FAQ Category: Lumbar Spine

Back pain isn’t a given – it’s not inevitable that we will get back pain as we get older. However, many factors play a role in back pain and with the wear and tear on the spine and discs, back pain is one of the most common complaints in the Western world.

The pain or injury can be caused from trauma to the spine earlier in life (falls, lifting injuries, accidents, etc), the development of arthritis in the spine, tumors, and many others.

The best way to reduce the risk of back pain and back injury is to take care of your back. Learn and perform good body mechanics when lifting; take proper precautions when doing activities that can cause back injuries, practice good posture, exercise, and maintain as healthy a lifestyle as possible.

When conservative measures fail with spinal stenosis, surgery may be the next step. Stenosis refers to a narrowing of the spinal canal. Congenital narrowing, combined with degenerative changes that come with aging, often bring on painful symptoms.

Conservative care is always the first line of treatment. Rest, antiinflammatory drugs, and steroid injections often work well. But when nonoperative care doesn’t change the symptoms, then decompressive surgery is considered.

In this operation, a portion of the bone around the spinal cord is removed. This takes the pressure off the spinal cord or spinal nerves. But sometimes the neural structures were pinched long enough and hard enough before surgery that there is some loss in sensory and/or motor control.

This may be temporary or permanent. Nerve tissue can heal but it’s a very slow process. Time can help resolve these final symptoms without further surgery. In some cases, a rehab program may also be beneficial.

You may be referring to a special imaging technique called fluoroscopy. It is a form of X-ray that sends images of your spine to a computer. The surgeon can then see inside your body while performing the operation.

This imaging method makes it possible to direct the needle for the epidural steroid injection (ESI) to the exact spot needed. Since there are vital structures in this area, accuracy is important.

A small error can result in puncture of the blood vessels. It’s even possible that the needle could penetrate the gastrointestinal tract. Fluoroscopy decreases the risk of complications from improper needle placement.

It is true that there is increased exposure to radiation with this type of imaging. But the procedure also takes less time with the improved visualization. The surgeon will make every effort to limit exposure time because the medical staff present is also exposed. And they are exposed at every use, whereas the patient is exposed one time.

You can reconsider your decision and discuss this with the surgeon before the procedure. Using fluoroscopy to apply the ESI directly to the inflamed nerve gives the best results. Pain relief may be an acceptable trade off to you for the amount of radiation dose you will be exposed to.

Centralization or the centralization phenomenon is a term used by physical therapists and physicians to describe buttock or leg pain that goes away or gets better with extension movements.

With centralization, the painful symptoms move from a place below the spine up to the midline of the low back area. This change occurs when the patient is placed in an extended position or moves the spine into extension.

Lying on your stomach in the prone position is one starting point. The patient uses the arms to press the upper body up off the table. This is a prone extension position or exercise. If the buttock or leg pain moves into the lower back area, centralization has occurred.

Extension can also be done in the standing position with the same results. In fact, both of these test positions are also used in the treatment of LBP when centralization occurs.

New guidelines on the diagnosis and treatment of low back pain (LBP) have recently been published. The American College of Physicians (ACP) and the American Pain Society (APS) worked together to develop these guidelines.

They reviewed recent results of studies for evidence of the benefit of various options in the treatment of LBP. The amount of benefit was described from small to substantial. The quality of evidence ranged from poor to good.

All evidence points to the need for patients to have proper guidance and education about back pain. The number one piece of advice should be to stay active. Taking a day or two to recover from a back injury or back pain is acceptable. But after that, activity and movement are essential.

Routine X-rays of all LBP patients are no longer the standard of care. Studies have shown over and over that such tests are not needed. They are expensive and drive up the cost of health care unnecessarily.

X-rays or other imaging studies are only recommended in certain situations. Diagnostic imaging may be advised for patients with signs of severe neurologic involvement. The same is true for patients with rapidly worsening neurologic symptoms.

If the physician suspects serious pathology such as a fracture or tumor, then X-rays will likely be ordered. But the history and results of the physical exam are usually enough to guide the doctor. These tools are useful in deciding the need for further testing and determining the best plan of care.

So far it looks like there may be more than one approach to low back pain (LBP). What works well for one person doesn’t always gain results for another.

There is general consensus that staying active is the most important feature of any back care program. Patients should strive for a balance of rest, exercise, recreation, and work-related activities.

