FAQ Category: Lumbar Spine

Lumbar (low back) pain is a common symptom in most golfers who stick with the sport over a long period of time. The repetitive motion, rotation, and strain from the golf swing create pressure on the discs of the spine. The increased load and force on the spine are intense enough to damage muscles, joints, discs, and even the ribs. More than one-third (34.5 per cent) of all injuries among golfers results in low back pain.

What can be done to prevent these common low back conditions in golfers? A recent article by physical therapist, Christopher Finn, from the Par4Success Golf Performance Center in Durham (North Carolina) suggests the following:

There is a new study from physiotherapists in New Zealand that caught our attention and may be one that you would appreciate. They showed that current motor, sensory, and reflex testing used to diagnose disc herniation and specific level of pathology may not be as accurate as previously thought. In fact, after pooling all the data together and analyzing the studies published so far, it looks like the accuracy value of the tests is poor at best.

After searching six of the most relevant electronic databases, they found 14 studies that matched their inclusion criteria. Their search history, search strategy, and algorithm (flow chart) for the studies was presented as an easily readable diagram. Study characteristics (e.g., author names, tests reported, type of physician examiner, herniation type and level) were presented in an easy-to-read table.

An in-depth description of the problems encountered with each study was provided. This helped explain why the neurologic testing to detect lumbar disc herniation and spinal nerve root involvement is not reliable enough to become a standardized test. Here’s a quick summary:

Accurate diagnosis of disc herniation can definitely be a complex and challenging process. There is no cookie cutter approach that is reliable. This is because the pathomechanics and pathophysiology of nerve root irritation causing leg pain, numbness, and/or weakness (referred to as radiculopathy) is complex.

For example, two patients can have the same type of disc herniation with pressure on the spinal nerve root from the bulging disc and still have very different symptoms. In fact, the pain patterns and symptom presentation for lumbar disc herniation is often quite variable.

There are several separate components of the problem that must be determined: is there a disc herniation and if so, what level? Is the disc compressing or chemically irritating one (or more) spinal levels? And again, if so, what level(s)?

Currently, there are no neurologic clinical tests that have been shown to conclusively diagnose disc herniation based on the presence of radiculopathy (symptoms from compression on a spinal nerve root). Future studies are needed to find and standardize clinical tests that are valid and reliable in accurately diagnosing nerve root irritation (radiculopathy) associated with disc herniation.

For now, the physician must rely on patient history (what you tell him/her happened and what are your symptoms) along with the results of clinical tests, electrodiagnostic tests, and imaging studies. Even when electrodiagnostic tests are done to confirm nerve involvement, severe disc herniation can be present with no signs of weakness or sensory changes. Sometimes even with all that information, it’s still not entirely clear what the problem is.

Patients who have surgery don’t always obtain relief from their symptoms so the decision to recommend surgery is not made easily or lightly. Conservative care is almost always advised. The physician follows the patient to see what kind of response occurs with nonoperative care. Even this information is diagnostic in nature.

It is possible that you might find another physician who would be more assertive and certain about your diagnosis. And there is nothing wrong with seeking out a second (or even third) opinion (especially if you are facing the possibility of spinal surgery). But give yourself some time to let nature take its intended course (healing) while you pursue a course of recommended self-care via the conservative approach.

As a patient and health care consumer, you have the right to make requests of this nature regardless of religious orientation or religious affiliation. Your surgeon will work with you to answer your concerns and meet your needs. But he or she will always keep your safety as number one when making decisions before, during, and after surgery.

During surgery steps can (and will) be taken to minimize blood loss. These measures can include 1) positioning you in such a way as to elevate the area of blood loss, 2) use of a tourniquet, 3) gentle handling of tissues, and 4) minimally invasive technique or MIS (instead of an open incision). The traditional open incision involves cutting through the many layers of spinal muscles and other soft tissue structures to gain access to the vertebral bones.

With minimally invasive surgery (MIS), a tube-shaped instrument is passed down through the soft tissues between muscle groups. The soft tissue structures are pushed aside without cutting them. This technique reduces the risk instability from damage to muscles, tendons, ligaments, and bone. MIS also makes it possible for patients to get up and moving again sooner, allowing for faster recovery. There are also surgical instruments that minimize blood loss such as the harmonic scalpel, argon beam and radiofrequency assisted thermal ablation.

Just before surgery several units of blood can be removed and replaced with a crystalloid or colloid solutions so blood volume is maintained. This process is referred to as Acute Normovolemic Hemodilution (ANH). It can be used when blood loss is expected. With ANH, any fluid lost during surgery contains fewer red blood cells and clotting factors are preserved. At the conclusion of the surgery the blood is reinfused to the patient. The entire process is completed through a closed circuit.

Another way to impact blood loss in the operating room is to avoid hypothermia (low body temperature). Hypothermia can prevent normal platelet function resulting in increased blood loss. During surgery, blood that is lost can be suctioned and saved. It is collected, mixed with anticoagulants, filtered and reinfused to the patient. The use of cell salvage can continue into the post-operative phase through the use of drains.

You will be interested to know that this idea of Bloodless Medicine and Surgery (the use of technological and pharmaceutical techniques to minimize blood loss and avoid the use of allogeneic blood transfusions), has developed in recent years. It is now a well-known concept referred to as Patient Blood Management. Although the community of Jehovah’s Witnesses who seek medical care but decline the use of most forms of transfusions helped spearhead these changes, anyone can benefit from them.

Patient Blood Management uses evidence-based medicine to develop an individualized plan for each person to minimize or eliminate the need for transfusions. Ask your surgeon about this concept at your next appointment before the scheduled surgery.Find out what can be done in your individualized plan to avoid unnecessary blood transfusion.

