FAQ Category: Lumbar Spine

Injection of a local anesthetic and steroid is a common treatment for lumbar facet joint osteoarthritis (OA). Studies don’t support the use of this approach for everyone. Research has shown that it simply doesn’t work for some people.

Scientists are trying to discover who can benefit most before just injecting all patients who have painful and disabiling OA of the joints. Finding the right candidates for the treatment may not be the answer. Perhaps there’s an optimal dose per injection or number of injections that are needed for successful results.

New therapies are being studied. One of those is the injection of hyaluronic acid (HA) into the lumbar facet joints. HA has been used with good success in other joints affected by OA.

Most of the trials have been done on large joints such as the hip, shoulder, or knee. The facet joints are much smaller and may require a slightly different approach. One of the first studies using HA in lumbar facet joint arthritis has been published. The results were disappointing as there was no decrease in pain or improvement in function.

More study is needed in this area. HA has been shown to improve the flow of synovial fluid and relieve joint pain in the knee. It is a safe and effective treatment. If the same approach can be refined and perfected for the lumbar spine, it could offer patients an alternative to steroid injections.

Disc removal can take several forms. Discectomy is the complete removal of the entire disc. The disc is made up of two distinct parts. The inner gel-like core is the nucleus pulposus. The tough fibrous outer covering is called the annulus. When both parts are removed, the patient often has a spinal fusion at that site to prevent the area from collapsing.

Sometimes the surgeon just removes any torn pieces or fragment of the disc. In another procedure called a nucleoplasty, just the inner core is taken out. All of these operations fall under the broad category of surgical decompression techniques for disc protrusion.

The surgical decompression procedure is relatively safe when it is performed by a trained and experienced surgeon. There’s always a risk of infection with any type of operation. Nucleoplasty is no different. Antibiotics may be used before, during, and after the operation to prevent infection.

Because a needle is used to remove the disc material, there can be some residual soreness where the needle was inserted. If the needle punctures a nerve or blood vessel, there can be some nerve damage or prolonged bleeding. If heat is used as part of the procedure to destroy disc material, there can be damage to the nerve or end-plate (next to the disc).

Some patients report an increase in their back and/or leg pain and numbness. There may even be new areas of back pain that develop. These symptoms are temporary and go away within the first two weeks after the procedure. And in the worst case scenario, it’s possible that the heat probe used to destroy disc material could come in contact with the normal, healthy annulus.

Recent review of available studies suggests that epidural steroid injection in chronic low back pain may be beneficial at least short-term, particularly in those persons who are unresponsive to other conservative care such as physical therapy and anti-inflammatory medications.

Recent review of available studies indicates that non-target specific epidural spinal injections may provide short-term benefit for chronic low back pain. However, if chronic low back pain has been diagnosed as discogenic, evidence may suggest that a transforaminal epidural steroid injection may be more appropriate.

A recent review of studies available, indicates that transcutaneous electrical nerve stimulation (TENS), may provide immediate decrease in pain intensity. However, there was no evidence that TENS can improve short-term or long-term pain or perceived disability for chronic low back pain.

A recent review of studies available to evaluate the benefit of several physical therapy modalities in chronic low back pain failed to identify any eligible studies for the use of interferential current, electrical muscle stimulation, ultrasound, and hot and cold packs. The only modality that could be studied involved the use of transcutaneous electrical nerve stimulation, TENS. While TENS can provide immediate decrease in pain intensity, it does not seem to provide short-term or long-term pain relief or decrease perceived disability. Other physical therapy treatments such as exercise may be beneficial however.

A recent review of the literature found that muscle relaxants do not appear to be beneficial for long-term use in chronic low back pain

While lidoderm patches have shown promise in reducing low back pain and musculoskeletal pain, there are no randomized controlled studies evaluating their usefulness in chronic low back pain.

There is not sufficient evidence to support surgical interventions for chronic low back pain in the absence of instability, infection, or tumor. Functional restoration, fear-avoidance training, lifestyle modifications, education, and supportive adaptive techniques likely provide more appropriate treatment with fewer complications.