A biomedical approach treats the symptoms with medications, rehab, and possibly surgery. A psychosocial approach looks at the behaviors, beliefs, and stresses in the patient’s life and tries to moderate them.

A review of many studies of therapies for back pain has been done. Results of nondrug therapies were reported for acute low back pain and chronic low back pain. Acute refers to the early onset of symptoms. This is usually within the first two weeks to two months of pain. Chronic back pain refers to painful symptoms that have persisted beyond three months.

There is fair evidence that spinal manipulation offers some benefit to patients with acute back pain. Hot packs or heating pads offer moderate relief of painful symptoms in the early phases of back pain.

Relaxation techniques, acupuncture, and massage provide moderate relief of pain and have fair quality of evidence. Exercise, rehab, and spinal manipulation have been proven more effective for subacute or chronic back pain.

Don’t despair if you haven’t found the right treatment for you. Sometimes it takes a while to find the treatment approach or combination of treatment methods that work best for each individual. A physical therapist can also help you with this.

Wear and tear of the discs and facet joints above and below a level that has been fused has haunted many people after fusion surgery. This in part is due to increased motion and shearing forces at these levels because the fused level has lost some of its mobility. There is now a published study that shows that in human subjects, disc replacement allows motion at the segment that is operated on that is very similar to people who have not had surgery. Theoretically, this should eliminate problems with wear and tear above and below the segment where the disc has been replaced. This appears to be the greatest advantage of disc replacement vs. lumbar fusion.

A recent study showed that healthy subjects with no back pain who were required to sit motionless for two hours complained of low back pain. Pain was improved with both a lumbar support that could inflate with a fixed amount of air and a lumbar support that was able to inflate and deflate alaternately. Given the cost and availability, a standard lumbar support is shown to help reduce low back pain while sitting for two or more hours.

Ideally, this is a question you should ask your physician. Each patient is different and some may be more susceptible to certain complications than others. As well, complications can also occur as a result of the patient’s overall health and not just the surgery.

That being said, the most common complications include the screws in the hardware becoming loose, a break in the hardware, or the graft or hardware may move (migrate). In some people, the area around the fusion may begin to degenerate, requiring more surgery.

Narrowing of the spinal canal is called spinal stenosis (SS). It is a common cause of back and/or leg pain and difficulty walking in older adults. Even people born with perfectly normal spinal canals can develop stenosis.

Anything that narrows the open space around the spinal cord can cause stenosis. Sometimes arthritic changes in the bone can narrow this opening. Bone spurs form or the vertebral body starts to collapse.

Changes in the spinal joints can also contribute to the problem. And it’s not uncommon for the main spinal ligaments such as the ligamentum flavum (LF) along the back of the spine to get thicker. During movement, the LF can get pinched inside the spinal canal.

Patients with certain congenital shapes of the spinal canal can also develop (SS). Narrowing of the spinal canal caused by the natural shape of this opening combined with degenerative changes can result in symptoms associated with SS.

The surgeon can reshape the spinal canal. Using a surgical microscope, surgical instruments are passed into the spinal canal. The microscope gives the surgeon a clear and constant view inside the spinal canal. A special high-speed, diamond-tipped drill is used to shave away bone.

The procedure is called a microdecompression. Bone spurs can also be removed with this technique. If necessary, the LF can be cut and removed.

Once you consult with the neurosurgeon, you’ll have a better idea of what is planned for your situation. Each operation is carefully planned based on the anatomy of each patient. Many improvements have been made in this procedure so that patients of all ages and complexity can be safely and effectively treated for this problem.

Degenerative spinal stenosis usually affects the lumbar spine (low back). Older adults start to experience changes with aging that narrow the opening for the spinal cord and spinal nerves. This narrowing is called stenosis. The result can be a very painful condition that limits function and daily activities.

Treatment for spinal stenosis is usually conservative at first. Doctors like to give their patients three to six months to get relief without the trauma of surgery. Medications, steroid injections, and lifestyle changes are often helpful. Physical therapy is also effective in relieving pain and improving function.

When these measures don’t help, then surgery may be considered. The operation involves removing bone from around the nerve tissue. This is called decompression. Sometimes spinal fusion is required at the same time to stabilize the spine.

There are some very serious potential complications from this operation. Patients who are in poor health or very old often have a poor result after surgery. These factors may prevent them from having the procedure.