Patients in need of surgery for severe, chronic back pain can benefit by today’s modern surgical techniques, especially minimally invasive surgery (MIS) for spinal fusion. Many studies have been done comparing different methods, techniques, and approaches. Given your situation and specific question, there is a recent study published that you might find of special interest.

In this study from the Rothman Institute Department of Orthopaedic Surgery (Thomas Jefferson University), two groups of patients having spinal fusion were compared. All 162 patients had an anterior lumbar interbody fusion (ALIF) first and then a second procedure. The second procedure was a posterior fusion with either an open incision (group one) or a minimally invasive approach (group two). Some patients (but not all) had a decompression of the nerve tissue as part of the second procedure.

A little information about the advantages of the minimally invasive surgery (MIS) gives a greater appreciation for why this approach is being studied so closely. The traditional open incision involves cutting through the many layers of spinal muscles and other soft tissue structures to gain access to the vertebral bones.

With MIS, a tube-shaped instrument is passed down through the soft tissues between muscle groups. The soft tissue structures are pushed aside without cutting them. This technique reduces the risk instability from damage to muscles, tendons, ligaments, and bone. MIS also makes it possible for patients to get up and moving again sooner, allowing for faster recovery.

Fiber optic lighting and advanced imaging technology aid the surgeon in seeing inside the body to perform the necessary steps. After removal of the disc from an anterior (front of the body/spine), bone graft was placed inside the disc space to maintain normal disc height. Then the patients were turned over and operated on from the back. This was when the spinal fusion was done using either the open or minimally invasive approach.

Results were compared using a variety of measures including amount of blood lost during surgery (and need for blood transfusion), length of surgery and minutes of time exposed to fluoroscopy, length of hospital stay after surgery, and complications (type and severity).

As it turns out, blood loss and the corresponding transfusion rates were greater in the open group. But a second look at this difference showed that it was the patients who had an additional surgical procedure (neural decompression) who experienced these complications. And as expected, the MIS group was exposed to longer periods of radiation exposure due to the increased need for fluoroscopy during the procedure.

The unique aspect of this study was the fact that patients had an open anterior spinal fusion followed by a posterior spinal fusion (either by open or a minimally invasive approach). It sounds like this is the type of surgery your surgeon has proposed for you.

The authors of this study concluded that minimally invasive posterior fusion following open anterior spinal fusion does have the advantages of less blood loss and therefore less need for a blood transfusion. MIS was also associated with a shorter hospital stay (and lower costs). Blood loss was greater in the patients who had open neural decompression.

However, rates of major complications such as blood clots, infection, or need for revision surgery due to problems with hardware were similar between the open and MIS group. The benefit or value of a minimally invasive procedure when performing a posterior spinal fusion with decompression may be compromised. And with the increased exposure to radiation required by the added decompression procedure, it may be that the open incision approach is best when decompression is needed.

Your surgeon will be evaluating your case carefully and making decisions based on many personal factors (e.g., your age, size, general health, presence of other medical problems, smoking/tobacco use history, number of spinal levels being fused, diagnostic reason(s) for this surgery) and so on. If it has not been explained to you why the procedure will be done as described, you may want to ask your surgeon for a more in-depth explanation of what will be done and why.

You may find the information presented through the SPORT studies helpful in answering this question. SPORT stands for Spine Patient Outcomes Research Trial. It is an ongoing long-term study conducted at 13 medical centers across 11 states in the United States. These medical centers provide multidisciplinary treatment to patients with spinal disorders including degenerative spondylolisthesis. Patients are followed at regular intervals and outcomes are measured in terms of pain, function, and disability.

Degenerative spondylolisthesis occurs with aging most often affecting the L4-L5 level in people over 50 years old. Women are affected six times more often than men. Spondylolisthesis alters the alignment of the spine. In this condition, degeneration of the disc and facet (spinal) joints can lead to one of the vertebral bones to slip forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. The spinal canal narrows (a condition called stenosis) putting pressure on the spinal nerves.

Previous SPORT studies have shown that patients have more improvement with surgery compared with a conservative (nonoperative) approach for the problem of degenerative spondylolisthesis with multilevel stenosis. Patients enrolled in a recent SPORT study who had leg pain or discomfort and other neurologic symptoms for at least three months were diagnosed with single-level degenerative spondylolisthesis and single or multi-level lumbar stenosis. This was the first study to compare the results of surgery for single-level degenerative spondylolisthesis accompanied by multilevel stenosis. The patients were divided into two groups. One group (130 patients) had a decompression procedure at more than one level (for the stenosis) and a fusion at one level (for the spondylolisthesis). The second group (77 patients) had the same multilevel decompression but only a single-level fusion.

Because SPORT is an ongoing data collecting type of study, many different pieces of information are collected about the patient, symptoms, insurance, clinical observations and test results, levels and severity of dysfunction, operative problems and results, and so on. This makes it possible to present tables of comparisons for patient demographics, comorbidities, fusion levels, and outcomes.

Although the multilevel fusion procedures took longer and the patients had more blood loss, there were no differences between the two groups in terms of blood replacement, complications during or after the surgeries, or number of reoperations required. Most other comparisons were similar between the two groups. The only real trend was for greater improvement of physical function in the single-level fusion group compared with the patients who had multilevel fusion. But that was only seen after the third year and the benefit evened out between the two groups after the fourth year of follow-up.

This study offers the additional information that surgical results are very similar when treating patients who have single-level degenerative spondylolisthesis and multilevel lumbar stenosis using different surgical approaches. Whether performing a single-level fusion procedure or a multiple-level fusion, the outcomes (measured as bodily pain and function) were about the same (i.e., not significantly different).