Structural changes such as disc degeneration, annular tears, and end plate changes often seen in persons with chronic low back pain are also seen in populations that are asymptomatic. The absence of serious structural disease in persons with debilitating chronic low back pain could be explained by psychosocial factors. Several studies demonstrate that outcomes using cognitive behavioral therapy with a psychologist are similar to those with fusion, with fewer complications.

There are no studies that evaluate the usefulness of trigger point injections for chronic low back pain. Use of local anesthetics versus corticosteroids are better tolerated and have fewer side effects and costs associated with them. If beneficial, will likely be short-term.

Recent guidelines and literature reviews do not support the use of botulinum toxin for chronic low back pain. However, there may be exceptions where it may be reasonable to consider.

The Swiss Ball exercise program has become very popular over the last 10 years. Many ball exercises have been used to improve muscle tone, strength, and stability. The exercises are especially targeted at folks with back pain. The ball helps gain strength in the core muscles of the trunk and abdomen. Strengthening the core seems to help improve spine stability.

The ball can also be used to strengthen the legs, arms, and trunk. A ball exercise program makes it possible to strengthen at home without a lot of equipment or a membership in a health club. It is lightweight and easy to use in a limited amount of space.

Keeping an exercise diary may be helpful. You can record what exercises you’ve done, how often, and how many. The goal is to increase the intensity of the exercises while decreasing the number of repetitions and sets done daily.

Safety is important so you’ll want to set up your space to avoid any problems. Make sure the ball is inflated enough to be firm and supportive. Clear the area from any furniture that might get in your way. Following a program on TV may not be at your level, so start slowly and work up gradually. Sometimes using a mirror can be very helpful.

Patients suffering from back and/or leg pain from disc herniation may find relief with removal of the disc. But studies show this isn’t always the case. Some patients get no relief from their symptoms. They may even have worse back pain. This condition is referred to as failed-back surgery syndrome.

At one time, there was concern that failure to remove the entire disc would eventually result in reherniation and a reoperation. More recent research suggests that removing as little disc material as possible is best. In fact, if at all possible, the surgeon should not enter the disc space at all. Only those disc fragments in the intervertebral (between the vertebrae) space should be removed.

There appears to be greater (not less) degeneration at the affected segmental area after disc removal. And long-term studies show that patients who have the disc removed have worse results 10 years later compared with patients who are treated nonsurgically.

It’s not clear yet why failed-back surgery syndrome occurs. Studies are ongoing to find predictive factors that might help sort out which patients will be helped by disc removal. At the same time, the operative technique is being refined to give better overall results. Surgeries are becoming more and more refined with less disruption of the soft tissues and bony structures around the disc. Likewise, minimizing invasion of the disc material seems to be giving better results.

You may want to ask your surgeon to explain his or her thinking and planning for you. But be aware that many studies show significant changes on MRI in patients who have absolutely no symptoms. And the reverse is also true. Patients with no obvious changes on X-rays or MRIs can have significant symptoms. Most normal discs are seen on MRIs as pushing beyond the borders of the neighboring vertebral body.

These are some of the reasons why doctors don’t rely solely on imaging studies to make a treatment recommendation. Your history and clinical presentation, along with results of any additional testing are all taken into consideration. In most cases, surgery is held out as the last resort. It is advised only after at least six months of conservative care has failed.

Researchers are studying the structures of the spine trying to figure out just where the pain is coming from. If the disc itself isn’t the source of the pain, then what is? It’s puzzling that some patients who have the disc removed have relief from their painful symptoms. Yet others who have the same type of back pain and who have the same type of surgery to remove the disc still have pain after the operation.

There’s still much we don’t know about back pain, its source, and how to treat it effectively. Your experience is a good example of this concept.

What you are suggesting is actually the direction surgical treatment may be headed. It used to be that the total disc was removed. This procedure is called a discectomy. Discectomy was done to avoid further disc breakdown and a second herniation of the remaining tissue.

But more recent studies suggest that discectomy may actually speed up disc degeneration. Loss of disc height and damage to the end plates (cartilage between the disc and the bone) seem to be linked with discectomy. The end-result is an unfavorable outcome after surgery for some patients.