Surgeons are working to improve the surgical technique. Methods are being tried to avoid the invasive nature of a decompression procedure. Microdecompression (decompression that is done with a microscope) is helping to reduce the amount of time in surgery, reduce blood loss, and speed up the recovery process.

It might be a good idea to go with your grandmother to her next appointment and talk with her doctor. If you don’t live in her area, then perhaps a phone call (with her permission) would help you understand her particular situation and treatment options. You may want to ask if she is a good candidate for microdecompression or other less invasive procedures for this problem.

The term flatback syndrome was first used back in the early 1970s. Surgeons noticed patients who had surgery for scoliosis (curvature of the spine) ended up with a very flat low back area. Instead of the natural lordosis (swayback position) of the lumbar spine, there was a definite flattening of the area.

Flatback syndrome is a postural disorder that results in the patient trying to maintain the face and eyes forward for maximal function. When the low back flattens, the knees bend and the upper spine hyperextends to accomplish this horizontal gaze.

Flatback syndrome can also occur in older adults without scoliosis. Degenerative changes such as disc narrowing and vertebral collapse can lead to a similar problem referred to as lumbar degenerative kyphosis (LDK).

LDK is the most common cause of spinal deformities affecting the lumbar spine in older Asian adults. Field workers who are in a constantly stooped or squatting position are especially at risk.

Your grandmother may have a condition referred to as lumbar degenerative kyphosis (LDK). A flat low back and compensatory curved upper back results in a stooped posture. In an effort to keep the face and eyes on a level track, the patient may bend the knees while the head and neck hyperextend.

In this condition, the discs between the vertebrae thin out. The bodies of the vertebral bones start to collapse. The presence of osteoporosis (brittle bones) so common in older adults compounds the problem.

Spinal surgery for LDK depends on several factors. The patient’s symptoms and severity of the problem are important. But even more importantly is the patient’s desite to correct the deformity. Old age, poor bone quality, and lifestyle are negatvie factors and must be taken into consideration.

If the patient can’t adapt to changes in lifestyle after the surgery, then the results may not be worth the time, cost, and effort. Squatting must be replaced by sitting in a chair. Sleeping in a bed is advised. Working in the fields may no longer be possible.

Adult spinal deformities are a complex and challenging problem for both patients and surgeons alike. Right now our knowledge and understanding of the best approach with these conditions is fairly limited.

Scientists are trying to develop a classification scheme to help label conditions that are alike. They hope to find a common language to talk about each condition. In this way, studies could be done at different clinics and hospitals using the same ways to group, describe, treat, and compare patient results.

But the problem is that each patient has his or her own unique deformity. There are differences in the location and severity of the spinal changes. And even when two or more patients have a similar condition, their symptoms can vary greatly.

Some may have pain while others do not. The impact of the condition on the patient’s life, function, and level of disability can also vary widely. One type of surgery may be beneficial to some, but not all, patients.

Studies are just beginning to be published showing patterns in treatment and outcomes based on one or two classification methods. The type of deformity and amount of imbalance may help direct the surgical approach and technique used. Each surgeon chooses the surgical strategy that bests suits the patient’s needs and his or her own expertise and experience.

Scoliosis is an abnormal curvature of the spine. Exercises, bracing, and surgery are common ways to treat this in children and teens. Untreated scoliosis in the adult may be approached differently from adolescent scoliosis. The surgeon will take into account your age and symptoms.

If you don’t have any pain or disability, then a conservative program of stretching and exercise may be all that’s needed. But if pain and disability have led to a loss of function, then surgery may be needed.

A thorough exam must be done to determine your orthopedic and medical needs. X-rays to measure the curve and classify your spinal deformity will be done. The radiologist looks at the location of the spinal curvature, the axis and angles of the bones, and the pelvic position.

The lower lumbar curve called lordosis will be reviewed carefully. Studies show that too little or too much lordosis may lead to disability requiring surgery. The type of surgery and approach (front, side, back) depends on the degree of deformity.

In the older adult, degenerative changes of the discs, soft tissues, and vertebrae are also taken into consideration. Patients with the most severe deformity and disability seem to have the best results.

It’s not clear what optimal care is for adults with scoliotic deformity. More studies are needed to compare type of deformity with results after surgery. This will help guide surgeons in choosing the right patient for surgery and selecting the best operative strategy.

MRI is a helpful tool for assessing the shape and structure of soft tissue in the spine. Measuring the diameter of the spinal canal helps identify the presence of spinal stenosis (SS).