Therefore, given that surgery is often very beneficial for this condition, surgeons may want to limit fusion to just the spinal level where instability from the degenerative spondylolisthesis is present. In this way, patients are not exposed to longer operative times. And they are saved from higher levels of blood loss. This is an important consideration for older adults with multiple medical problems. It may be argued that fusing additional levels prevents future adjacent-segment disease but this remains under investigation.

Degenerative spondylolisthesis occurs with aging most often affecting the L4-L5 level in people over 50 years old. Women are affected six times more often than men. Spondylolisthesis alters the alignment of the spine. In this condition, degeneration of the disc and facet (spinal) joints can lead to one of the vertebral bones to slip forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. The spinal canal narrows (a condition called stenosis) putting pressure on the spinal nerves.

Some of the best information available about the treatment of spinal disorders comes from the results of SPORT studies. SPORT stands for Spine Patient Outcomes Research Trial. It is a long-term study conducted at 13 medical centers across 11 states in the United States. These medical centers provide multidisciplinary treatment to patients with various spinal disorders.

Because SPORT is an ongoing data collecting type of study, many different pieces of information are collected about the patient, symptoms, insurance, clinical observations and test results, levels and severity of dysfunction, operative problems and results, and so on. This makes it possible to present tables of comparisons for patient demographics, comorbidities, fusion levels, and outcomes. Patients are followed at regular intervals and outcomes regarding pain, function, and disability are often the main area of focus.

Previous SPORT studies have shown that patients have more improvement with surgery compared with a conservative (nonoperative) approach for the problem of degenerative spondylolisthesis with stenosis. Benefits from the surgery were perceived by patients within the first three months after surgery and maintained for years afterwards. The study groups then turned their attention toward what type/extent of surgery yields the best results.

Most recently, the SPORT groups compared the results of surgery for single-level degenerative spondylolisthesis accompanied by multilevel stenosis. The patients were divided into two groups. One group (130 patients) had a decompression procedure at more than one level (for the stenosis) and a fusion at one level (for the spondylolisthesis). The second group (77 patients) had the same multilevel decompression but only a single-level fusion.

Although the multilevel fusion procedures took longer and the patients had more blood loss, there were no differences between the two groups in terms of blood replacement, complications during or after the surgeries, or number of reoperations required. Most other comparisons were similar between the two groups. The only real trend was for greater improvement of physical function in the single-level fusion group compared with the patients who had multilevel fusion. But that was only seen after the third year and evened out after the fourth year of follow-up.

This study offers the additional information that surgical results are very similar when treating patients who have single-level degenerative spondylolisthesis and multilevel lumbar stenosis using different surgical approaches. Whether performing a single-level fusion procedure or a multiple-level fusion, the outcomes (measured as bodily pain and function) are not significantly different.

As a result of this study, surgeons may decide to limit fusion to just the spinal level where instability from the degenerative spondylolisthesis is present. In this way, patients are not exposed to longer operative times and saved from higher levels of blood loss. This is an important consideration for older adults with multiple medical problems. Your choice of treatment may depend on your age, severity of symptoms and condition, presence of other medical conditions, and surgeon preferences.

Acupuncture as an alternative treatment to traditional medicine has been making the news. More and more studies are showing its positive effects on chronic low back pain. But differences in how the studies are conducted have left some lingering doubts as to the true benefit of this treatment. Since patients receiving a placebo treatment seem to fare as well as those receiving the “true” acupuncture treatment, further study is needed.

In the meantime, what has been shown so far has been very promising. One of the valuable “side effects” or benefits of acupuncture is both a reduction in the severity of pain as well as how “bothersome” that pain is for each patient. When pain is reduced, function and ability increase — two additional side effects, if you will.

But you are really asking more about the adverse effects — what some might refer to as the negative effects of acupuncture. Most adverse effects reported are mild and temporary. Some patients say their back pain increases at first and then subsides. Some people do not tolerate the local pain from the needle insertion. There is the possibility of bruising where the needle goes into the skin if a tiny vein is punctured.

Because acupuncture needles are inserted along lines of energy called meridians, it is possible to experience pain somewhere else along that meridian. So acupuncture for low back pain may result in pain in the shoulder or foot. Sometimes patients report feeling sluggish or having overall body aches in the first 24 to 48 hours after the acupuncture treatment. But all of these potential side effects go away in time. And often the person feels much better than before the treatment.

When you meet with your intended acupuncturist, you can certainly ask this question and see what his or her experience has been. There is also some evidence from studies that patients having a positive expectation of the treatment benefit improvement in painful symptoms. This occurs in cases where “sham” acupuncture is delivered. Sham acupuncture refers to nonpenetrating acupuncture. A blunt-tipped needle is used to make contact with the skin but without piercing through the skin.

More and more studies are showing the positive effects of acupuncture on chronic low back pain. But differences in how the studies are conducted have made it difficult to narrow down the protocol to a specific number of treatments that is best for everyone. Individual patient differences (e.g., personality, stress and response to stress, socioeconomic) factors, psychological factors, and even workplace-associated contributing factors can affect results.

New information from a recent study from the Department of Korean Rehabilitation Medicine may provide some useful information. They designed a study to compare the results of true acupuncture with sham acupuncture treatment. The two different types of treatment were used in the care of patients ages 18 to 65 who had nonspecific chronic low back pain (cLBP or LBP). Each patient reported pain levels as being a six or higher on a scale from zero (no pain) to 10 (severe pain). Patients were assigned to the sham treatment and the real acupuncture treatment in a random fashion.