Artificial disc replacement (ADR) is a fairly new option. Once the disc is removed, a special device can be implanted in its place. This ADR maintains the normal disc height and preserves motion at that spinal segment. If only a small piece of the disc is loose, then a sequestrectomy can be done. In this procedure, the surgeon only removes the disc fragment leaving the rest of the disc alone.

Early studies so far show that sequestrectomy may be superior to discectomy and a good option for some patients.

The principle of lifting is the same whether the object is heavy or light. Many people have “put out” their backs just by picking up a piece of paper off the floor, for example.

When bending to pick something up, you should always use your legs to bear the weight, not your back. This means you should not bend at the waist when lifting.

Stand straight and bend at the knees as you lower yourself closer to the ground. Pick up the object without bending at the waist. If the object is heavy, be sure to bring it as close to your body as is possible so your body absorbs the weight and not the your arms and upper body.

Once you have the object securely and safely in your arms, move back up to a standing position, always using your leg muscles to do the work.

The Roman chair is designed to isolate and strengthen the back extensor (low back) muscles. The device places the person in a prone (face down) position. The legs are out straight. The spine is straight.

The chair keeps the pelvis and hips in correct alignment. The person starts by bending forward (at the waist). Then the upper back is extended (comfortably) as far as possible.

Some people can hyperextend (extend past a neutral position). And some Roman chairs are designed to provide a variable (rather than fixed) angle. Changing the angle increases the resistance to lumbar muscle activity.

Remember that every exercise program has some risk involved. With back strengthening exercise, musculoskeletal injury is possible. And back exercises performed under load can cause fracture or disc herniation. The risk is small but must be considered.

With the Roman chair in particular, great care must be used to avoid back injury. If you are new to the Roman chair exercise, consult a fitness professional when setting up your program.

Anyone with heart disease or heart health issues must seek medical advice before starting a new exercise program of any kind. There is a risk of heart attack or stroke with strenuous exercise for some people.

You may be looking for a lumbar extensor-strengthening program. This type of strength training is referred to as progressive resistive exercise (PRE). Gradually adding load and overload to the extensor muscles is a way to build muscle bulk and strength.

The PRE method was developed based on principles of weight lifters and body builders using free weights (barbells and dumbbells). Muscle strength is increased by slowly adding more weight and by increasing the number of repetitions.

There is specific isokinetic exercise equipment for strength training that isolates the back muscles. Most of these machines are available through a physical therapist.

Health clubs and fitness centers may offer benches and Roman chairs as another way to strengthen back muscles. But floor exercises, stability balls, and free weights are still the most economical exercise program for this type of strength training.

In addition to a strengthening program, many people also add lumbar stabilization exercises. Sometimes this is referred to as core training. With this type of exercise, low load, low intensity exercise is used. The exercises are often isometric. Isometric means that resistance is applied to the muscle but without moving any body parts. Many of the Pilates exercise programs available today focus on core training.

When just beginning an exercise program, it’s always recommended that you have a medical exam first and get your physician’s okay. Attending supervised classes at an exercise facility is a good way to get started.

If you have had a previous injury or are concerned about injuring yourself while doing an exercise program, then you may want to consider working with a physical therapist or athletic trainer. Safety is a concern. The goal is to strengthen the spine without causing a debilitating injury.

Prolotherapy has been around for more than 60 years. The basic idea is to inject a solution into ligaments or joints that causes an inflammatory reaction. The end result is a build-up of collagen fibers and connective tissue. Pain from joint laxity decreases as the joint fills in with organized scar tissue.

Most people experience a decrease in painful symptoms after treatment. But adverse events can occur. The most common problem to develop is an increase in pain and/or stiffness. These symptoms occur at the site of the injection. They are usually temporary and go away 12 to 96 hours after the injection.

A small number of patients report bruising at the injection site. Less common side effects can include headache, leg pain, nausea, and diarrhea. Rarely, disc injury, hemorrhage, or nerve damage occurs. There have been no reports of death with this treatment. Permanent injury is possible but very rare.

There are some risk factors to be aware of. Obesity, use of tobacco products, and mental illness can increase the risk of post treatment problems. Anyone with serious health issues or an inability to do the required range of motion exercises after injection may not be a good candidate for this treatment.