FAQ Category: Lumbar Spine

Research has shown us that a multidisciplinary approach to chronic pain works best. This means there’s a team of professionals specifically trained in the care of patients with this problem.

The members of the team may vary from clinic to clinic. But usually there is an orthopedic surgeon, physical therapist, and clinical psychologist or other behavioral specialist. Some centers also include an acupuncturist, chiropractor, osteopathic physician, and/or nurse.

Each team member brings a slightly different approach. All are there to assist the patient in regaining as much function as possible. This means educating you so that you can achieve your goals and enjoy an improved quality of life.

Increased awareness, improved problem-solving skills, and better communication are part of the educational process. Studies show that patient perceptions and beliefs play a large role in mental and physical health. Beliefs also play a role in forming our healthy and unhealthy behaviors. All of these factors affect pain and pain perception.

A psychologist works with the patient in all these areas. The psychologist also offers assistance with anger management, relaxation, and coping skills. Go to your appointment with an open mind. Listen to what this person has to offer. Use what seems most appropriate for you.

You are describing a problem linked with spinal fusion called adjacent segment degeneration (ASD). It’s believed that mechanical pressures or malalignment in the spine generates enough force through the fused segment to cause deterioration of the bone and soft tissues at the next level (above or below the fused site).

Many patients don’t even know there is anything changing at the adjacent levels. Like yourself, without an X-ray, no one is the wiser. But despite significant changes, there may be no signs or symptoms of a problem. When pain or other symptoms occur, surgery may be indicated to stabilize the spine. More often, a wait-and-see approach is taken.

Fusing another level doesn’t always solve the problem. It can make things worse because the original problem hasn’t been dealt with and now there’s a second surgery. And experts agree that X-ray evidence of ASD doesn’t necessarily mean you’ll end up with any problems.

It might be best to sit down with your surgeon and go over the results of this exam. Be prepared with any questions you have. Weigh all the pros and cons and consider all your options before coming to a firm decision about what to do next.

One of the potential complications after spinal fusion is degeneration of the next level. The adjacent level can be above or below the vertebra. So, for example, if you had an L3-L4 fusion, the next level above is L2 and the adjacent level below is L5.

Once a vertebral segment has been successfully fused, movement is no longer possible at that level. This means the force that is transmitted to and through the spine at the fused level must be transferred to the next level where movement does occur.

Studies show that the level above is affected two to three times more often than the segment below. In a small number of people, areas above and below the fusion develop ASD. Over time, it appears that the added force can create a degenerative effect at the next level.

There is a wide range of change that can occur to suggest the start of a problem.
The presence of any of these changes is referred to as adjacent segment degeneration (ASD). For example, there may be a 10 per cent (or more) loss of disc height between two segments.

With a narrower disc space, increased pressure is applied to the nearby facet (spinal) joints. The added compression causes an overgrowth of tissue around the joint. This is labeled capsular hypertrophy. Then bone spurs can start to form. There may even be a vertebral compression fracture.

Any one of these changes is defined as ASD. By the time symptoms develop, several of these degenerative changes have occurred. Your new symptoms may be from ASD but not always. Your orthopedic surgeon will do a thorough exam and evaluate the X-rays along with your clinical presentation when making an accurate diagnosis.

Studies show that anyone who has lumbar surgery for any reason is already at risk for reoperation. And it doesn’t seem to matter who you are — age, gender, and type of problem don’t seem to make any difference.

Rates of reoperation for lumbar discectomy are around 12 per cent. Most of these are Type 2 disc herniations according to the Carragee classification system. Type 2 means there is an opening or defect in the outer covering of the disc and a fragment of disc separated from the main disc.

But in a smaller number of patients, disc reherniation can occur with calcified or hard discs. This is a fairly new finding reported in the medical literature. Researchers are taking a closer look to see who might be at risk for this type of presentation.

Most surgeons are aware that there is a 10 per cent reoperation rate for any back surgery. Repeat procedures are common among patients who have had a disc removal for herniation. Estimates are as high as 12 per cent reoperation for this condition.

Conservative care is almost always recommended first. A three- to six-month trial of nonsteroidal antiinflammatory drugs (NSAIDs), physical therapy, and activity modification is often recommended before ever considering surgery. But if there
is nerve damage that can be permanent or bowel and bladder changes, then immediate surgery is advised.

Surgeons and their staff always go over the potential risks with patients regarding any surgical procedure. But if you are in pain at the time this conversation takes place, you may not remember it. Or you may assume those statistics don’t apply to you and schedule the surgery anyway.