In this study, 130 patients received nonpenetrating sham acupuncture or true (penetrating) acupuncture twice a week for more than six weeks. Nonpenetrating acupuncture means a blunt tipped needle was used to make contact with the skin but without piercing through the skin.

This way of providing a sham acupuncture treatment has been shown in past studies to be perceived as genuine by other patients. Points of stimulation used were NOT true acupuncture points to further differentiate the sham treatment from the real or true acupuncture treatment (which was applied to actual acupuncture points).

Results were measured based on patient report of how “bothersome” the chronic low back pain (cLBP) was, pain intensity, general health status, and level of disability and depression. Patients in both groups reported significant improvement in the first two weeks. But the real acupuncture group had a much greater reduction of “bothersome” pain.

Intensity of pain was also reduced more in the group receiving real acupuncture. Patients in the sham group who benefitted from this “treatment” may have been experiencing both physiologic and psychologic benefit from the expectation that acupuncture would help. The group receiving real acupuncture would have the same positive expectation but with the added benefit of a true physiologic (not just perceived) effect.

Acupuncture is considered a safe and effective treatment for chronic low back pain (cLBP). Real acupuncture reduces the intensity and bothersomeness of cLBP more than sham acupuncture. The exact number of sessions needed has not been determined and is likely patient specific. As a general rule based on patient and acupuncturist experiences, expect a minimum of six sessions. See how you are doing and then reassess the need for further treatment.

This is a very good question and one that has come under debate and discussion as well as study by physical therapists and other orthopedic health care specialists. In an effort to identify the most helpful conservative (nonoperative) care for these patients, a group of physical therapists recently conducted a systematic review and reported their findings.

They conducted a computer-assisted search of articles published in English over a span of 46 years (from 1966 to 2012). After gathering all the acceptable articles and compiling all the information, the authors organized the data into five tables. Information in these tables included:

1) Description of each study (design, patient demographics, training type and duration)

2) Type of injury (acute versus chronic, severity) and type of surgery (decompression, fusion, fusion with or without instrumentation)

3) Comparison of outcomes for nonoperative treatments (bracing versus activity restriction)

4) Comparison of outcomes for nonoperative treatments (bracing and physical therapy versus placebo/control)

5) Results for exercise interventions (core training, back strengthening, postural exercises, general exercise)

Although the information was carefully organized, as it turned out, many of the studies collected (and reported on) different things. There wasn’t enough consistency across studies to make comparisons with meaning. The authors report “limited investigation” and “lack of homogeneity” as the two main reasons there was no consensus on the role of conservative care or on outcomes of nonoperative care versus surgery for this condition.

There was one other major stumbling block in studying the effects of exercise: poor patient compliance. In other words, the patients didn’t do the exercises as prescribed (or didn’t do them at all)! With the limited evidence available, the best that can be said is that exercise to strengthen the core muscles (abdominals and trunk stabilizers) decreases pain and improves function.

No evidence but clear consensus (based on expert opinion or case studies suggest) suggested that bracing works better for healing the fracture when compared with restricted activity for children and teens with spondylolysis (fracture without separation). Some case series studies showed that more young people return to full activity (and sports participation) when bracing was combined with specific exercises.

There is also some evidence that specific core training to strengthen the abdominal muscles and trunk stabilizing muscles can aid conditions like spondylolysis. These findings may offer some direction in your child’s situation. It may be best to work with your physician and physical therapist to identify the most appropriate treatment for your young teenager.

Location and severity of injury, activity level, and likelihood of compliance are all important considerations in the planning process. There’s no sense in spending money on a brace that gets left under the bed or an exercise program that is never carried out. Having a physical therapist involved may provide the incentive needed to ensure or improve your child’s compliance with the recommendations.

As you have now discovered, sports athletes are not immune to low back pain. Bony defects such as spondylolysis and spondylolisthesis present from birth or as a result of stress fractures from overuse can be a common cause of painful lumbar instability. In the case of spondylolysis, the supporting bony column (called the pars interarticularis) fractures. As you pointed out, if the fracture displaces (separates) and the vertebral body shifts forward, the condition is referred to as spondylolisthesis.

Most athletes would prefer a nonoperative approach to treatment — but preferably one that gets them back on their feet and returns them to full participation quickly. In an effort to identify the most helpful conservative (nonoperative) care for these patients, a group of physical therapists conducted a recent systematic review and reported their findings.

They conducted a computer-assisted search of articles published in English over a span of 46 years (from 1966 to 2012). After gathering all the acceptable articles and compiling all the information, the authors found that many of the studies collected (and reported on) different things. There wasn’t enough consistency across studies to make comparisons with meaning. The authors report “limited investigation” and “lack of homogeneity” as the two main reasons there was no consensus on the role of conservative care or on outcomes of nonoperative care versus surgery for this condition.

There was one other major stumbling block in studying the effects of exercise: poor patient compliance. In other words, the patients didn’t do the exercises as prescribed (or didn’t do them at all)! With the limited evidence available, the best that can be said is that surgery (over conservative care) seems to be most effective for higher grades of vertebral slippage. And exercise to strengthen the core muscles (abdominals and trunk stabilizers) decreases pain and improves function.

No evidence but clear consensus (based on expert opinion or case studies suggest) suggested that bracing works better for healing the fracture when compared with restricted activity for children and teens with spondylolysis (fracture without separation). In adults, lumbar exercises helped some people recover and return to work. But there was inconsistency in the most effective type of lumbar exercises. For example, some people responded to extension exercises better than flexion exercises and vice versa.