Spinal stenosis is a narrowing of the spinal canal. This is the space where the spinal cord is located. Anything that closes down this area can put pressure on the spinal cord and cause serious problems.

However, studies show it’s possible to have spinal stenosis without symptoms. It’s also possible to have symptoms of SS without any observed changes in the spine.

Scientists suspect there’s a problem called central sensitization. It’s possible that neurologic symptoms occur due to changes in the central nervous system (brain and spinal cord). The theory is that central sensitization is actually the underlying cause of most chronic low back pain.

The degree of stenosis or narrowing may not be as significant as the changes that occur in the nervous system as a result of stenosis. Even a small amount of narrowing may send enough signals through the spinal cord to the brain to set up a painful response.

Of course, it is possible that there is some other explanation for your symptoms. Your doctor will be conducting further follow-up tests to find out what else might be going on.

Spinal stenosis refers to the narrowing of the space inside the spinal canal where the spinal cord is located. It is linked with age, rather than genetics.

As we age, certain anatomical changes cause a decrease in the spinal canal. First, the discs may thin out or even degenerate completely. Without this cushion between the bones, the vertebra itself starts to collapse a little.

The pressure of one vertebra against another causes a ridge of bone to form around the outside edge of the vertebra. This is called lipping. At the same time, the broad ligament that runs down along all the back of the vertebrae starts to thicken and press into the spinal canal.

The spinal joints may form bone spurs or an overgrowth of bone or cartilage called hypertrophy. All of these changes have the potential to narrow the space inside the spinal canal. The result is pain and other neurologic symptoms from pressure on the spinal cord or spinal nerves.

There are many possible causes of low back pain. If your pain does not go away within 10 days to two weeks, contact your doctor. If your back pain is accompanied by fever, sweating, or blood in your urine or stool, then see a doctor right away.

You may be referring to a spinal cord stimulator (SCS). This device is also called a dorsal column stimulator.It is an implanted electronic device used to help treat chronic pain.

The device delivers a low level electrical current through wires placed near the spinal cord. The pulse generator is about the size of a 50-cent piece.

The spinal cord stimulator will not cure your pain. Most people report at least a 50 percent decrease in pain. This should allow you to be more active. The need for less pain medication is also considered a successful result. Before having the device implanted, a trial is done with an external device for about a week.

If you do not obtain at least a 50 per cent decrease in painful symptoms, then you may not be eligible for internal implantation. Other factors that may be considered are the ability to operate the system or a psychiatric condition that might affect your ability to use the device.

A past history of blood clots may prevent your participation in the study. The presence of other health problems or conditions may exclude you. This can include conditions such as diabetes, arthritis, or lupus.
Each study will have its own eligibility requirements. You can ask whoever is setting up the study what are their eligibility and exclusion categories.

These are all very good questions that many managers and business owners face daily. You may have to approach each case individually. If the doctor or physical therapist has not identified a serious problem, then the general guideline for back pain patients is to get back to normal as quickly as possible.

Expecting too much of chronic back pain patients (given their pain) is not always helpful. In fact, this type of attitude or behavior has been labelled fear avoidance behavior. Sometimes patients engage in FAB themselves. They may avoid certain activities or movements because they are afraid it might hurt or they might reinjure themselves.

There is an actual test to identify FABs. It’s a survey of questions that cover physical activity and beliefs about work. If you suspect someone may be experiencing fear avoidance, it may be helpful to suggest an assessment. Physical therapists are trained to identify individuals with FAB. They can help patients change their fear-avoidance beliefs, attitudes, and actions.

It is true that low back pain (LBP) tends to come back. Experts refer to this as relapse and recurrence. Only about 25 per cent of adults who seek medical help for LBP recover fully over the next 12 months.

Recently, the role of psychosocial factors in LBP has been brought to light. It turns out that for most people, there’s not a specific spinal pathology causing the LBP. It’s the stress of work, finances, and psychologic issues such as anxiety and depression that really contribute to the start of LBP.

As a result, guidelines for management of LBP of unknown cause have been developed. These include: keep active and continue with daily, routine activities. Avoid bed rest and go back to work right away. Avoid passive treatments that feel good but don’t really address the problem.

Studies are underway now to see if following this plan can change the relapse and recurrence rate of LBP. Experts are also focusing on predicting who might be at risk for LBP and preventing it from happening. It may take a period of 10 to 20 years, but this type of research may eventually change the long-term picture of LBP.