Researchers are trying very hard to figure out who might be at the greatest risk for a poor outcome or recurrence requiring reoperation. Having predictive risk factors of this type could help surgeons guide patients in making the best treatment choice with the fewest risks (including the risk of reoperation).

No one can know for sure what effect pain can have on each individual’s function and abilities. As you suggest, some people are better able than others to push through the pain. Others perceive greater disability due to pain than you might in the same circumstances.

People who say they can’t do something “because my pain won’t let me” are medically labelled as symptom magnifiers if they do so unconsciously. If this is a conscious response in order to get out of doing work, then they are referred to as malingerers.

Most people who are off work due to a work-related injury or accident are being followed by a Workers’ Compensation (WC) case manager. It might be helpful to bring your concerns up to the manager or board for consideration.

Though they can’t discuss individual clients with you, the WC manager can take your thoughts and concerns into consideration when working with your employees getting them ready to come back as soon as possible.

There are ways to test for perceived disability due to pain (e.g., the Pain Disability Index (PDI)). Other tests such as the Patient-Specific Functional Scale (PSFS) can help measure functional limitations keeping the person from resuming work duties. Once areas of limitation have been identified, then the rehab program can be geared to deal with those specific problems directly.

Many studies have shown some interesting connections between back pain and tobacco use (especially smoking). First of all, smoking seems to be a risk factor for developing neck and back pain. Put another way, smokers are more likely than nonsmokers to experience chronic pain.

At the same time, nicotine, an active ingredient in tobacco seems to provide pain relief for certain kinds of pain. In particular, neuropathic (nerve) pain may be lessened by smoking.

Doctors still don’t think smoking is a good way to manage chronic pain. There are just too many negative health effects of smoking to go in that direction. And these days, there are many helps and aids to manage pain.

One of the best ways to help smokers quit smoking and assist with pain control is exercise. Study after study has shown positive benefits of even 10 minutes of physical activity and exercise.

Exercise raises endorphin levels. Endorphins are natural mood elevators. Exercise also helps with weight control, a natural concern for many people planning to quit smoking.

Many people find it works better to follow a smoking cessation plan rather than go cold-turkey. A nicotine patch, antidepressant medication, exercise, and support group combined together give the best results.

The first step may be to see your primary care physician for a check-up. It’s possible you have a medical problem that requires treatment. As is always the case, early diagnosis helps avoid complications and leads to a better end-result. This is true with both chiropractic care and traditional medical attention.

If it turns out you have a true musculoskeletal problem, then chiropractic care may be a good option for you. Studies show that patients with neck pain who see a chiropractor can get better. But the sooner you go, the better your chances are for a positive result.

There are some markers to help chiropractors determine who will improve with spinal manipulation. These are called predictive factors. They can be used to predict a positive result or a negative outcome.

Pain is one important factor, but so are the social variables such as level of education and work status (workers’ comp or sick leave). Patients with neck pain lasting less than three months seem to have the best results with chiropractic care. Patients with the worst perceived general health also seem to have good positive results of chiropractic care. This may be because they notice the improvement so much more than someone with mild symptoms.

But before your health declines any further, take steps to find out what’s wrong and seek treatment.

Your orthopedic and/or neurosurgeons should be able to advise you on this question. They will take your age, general health, and condition of the spine into consideration when making the suggestion to have surgery (or not).

Likewise, they will tell you what kind of surgery is needed (e.g., anterior versus posterior fusion, use of hardware such as screws or hooks). Possible problems and complications will be discussed with you. This can range from infection to pseudoarthrosis (false joint) and many things in between.

The biggest problem after long fusions of this type is movement at the segment due to the formation of a pseudoarthrosis. Studies show that this complication occurs in up to 24 per cent of patients who have the type of surgery you are considering.

Unless the spine is so brittle from osteoporosis, fusion is usually very successful. The spine is supported in a more upright position. The patient can breathe better. With improved posture maintained and the spine stabilized, there is less back pain.

Sometimes the implant devices create problems and have to be removed. Most of the time, the hardware and bone grafting used form a solid, immovable fusion.

In Japan, a group of surgeons have been experimenting with the use of prostaglandin E1 (PEG1) for lumbar spinal stenosis. Prostaglandins have a wide range of functions in the body. In this case, they are used to vasodilate (open) the blood vessels in the spine.