The lack of consensus or evidence-based agreement on the best way to treat these patients must be addressed in future high-quality research. In the meantime, your question goes unanswered as there is no known treatment protocol that yields the best results. The physician and physical therapist who are working with your son will be the best sources of information. Their advice and recommendations will be based on your son’s age, severity of the spondylolisthesis, and goals for return to activity and sports participation.

You didn’t mention why you aren’t happy with the results or what tests the surgeon used to measure “success.” Some studies do have ways of determining the minimum amount of change in test scores that are considered significant (and therefore a sign of “success”). You may find some help from a recently reported systematic review comparing the results of fusion surgery with results for nonoperative care for this condition known as degenerative disc disease.

They used careful selection criteria to get the best evidence possible. Studies included had to use validated patient assessment tools to measure outcomes (e.g., the Oswestry Disability Index, Short Form Health Survey). Perhaps you completed one of these two patient self-report tools. Patient satisfaction and X-ray results were also acceptable measures of clinical outcomes.

Articles considered unacceptable for review (inclusion) and therefore excluded were: 1) based on opinion, 2) only reporting on surgical technique, or 3) included patients receiving a fusion at more than two spinal levels. In addition, studies that were too small (less than 20 patients) or too short (follow-up was less than one year) were not included.

Twenty-six (26) studies with a total of over 3,000 patients met the necessary standards to be included. All patients had pain and loss of function as a result of degenerative disc disease in the lumbar spine (low back). Spinal surgery done was fusion at one or two levels.

Specific information used to compare results included length of follow-up time, patient age, baseline back pain information, change in outcome scores, fusion rates, reoperation rates, and level of patient satisfaction.

Pain relief and improved function were reported for the fusion patients in the majority of cases. Overall patient satisfaction was 75 per cent for patients who had the fusion procedure, while patients in the nonoperative group reported a much lower rate (55.6 per cent) of satisfaction. The percentage of patients who had a successful fusion was 84 per cent. Seven per cent (7%) of the total group had a second surgery due to a failed first surgery.

Patients evaluating results of surgery versus nonoperative care for degenerative disc disease should keep in mind that these two treatments are not really competing with one another. Patients aren’t usually given the opportunity to choose between them.

Instead, treatment is offered in a series: first conservative care with medications, physical therapy, and rest. Then, if the treatment fails, follow-up surgery (spinal fusion) is advised. Surgeons who seek the best evidence available to support their clinical decisions may rely on systematic reviews like this one to direct and guide them.

Patients like yourself with chronic, persistent low back pain from degenerative disc disease (DDD) will be interested in the results of of a recent study. The authors (surgeons from four well-known Spine Centers in the U.S.) collected, reviewed, and summarized data from studies comparing surgical fusion with nonoperative (conservative) care.

They used careful selection criteria to get the best evidence possible. Studies included had to use validated patient assessment tools to measure outcomes (e.g., the Oswestry Disability Index, Short Form Health Survey). Patient satisfaction and X-ray results were also acceptable measures of clinical outcomes.

Articles considered unacceptable for review (inclusion) and therefore excluded were: 1) based on opinion, 2) only reporting on surgical technique, or 3) included patients receiving a fusion at more than two spinal levels. In addition, studies that were too small (less than 20 patients) or too short (follow-up was less than one year) were not included.

Twenty-six (26) studies with a total of over 3,000 patients met the necessary standards to be included. All patients had pain and loss of function as a result of degenerative disc disease in the lumbar spine (low back). Spinal surgery done was fusion at one or two levels.

The authors provided several summaries of data from studies that compared results of surgery versus nonoperative care for this condition. Information was compiled for both randomized and nonrandomized controlled trials. They included length of follow-up time, patient age, baseline back pain information, change in outcome scores, fusion rates, reoperation rates, and level of patient satisfaction.

Overall patient satisfaction was 75 per cent for patients who had the fusion procedure, while patients in the nonoperative group reported a much lower rate (55.6 per cent) of satisfaction. The percentage of patients who had a successful fusion was 84 per cent. Seven per cent (7%) of the total group had a second surgery due to a failed first surgery.

Pain relief and improved function were reported for the fusion patients in the majority of cases. Type of fusion technique and age of the patient (young versus old) did not seem to affect success of the fusion procedure.

Patients evaluating results of surgery versus nonoperative care for degenerative disc disease should keep in mind that these two treatments are not really competing with one another. Patients aren’t usually given the opportunity to choose between them.

Instead, treatment is offered in a series: first conservative care with medications, physical therapy, and rest. Then, if the treatment fails, follow-up surgery (spinal fusion) is advised. Surgeons who seek the best evidence available to support their clinical decisions may rely on systematic reviews like this one to direct and guide them.

Summary: Collecting information on treatment results like in this review (especially success and failure risks and rates) is important today because of the large number of people missing work or seeking medical care for chronic low back pain. The high cost of fusion surgery also warrants knowing if surgical care is the best way to go.

As this systematic review showed, patients who do not get relief from their painful, disabling symptoms with nonsurgical treatment may find surgical fusion is a very good next step in the treatment algorithm (clinical decision pathway).

One of the main concerns after cervical (neck) fusion or disc replacement is the risk of adjacent segment disease (ASD). Adjacent segment disease refers to breakdown of the vertebrae next to a spinal fusion or disc replacement implant.

Studying the causes and ways to avoid adjacent segment disease (ASD) after fusion or disc replacement become a major focus of research these days. But with the ever changing surgical tools and techniques, it is difficult to compare studies from 10 years ago with current studies. And that dilemma will continue into the future as treatment strategies change with evolving technology.

