ways to classify chronic low back pain patients according to function is only one of the new directions health care providers are moving. Future studies will also have to look at changes made after CLBP patients complete a treatment program. This will help identify what works best for each subgroup identified.

Many people have progressive degenerative changes in the spine that never cause them any problems. So there’s no guarantee that even if your condition gets worse that your symptoms will get worse.

But if they do, the typical progression of symptoms is low back pain along with buttock, thigh, and calf discomfort. Most patients describe this discomfort as aching, burning, and/or cramping. Numbness and tingling may occur in the calf and foot.

When the L5S1 nerve root is pinched, pressed, or inflamed, there can be some motor involvement, too. This means the motor nerve to the muscle is affected. Muscle weakness and atrophy can develop over time. A partial footdrop can even develop.

Most of the time, the symptoms are worse with spinal extension. This makes standing up straight and walking difficult. Bending over or flexing at the hips seems to help with the painful symptoms but can cause other problems to develop.

Get help before you get to this point. A six-to-eight week program of conservative care can make a difference. Antiinflammatory drugs, physical therapy, and even an epidural steroid injection can offer significant pain relief and put off surgery. But if these measures aren’t successful in alleviating the pain, then decompressive surgery may be needed.

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.

There are various techniques for performing lumbar fusion surgery. It is important for the surgeon to consider what approach will allow the best decompression of neural structures, best placement of instrumentation or fusion materials, and restoration or maintenance of the normal saggital curve of the spine. The goals are to lessen the likelihood of pseudarthrosis or nonunion of the fusion, improve neurological function, and minimize the need for further surgery.

Not necessarily, though you should bring your question and your concerns to your surgeon for clarification. What has changed in the last 10 years is our understanding of the cost-savings associated with early surgical intervention for disc herniation.

We know that the long-term outcomes are the same whether you have disc surgery or stick with conservative (nonoperative) care. But some patients don’t want to wait the full year (or longer) that it takes to reach full healing and maximum potential. Severe sciatica and low back pain from disc herniation can be extremely painful and very disabling.

If your pain is mild to moderate, then it might be better to manage it with other less invasive modalities. This could include medications, physical therapy, chiropractic care or other complementary and alternative modalities. Keep in mind that there’s a financial cost to conservative care along with the lost wages and reduced work productivity you incur while you are off work.

While there is general agreement that exercise is a key factor in recovery from low back pain, the optimal type, frequency, intensity, or duration of exercise remains unknown.

The most recent trend in research is to look for subgroups of patients who respond well to one type of exercise versus another. These groups could be based on age, length of time with back pain, presence of back pain alone or back pain and leg pain, and so on.

Part of the problem in identifying exercise guidelines has been with the researchers. Studies aren’t always of the highest quality, so the results can’t be used to develop exercise guidelines. Some studies introduce bias without realizing it. Others may not report the results in a way that is helpful to others when reviewing the evidence.

A recent meeting of experts in the Netherlands has resulted in a call for improved design, conduct, and reporting of clinical trials. Some variables can’t be changed, but there are many ways the research itself could be improved. Reducing flaws in study designs and improving the quality of research could go a long way in improving our knowledge of exercise as a treatment tool for low back pain.

Total disc replacement (TDR) for disc disease degeneration (DDD) is a fairly new treatment method available. We have only just begun to scratch the surface in understanding how well these implants work and how one compares to the other.

There are two metal-on-polymer implants: the ProDisc II and the CHARITÉ. The most important factor in outcome is probably the surgeon’s familiarity with the procedure and surgical technique. Most surgeons choose one implant device to become familiar with and gain experience using the one selected.

Having said this much, let’s look at the known differences between these two implants. The ProDisc II is a constrained device. This means it is implanted into the bone with very little movement of the implant allowed inside the disc space. Despite front-to-back and side-to-side forces, the implant stays in one place. It is necessary to distract the two vertebral bodies more to insert the implant than with the CHARITÉ.

The CHARITÉ model is unconstrained. This gives the patient greater spinal range of motion but also puts the person at risk of an implant dislocation. It depends on the facet joint to maintain stability. But that puts more potential stress and strain on these joints.

Both the ProDisc II and the CHARITÉ allow axial rotation (twisting) motions. There is some concern that this feature can cause further facet joint damage. Some early studies suggest that changes in the facet joints are likely at the level of the implant. Researchers will be following patients to see if anything comes of this as more time passes.

Disc height increases dramatically from before to after implantation of a total disc replacement (TDR). That’s good because that is what the implant is supposed to do. Restoring normal disc height takes pressure off the nearby facet (spinal) joints, too.

At first, when the implant is inserted, there is a small space between the curved, upper endplate of the vertebra and the flat top of the disc replacement plate. The two shapes don’t match exactly. Over time, the bone settles down around the implant and there’s a slight loss of space.

But it’s also possible for the implant to sink down into the bone. This is called subsidence. Loss of disc height can occur from progressive subsidence. That’s why it’s important to keep your follow-up appointments and have periodic imaging tests. The surgeon will follow your progress and let you know if the changes are within normal limits or something to be concerned about.