The result is improved blood flow to the spinal cord, spinal nerves, and nearby tissues. This has been shown to help patients who have both compression and blood loss in the epidural area. The epidural space is where the spinal cord is located inside the spinal canal.

Some patients may benefit from the use of a device called the X-STOP®. The X-STOP® is a metal implant that is inserted through a small incision in the skin (using a local anesthetic). It is designed to fit between the spinous processes of the vertebrae in the low back. It stays in place permanently without attaching to the bone or ligaments in the spine.

Before trying something like the PEG1 or X-STOP, physicians recommend a trial of conservative (nonoperative) care. A fair trial of antiinflammatory drugs, physical therapy, and epidural injections is usually indicated. “Fair trial” refers to at least three to six months’ time.

If symptoms have not changed, function has not improved, and quality of life remains impaired, then surgery is the next step. With today’s minimally invasive procedures, even patients with complications may be a candidate.

These are the very same observations and questions a group of researchers at Johns Hopkins Medical School have been asking and studying. Clearly, there is a relationship between sleep and pain. Many studies have supported this view.

There’s even a day-to-day relationship. Sleep the night before affects pain levels the next day. But the relationship is even more complex than that. Younger adults who are overweight tend to report magnified pain. Likewise, patients with multiple other health issues also have more pain than those who have chronic pain alone.

We’re not sure there is a good explanation yet. Scientists think there is an overlap between neurologic, biologic, and pain-modulatory systems. Poor sleep seems to have the effect of arousing systems that regulate consciousness. Beyond that, there isn’t a clear understanding yet of just exactly what is happening.

Marijuana is a drug but its use as herbal therapy for medical conditions is limited. A physician’s prescription is required. And it is only legal in a few states in the U.S.

Medical marijuana has been used to treat nausea, vomiting, and chronic pain. Research is ongoing into its use with glaucoma, atherosclerosis, migraines, loss of appetite, and addictions. Likewise, it is being investigated for patients with arthritis, panic disorder, insomnia, depression and other mood disorders, and muscle spasms, to name a few.

Medications with properties similar to marijuana are available while others are in various stages of development. They have the distinct advantage of being ingested orally in pill form without the negative effects of smoking a chemical.

The United States federal government does not currently recognize any legitimate medical use for marijuana. The United States Food and Drug Administration (FDA) has issued an advisory against smoked medical marijuana. The FDA points out that the potential for abuse combined with the lack of supporting evidence makes this an unacceptable choice at this time. Safety and effectiveness have yet to be proven with this product.

Likewise, there have been some studies that show smoking regular cigarette tobacco has some potential analgesic (pain relieving) properties. But the adverse side effects of smoking make this a less than optimal choice for pain control.

There is still help for chronic pain sufferers. If you have not been evaluated at a pain clinic where pain management is a specialty practice, then that may be the place to start. A proper evaluation of your current health and pain status is needed to plan an appropriate program of intervention. Health care providers are much more tuned in now than ever before to patients’ overall needs including physical, spiritual, emotional, and psychologic.

A limbus fracture is avulsion or separation of the end of the vertebra where it attaches to the annulus of the disc. Most limbus fractures occur in the lumbar spine. Risk factors for limbus fractures include young age and skeletal immaturity.

A recent study evaluated lumbar fusion using periosteal cells harvested from the tibia that were cultered and then placed in a polymer fleece. This was compared to fusion surgery using the standard cancellous bone harvested from the iliac crest. At six months, 63.6 percent of subjects using periosteal cells versus 20 percent of the subjects using cancellous bone were fused according to dynamic radiographs. At nine months, 90.9 percent of the subjects using periosteal cells demonstrated fusion versus 40 percent of the cancellous bone group.

A recent study of 200 subjects undergoing single level lumbar fusion demonstrated that those using and engineered tissue called polyglactin-poly-p-dioxanone fleece healed three to six months sooner than those not using engineered tissue.

Pain control for patients with chronic low back pain can be quite a challenge. The cause of the problem must be considered along with many other variables. These include the patient’s age, general health condition, and medications already being taken.

If pain relievers don’t help, it’s natural to try something else. But your concerns are important. Without knowing your father’s exact diagnosis, here’s what we can offer. First, many strong pain relievers fall into the drug class of opioids. Used appropriately, opioids can be very effective. It’s important to avoid dependence and addiction while managing any negative side effects.

Patient selection for the use of epidural steroid injections (ESIs) is also important. Studies show ESIs are recommended for use in patients with sciatica (back and buttock or leg pain from pressure on the sciatic nerve). Use of ESIs to treat spinal stenosis cannot be supported from studies done so far.