Even so, efforts are being made to study the problem of adjacent segment disease (ASD) and ways to avoid it. Focusing on the causes of the problem may help surgeons identify avoidance strategies.

Currently, there are three known causes of adjacent segment disease. They are: 1) the natural history (what normally happens) in the disc at the next level, 2) the biomechanical stress and increased motion placed on the next level because of the fusion, and 3) anatomical disruption of the vertebral segment at the next level from the surgery.

Available evidence suggests that strategies to avoid ASD seem to be working better for the cervical spine than for the lumbar spine. And ASD may be less likely to develop after disc replacement compared with spinal fusion. This is especially true for younger patients who may be at less risk for degeneration from the natural aging process compared with older adults.

Matching strategies with causes isn’t easy. For example, to know for sure if natural history (the natural tendency for the spine to degenerate over time without surgery) is the real problem is difficult to study. Providing needed surgery for one group of patients while comparing them to a control group (those who don’t have the surgery) isn’t ethical. So the true incidence of ASD linked with natural progression of disc degeneration is likely to remain unknown.

Studying the biomechanical changes at the adjacent levels is a bit easier. Researchers can measure the increased motion at the next vertebral levels and measure the increased pressure on the disc in between the vertebrae.

These kinds of changes are more likely after fusion (because of loss of motion) than with disc replacement where motion is preserved. Determining the exact biomechanical changes that contribute to ASD and finding ways to change that relationship are the focus of many current studies. To date, there has been a wide range of conclusions about this variable. Some studies show that the natural tendency for discs to degenerate over time is the main cause of the problem while others point to the change in biomechanics as the most important factor.

But there’s no mistaking the fact that the surgery has an effect as well. Whether fusion or disc replacement, the structures are changed, the normal anatomy is altered, and the result could be aggravation of the adjacent levels. Studies are needed to show what anatomic parts must be preserved and not disrupted during surgery to prevent adjacent segment disease. Likewise, determining technical strategies during the procedure that might help avoid adjacent segmental disease will be important.

Given all the information we have so far, there is nothing wrong with your thinking/strategy. Taking into consideration your age, your surgeon’s opinions, your current (and hoped for) activity level, and the pros and cons for each procedure will give you the best guidance in making this important decision.

We can do better than that! We can give you the results of a recent study on this topic from surgeons at Walter Reed Military Medical Center and Thomas Jefferson University. They teamed up together to present the latest evidence on adjacent segment disease (ASD) and how to avoid it. The article is written for surgeons but patients may find some of the information of interest, too.

Studying the causes and ways to avoid adjacent segment disease (ASD) of the cervical (neck) and lumbar (low back) spine has become a major focus of research these days. But with the ever changing surgical tools and techniques, it is difficult to compare studies from 10 years ago with current studies. And that dilemma will continue into the future as treatment strategies change with evolving technology.

Even so, efforts are being made to study the problem of adjacent segment disease (ASD) and ways to avoid it. They say that strategies to avoid ASD seem to be working better for the cervical spine than for the lumbar spine. And ASD may be less likely to develop after disc replacement compared with spinal fusion.

Currently, the focus is on the causes of the problem — this approach may help surgeons identify avoidance strategies. There are three known causes of adjacent segment disease. They are: 1) the natural history (what normally happens) in the disc at the next level, 2) the biomechanical stress and increased motion placed on the next level because of the fusion, and 3) anatomical disruption of the vertebral segment at the next level from the surgery.

Knowing causes doesn’t necessary make matching treatment strategies easy. For example, to know for sure if natural history (the natural tendency for the spine to degenerate over time without surgery) is the main problem is difficult to study. Providing needed surgery for one group of patients while comparing them to a control group (those who don’t have the surgery) isn’t ethical. So the true incidence of ASD linked with natural progression of disc degeneration is likely to remain unknown.

Studying the biomechanical changes at the adjacent levels is a bit easier. Researchers can measure the increased motion at the next vertebral levels and measure the increased pressure on the disc in between the vertebrae.

These kinds of changes are more likely after fusion (because of loss of motion) than with disc replacement where motion is preserved. Determining the exact biomechanical changes that contribute to ASD and finding ways to change that relationship are the focus of many current studies. To date, there has been a wide range of conclusions about this variable. Some studies show that the natural tendency for discs to degenerate over time is the main cause of the problem while others point to the change in biomechanics as the most important factor.

But there’s no mistaking the fact that the surgery has an effect as well. Whether fusion or disc replacement, the structures are changed, the normal anatomy is altered, and the result could be aggravation of the adjacent levels. Studies are needed to show what anatomic parts must be preserved and not disrupted during surgery to prevent adjacent segment disease. Likewise, determining technical strategies during the procedure that might help avoid adjacent segmental disease will be important.

In summary, studies of adjacent segment disease (ASD) for the cervical and lumbar spines continue to report a wide range of variable results. Working to find avoidance strategies based on known causes of ASD will remain the focus of ongoing research. Long-term results will be difficult to judge given the ongoing changes in technology and surgical techniques used in these procedures. But this will not deter surgeons from trying to develop effective avoidance strategies.

Your surgeon is the best one to advise you. He or she will take into consideration your particular situation and individual factors (e.g., duration of symptoms, age, activity level and goals, location and severity of disease, and known facts about adjacent segment disease after fusion and disc replacement). Each surgeon will have his or her own strengths and expertise to offer. It is always best to take advantage of these when making treatment choices.

Pain from pressure on the nerves as a result of spinal stenosis can certainly be a deterrent in sticking with a plan of conservative care. And surgery can be the only way some patients obtain pain relief. But as you have discovered, the current practice is to try and manage symptoms using nonoperative techniques before considering surgery.