Back pain certainly does have our attention. Around the world, it is the same story: eight out of every 10 adults will have back pain sometime in their lives. It is a major cause of medical expenses. And along with that comes absenteeism and loss of productivity. Billions of dollars are lost each year from the indirect and direct costs of low back pain.

When acute low back pain lasts more than a couple of months, then it becomes a chronic problem. Quality of life is affected. Loss of function and disability become concerns. Teams of specialists around the world continue to focus on the problem of back pain. It appears to be a rather complex condition with social, physical, and mental factors.

Nonspecific low back pain continues to baffle and befuddle many people — patients and doctors alike. Studies have shown us that there are many factors to consider. Besides the mechanical disorder in the spine, there can be stressors and social factors that aggravate the condition.

Some people can predict the change in weather by their aching joints and increased back pain. This may be caused by receptors in the joints that respond to changes in pressure such as the barometric pressure. You may be one of those people without knowing it.

Others are aware that their own fears and phobias set them off. Fear-avoidance behaviors (FABs) have become a new phrase in our vocabulary. Patients who are afraid of reinjury or increased pain, stop moving or change the way they move to avoid back pain. This response to pain can actually result in increased painful symptoms and may be part of your clinical picture.

One good way to tell for sure is to keep a journal of events, activities, and stresses. At the same time, log in how you are feeling, what you’ve been eating, and how many hours of sleep you are getting. Exercise is also important. Keep track of the type, frequency, intensity, and duration of any exercise program you may be following.

By looking back over records of behavior and back pain, you may be able to identify a pattern to help you. This could be both factors that improve your symptoms and the things that seem to aggravate your symptoms. Then you can modify your lifestyle to include more of the positive factors and slowly reduce or eliminate those things that seem to aggravate your condition.

It was thought that instability following discectomy would preclude the use of total disc replacement in lieu of fusion. A recent study for the Federal Drug Administration compared results of total disc replacement, TDR, in 20 patients who had previous lumbar discectomy, and 67 patients who had not had previous lumbar surgery for disc herniation. The results showed that there was no significant difference between the two groups based on all four of the outcomes that were measured at follow up.

The greatest benefit is likely the maintenance of range of motion with total disc replacement. This is thought to decrease the likelihood of accelerated degeneration of adjacent levels as seen following fusion. Accelerated degeneration can sometimes necessistate extension of the fusion.

A recent study of 104 patients with rheumatoid arthritis for 10 years or longer showed that 45 percent had changes in the lumbar spine identified on either Xray or magnetic resonance imaging.

According to a recent literature review, 34 percent of patients who had fusion of the lumbar spine developed adjacent segment disease. In the literature reviewed, the rate ranged from 5 percent to 100 percent of patients. Adjacent segment disease is progressive degeneration of the spine either above or below the fusion level at a rate greater than would be expected. It is asymptomatic. Adjacent segment disease shows progressive degeneration and is symptomatic, causing symptoms which correlate with the segment involved.

The authors of a recent literature review felt that there was a correlation between fusion and the development of adjacent segment degeneration compared to total disc replacement. The authors also felt there was a stronger correlation between fusion and the development of adjacent segment disease compared to total joint replacement. Because the studies that were available to review were not high in quality, they could only make a weak recommendation for the use of total disc replacement versus fusion.

No formal recommendations have been made to date. A recent study evaluated driver reaction time, DRT, in persons with lumbar radiculopathy who underwent selective nerve root block, SNRB. Whether the block was done on the right or left, immediately following SNRB driver reaction times on average were slower. At two weeks, the DRT remained slower than prior to the procedure in those with right sided SNRB. At six weeks after SNRB, DRTs were at baseline on average. Of the persons tested in this study, even though slower than controls, DRT was still within the range of normal subjects when tested on the road.

A recent study showed that at two weeks following SNRB driver reaction time on average can remain slowed. At six weeks following SNRB, driver reaction time had returned to baseline on average. Testing at three, four, and five weeks was not performed.

Back school for health education about back pain started in 1969 in Sweden. At first it was thought that a weak back and back-straining work increased the risk of low back trouble.

Back school has proven most effective for patients with chronic nonspecific low back pain (LBP). In nonspecific LBP the cause is unknown but is likely related to the soft tissues, joints, ligaments, and sometimes disc problems. There is no infection, tumor, or fracture present.

Today, there are many variations in the content and intensity of back schools. You’ll find programs offered by people with various training and background. Exercise physiologists, physical therapists, chiropractors, and sports trainers are just a few of the disciplines with training in this area.

The daily program or intense six-week program of the 1970s and 1980s has been replaced by a shorter course of instruction. Patients meet with a physical therapist for one to four sessions spread out over several weeks to a month. Some programs are extended up to eight weeks. Some offer a specific 3-hour question and answer session. Most programs cover basic anatomy, pathologies, and biomechanics. Advice on lifting, exercise, and general fitness is usually included.

Updated programs that incorporate new ideas based on more recent evidence may not be referred to as Back School. Other names such as Back Care Boot Camp have replaced this one.