ESIs are considered a less expensive, less risky way to treat chronic low back pain without resorting to surgery. Even so, in the VA system, treatment isn’t always driven by cost considerations. As you pointed out, this can be a problem if patients are being over treated for a problem.

If your father will give you permission to speak with the clinic staff, you might try contacting the socal worker or case manager assigned to your father’s case. Present your concerns and find out more about the plan and any other options for pain management that may exist.

Your mother may be suffering from a condition called kinesiophobia (fear of movement). Chronic pain sufferers with kinesiophobia are so afraid that movement or physical activity will make their pain worse that they stop moving. Then they get into a cycle of movement avoidance, disuse, more pain, depression, and hypervigilance.

Patients with fear-avoidance behavior (FAB) of this type can respond to a specific type of rehab program. Usually a psychologist and a physical therapist work together to gradually progress patients through a cognitive, behavioral, and physical program.

Patients are asked to rate their expected pain before completing a task. They are guided through the physical activity. Then they re-rate the actual (experienced) pain. Usually, the expected pain is overpredicted. The actual pain is lower than anticipated.

Through this process, patients begin to see how their fear-based expectations set themselves up for failure. You are right that moving a little more would help. But she may need the supervision and assistance of a team of health care professionals to break free of long-standing fear-avoidance behaviors.

The process of moving from acute low back pain to chronic low back pain remains a mystery. Risk factors such as age, gender, and environmental and occupational issues have all been suggested. Psychosocial factors and educational levels have also been tested as possible contributors.

There doesn’t seem to be one major risk factor that is present in every case. Instead, it’s more likely that there are a variety of combinations that are different for each person.

However, there is one model that may help describe this process. That’s the fear-avoidance model. In this model, there is a cognitive-behavioral reason for why some patients with acute injury develop chronic pain (and disability) while others do not.

Fear that physical activity and movement will cause pain and/or reinjury causes patients to stop moving. This reaction to pain is called kinesiophobia (fear of movement). The person by nature or by experience has come to a place of overpredicting pain and catastrophizing what could or might happen.

Women seem to overpredict pain more often and at a higher level of intensity compared to men. Moving greater distances at higher speeds also creates an elevated sense of fear compared to smaller movements at lower speeds.

No one is exactly sure why one person develops fear-avoidance behaviors and someone else with the same or similar injury doesn’t. Researchers are actively exploring studies to find out more about this phenomenon.

You have asked a very good question that may not have an exact answer. In the presence of disc disease, exercises can indeed make the situation better or worse. The trick is to keep moving without stressing or overloading the compromised discs.

Care should always be taken to avoid vigorous or sustained loading at the end range of trunk motion. In other words, don’t stay in one position too long. And don’t go to the end range of full flexion or extension and hold that position.

In general, vigorous exercise is not recommended until healing has occurred. The first place to start may be with lumbar stabilization exercises. You may have heard these referred to as core training. The trunk (back and abdominal) muscles are targeted. Strengthening the core improves the spine’s ability to handle loads that might otherwise cause injury.

Timing of the exercise program is also important. In the early morning, the discs are full of fluid and less able to withstand extremes of flexion and extension. It’s best to delay loading the spine until you’ve had a few hours to move about. Movement squeezes some of the excess fluid out of the discs. This makes it less likely that a bulging disc will press against the sensitive spinal nerve roots.

If you are having trouble finding the right exercise program, consider making an appointment with a physical therapist. The therapist can guide you through the process of starting and progressing an appropriate exercise program.

Recent studies have dispelled the notion that age and manual labor are the main risk factors for disc disease. We now know that genetics plays the most important role in the development of disc bulging and herniation.

Patients who are diagnosed with disc protrusion at a young age have a high rate of family members with this same problem. In fact, someone with a disc problem before age 21 is four or five times more likely to have a positive family history of disc disease.

This doesn’t mean that other factors aren’t important. Besides genetic factors, lifestyle and nutrition can make a difference. Sustained positions at the end range of motion can create an environment of load and stress. But lifting heavy loads hasn’t been directly linked with disc degeneration. In fact, competitive weight lifters have fewer disc problems than the average adult.

Many people are affected by degenerative disc disease every year in the U.S. Researchers are actively studying patient groups trying to find cause and effect. If modifiable (changeable) risk factors can be identified, then prevention may be more likely.