Spinal surgery can be done with minimally invasive techniques but more often, it is performed with an open incision. The risk of complications such as infection, dural tears (lining of the spinal cord), nerve damage, bleeding, and life-threatening blood clots makes this a second-tier choice at best.

Conservative care must be multi-modal meaning a combination of many different approaches. Pain control through medications, physical therapy, chiropractic care, acupuncture, and even relaxation/meditation techniques is strongly encouraged. And once nerve tissue is irritated, it can take six weeks up to six months to get control of the symptoms. But it is possible and even probable that with careful management, you will see some results soon.

Before considering open surgery, many patients try epidural steroid injections. Up to three injections (spaced apart by one to four weeks) of a numbing agent and antiinflammatory drug are placed into the area around the spinal nerve roots. Pain relief is the goal with the hope that reducing inflammation, reducing pressure on the nerves, and turning off pain signals can be achieved without surgery.

So, the first order of business is to get control of the pain. Your surgeon or primary care physician can help you with this. Medications may include antiinflammatories and analgesics (pain relievers) possibly even including narcotic drugs if less potent drugs are not effective. But do not depend on medications alone to do the trick. Make every effort to use any and even ALL of the methods for nonoperative care suggested. Given enough time, the body will often heal itself.

According to a recent study called Spine Patient Outcomes Research Trial (SPORT), patients who have spine surgery (laminectomy and/or fusion) have different results depending on where the surgery was done. These are the findings of a recent review of data collected from 13 spine centers in 11 different cities across the United States. Naturally, the reasons for these differences in outcomes are of interest but will have to wait for another study.

For now, this study shows that patients with stenosis (narrowing of the spinal canal) or degenerative spondylolisthesis (age-related fracture and slippage of the vertebra) who have the same surgery may not get the same results.

Most of the time this type of surgery is successful with good postoperative outcomes. But there are cases where there is no change in painful, limiting symptoms, and the patient ends up having another surgery.

There are many different reasons why some patients don’t fare well after these procedures. Sometimes the patient was misdiagnosed or the surgical technique failed. In other cases, the spine was unstable and this problem wasn’t addressed during the surgery. Many studies have shown that over time, adjacent segment disease (breakdown of the spinal segment next to the fusion site) is a problem.

In each of the nearly 800 similar cases, surgery performed varied slightly and the number of levels operated on was anywhere from one to three or more. Events associated with the procedures (e.g., length of time in the operating room, amount of blood lost, number of dural tears) varied from center to center. And there were significantly different reports on how long patients stayed in the hospital and the number of wound infections.

Long-term results (measured at one, two, three, and four years after surgery) were also significantly different across the spinal centers involved. For example, the number of patients who required another surgery ranged from five to 21 per cent. The level of pain and physical function reported by patients was also different.

The data was collected and analyzed in such a way as to make sure that these differences were directly linked with the effect of the center rather than being due to patient factors such as age, size, smoking history, socioeconomic status, or level of preoperative exercise. Factors that may be important (but as yet unproven) include: surgeon preference for certain techniques, patient genetics, neurobiological responses to the underlying condition, and differences in patient response to pain.

This study cannot answer the “why” of differences in response to surgery for these two conditions. But it does support the idea that there are broad ranges of patient outcomes across centers for the same conditions using similar surgical approaches.

When looking for a surgeon/center where you can get the best results, it may be best to consult with your local surgeon. He or she may have contact or association with a surgeon of good repute who can help you. The information from this study may give you some idea as to what questions to ask and what to look for when finding a surgeon or center with good outcomes for this particular procedure.

Crossover refers to patients who start in one group (e.g., injection group) and end up going (crossing over) to the surgical group (or vice versa). Since you are participating in this study comparing epidural steroid injection with surgery, you might find the results of a recent (similar) study of interest.

In this study, results for patients who received ESI for their symptomatic (with symptoms) lumbar stenosis were compared with outcomes of patients who did NOT receive the injection.

Everyone in both groups did have painful neurologic symptoms and had tried at least three months of nonoperative care without success. The type of conservative care they received included home exercise, nonsteroidal antiinflammatory drugs, education and counseling, and active physical therapy.

The researchers were very thorough in examining characteristics of patients and any factors that might affect the results. They looked at age, smoking status, general health, presence and types of other health problems, marital status, work or employment, income, education, race, body mass index, and many other variables.

Details of the symptoms and stenosis (location in the spine, severity, duration, affect on activities) were also recorded and analyzed. Anyone who ended up having surgery (from either group — those who had the steroid injection and those who didn’t) were also examined carefully. Information was collected on type of surgery, length of stay in the hospital, postoperative complications, additional surgeries, blood loss, and number of minutes in surgery.

In the end, they found that patients who had the epidural steroid injections (ESI) during the four year study period had significantly less improvement in symptoms over anyone else. That included patients who had surgery (and those who didn’t have surgery). The main conclusion of this study was that patients with lumbar spinal stenosis who have ESI have worse results than those who don’t have ESI.

A second observation from the study was related to patient crossover. The surgical group had better results than the injection group. So the patients who crossed over from originally being in the surgical group to the injection group may have had worse results than if they had stayed in the surgical group.

Patients in the ESI group who had the injection and then crossed over to have surgery also had worse results than the surgical group who did not have any injections. The surgery took longer for the ESI-crossover-to-surgery group. They were also in the hospital longer without any measurable benefit from the procedure.

With all that data collected, the authors went digging for an explanation. Other studies have suggested that earlier treatment with ESI might make a difference. Obesity and emotional instability have been linked with poorer results using ESI. Sometimes outcomes are significantly worse when patients have both stenosis AND lumbar disc degeneration.

The possible explanations offered by this group of researchers included: 1) adding fluid from the injection to an already narrow spinal canal may make the symptoms worse instead of better, 2) the steroid drug may damage nerve roots, and 3) the injected substances (numbing agent and steroid) may be viewed by the body as “toxic” and cause direct injury to nerve cells and/or scar tissue to form around the nerve tissue.

In the end, from this study it looks like epidural steroid injection for lumbar spinal stenosis may not be the best way to avoid surgery. The surgical group had better results than the injection group. So the patients who crossed over from originally being in the surgical group to the injection group may have had worse results than if they had stayed in the surgical group.

Future studies may be able to determine who would be a good candidate for ESI before surgery (and who should go from conservative care to surgical care without ESI). Until patient selection for ESI versus surgery is clearly determined, patients should be advised that choosing ESI to avoid surgery isn’t always the best option.

Lumbar spinal stenosis (stenosis of the low back) is a common cause of back problems in adults over 55 years old. Symptoms of buttock or leg pain occur with or without back pain when the nerves in the spinal canal are compressed or pinched.

The spinal canal is the hollow tube formed by the bones of the spinal column. Anything that causes this bony tube to shrink can squeeze the nerves inside. As a result of many years of wear and tear on the parts of the spine, bone spurs may form and ligaments thicken closing around the spinal canal. Anything that narrows the spinal canal opening for the spinal cord and spinal nerves can put pressure against the nerves.

Many older adults never know they have this condition. They are said to be asymptomatic (without symptoms). But for those who do experience the back, buttock, and/or leg pain (and sometimes tingling/numbness), treatment is important.

When all nonsurgical, noninvasive treatments have been tried without success for lumbar spinal stenosis, surgeons often try epidural steroid injections (ESI). Most people want to avoid surgery, which is why they run the gamut of all conservative approaches ending with steroid injections before surgery.

Those individuals who end up having surgery to remove bone from around the nerve can get relief from symptoms. But one thing to know is that having epidural steroid injections (ESIs) first before surgery can actually affect the benefit of the surgery. The results we will report to you here are based on a recent study comparing outcomes from treatment (injections versus no injections) for patients with lumbar spinal stenosis.

In this study, everyone in both groups (those who had injections, those who didn’t) had painful symptoms and had tried at least three months of nonoperative care without success. The type of conservative care they received included home exercise, nonsteroidal antiinflammatory drugs, education and counseling, and active physical therapy. Some of the patients (from either group — those who had the steroid injection and those who didn’t) ended up having surgery .

In the end, they found that patients who had the epidural steroid injections (ESI) had significantly less improvement in symptoms over anyone else. That included patients who had surgery (and those who didn’t have surgery). The main conclusion of this study was that patients with lumbar spinal stenosis who have ESI have worse results than those who don’t have ESI.

A second observation from the study was related to patient crossover. Crossover refers to patients who start in one group (e.g., injection group) and end up going (crossing over) to the surgical group (or vice versa). In this study, the surgical group had better results than the injection group. So the patients who crossed over from originally being in the surgical group to the injection group may have had worse results than if they had stayed in the surgical group.

Patients in the ESI group who had the injection and then crossed over to have surgery also had worse results than the surgical group who did not have any injections. The surgery took longer for the ESI-crossover-to-surgery group. They were also in the hospital longer without any measurable benefit from the procedure.

From this study it looks like epidural steroid injection for lumbar spinal stenosis may not be the best way to avoid surgery. Future studies may be able to determine who would be a good candidate for ESI before surgery (and who should go from conservative care to surgical care without ESI). Until patient selection for ESI versus surgery is clearly determined, patients should be advised that choosing ESI to avoid surgery isn’t always the best option.

Since you have already gone this far, the rest of your journey will require advice from your surgeon. You may want to discuss the information offered from this study and evaluate the pros and cons for your individual situation. It may not hurt to listen to your “gut” on decisions like this one until a clear solution is presented.

There is a new study from The Netherlands that might be helpful to you. They conducted an extensive survey of the published studies comparing three treatment approaches to symptomatic lumbar degenerative disc disease: conservative care and rehabilitation, spinal fusion, or the newer option of disc replacement

Current clinical practice seems to be moving away from spinal fusion and more toward lumbar disc replacement for symptomatic degenerative disc disease. The implants were first invented and designed to help with the problem of adjacent spinal disease that often occurs at the level above or below a fused segment.

After an extensive search on-line, the authors found seven studies that compared results of disc replacement, fusion, or rehabilitation. Combining all the patients in all seven studies, there was a total of 1301 people included. Only one of those studies really looked at rehabilitation.

Analysis of findings showed that patients improved no matter what type of treatment was applied. Patient satisfaction was greater in the group who had a total disc replacement. As intended, these implants did allow patients more natural motion.

But using a five-point criteria for assessing these studies, they found all had low quality evidence. None of the studies looked at subsequent adjacent segment disease, which is the main reason the implants were developed in the first place. The follow-up was two years or less, so long-term results aren’t really available. And many of the studies are funded by disc manufacturers, so there is a need for unbiased research without conflicts of interest.

The authors suggest directed their comments to surgeons and advised caution in the use of disc replacements. They suggested that until high-quality studies with long-term results are available, it should not be assumed that “newer is better.” In other words, this new direction away from spinal fusion toward disc replacement hasn’t been adequately proven as the best approach for everyone. That doesn’t mean this treatment method isn’t ever to be used. Careful patient selection and surgeon experience and expertise with the procedure are key ingredients to a successful result.