FAQ Category: Lumbar Spine

National guidelines for the management of low back pain (LBP) recommend staying as active as possible. Rest may be advised during the first 24 hours but after that, patients are encouraged to get up and keep moving. These guidelines are based on evidence from many studies of LBP patients.

Fear of movement and recurrence of pain or injury are called fear-avoidance beliefs (FABs). A high level of FAB is a risk factor for acute LBP becoming chronic LBP with resultant disability. The discovery and understanding of FABs is fairly new.

A recent study from France showed that many general practitioners (GPs) hold to FABs themselves. This leads to patient advice to take it easy when activity should really be the order of the day. According to the results of the study, older doctors in rural settings were more likely to have high scores on the FAB questionnaire.

Efforts to educate both patients and physicians are underway in the U.S. as well as other countries. Such steps may help reduce the high cost of care for disability associated with chronic LBP.

Care for patients with low back pain (LBP) has evolved over the years. Many changes have occurred. Most of these changes are the direct result of research and scientific investigation.

Back schools were very popular in the 1970s. Postural training and patient education were the main focus of this treatment. Patients learned about their own anatomy and how the back works. Various ways to lift properly and safely were also part of the back school concept.

By the end of the 1980s, the role of physical deconditioning was recognized. Back care programs changed to include functional restoration programs (FRPs).

FRPs were based on the idea that deconditioning develops as a result of inactivity from LBP. The FRP was designed to improve spinal flexibility and muscle strength. There was also an aerobic component to improve endurance and reduce depression and anxiety. Psychologic and occupational counseling were also included.

In the 1990s, the focus of back care has shifted again. Ergonomics became the new direction of treatment. Ergonomics refers to designing tasks and work areas to maximize efficiency and work quality for workers. The idea of improving ergonomics has also impacted sports and leisure activities.

Today scientists are sorting through all of the components of back care. They are looking for what works for each individual patient. Some may need endurance training while others need strengthening. If testing shows good strength, endurance, and flexibility, then the patient may need more of a psychologic approach.

Throughout all the years, one thing is clear. Exercise reduces pain and improves mood. It’s not clear just yet if one type of exercise is better than another. It appears that patients benefit no matter what type of exercise is followed.

Many programs for low back pain include intensive exercises that the patient may not need. If spinal flexibility, strength, and endurance all test within the normal range, then greater attention is given to the work environment and psychologic status.

It doesn’t mean the patient has a mental disorder. But many studies have shown that psychosocial factors can play a key role in chronic low back pain (LBP). For example, fear of pain and fear of work-related activities that might cause pain change the way a person moves. Fear of pain caused by movement results in a gradual decline in function.

Pain, loss of motion, and loss of function create distress, anxiety, and depression. The patient starts to feel more and more disabled by the pain and its effects. Getting back to work may not be possible until these psychologic factors are addressed.

Physical exercise has been shown to help reduce LBP and improve mood. For this reason, exercise is usually combined with a program that has a psychologic or counseling focus. Both together can help patients overcome attitudes and fears toward physical, work, and even leisure activities.

Talk to your surgeon and get his or her perspective. Find out what the chances are for a good outcome. Ask if you have any risk factors that would increase the likelihood of problems after surgery.

Be aware that there are two kinds of complications after surgery. Minor complications do not affect the patient’s recovery. Once the problem is corrected, the patient goes on to heal as well as if the problem had never occurred.

Major complications do affect the patient’s recovery in a negative way. These type of problems include blood clots, infections, and permanent nerve damage. Some patients may suffer problems breathing and even death as a potential major complication.

Age has been directly linked with increased diseases and other health problems. These are called comorbidities. Heart disease, hypertension, and diabetes are common comorbidities among older adults.

A recent study was done on risk factors and complications after spinal fusion for scoliosis. The results showed that age and comorbidities do not increase the risk for complications. Age by itself is not considered a reason to decline surgery for this problem.

The gold standard for surgical treatment of spondylolisthesis (slipped vertebra) is an operation called posterolateral fusion (PLF). Bone graft material is either donated or taken from the patient’s pelvic bone to form the fusion.

Decompression (disc removal) is done as part of a different procedure called posterior lumbar interbody fusion (PLIF). Once the disc is removed, then a wedge can be placed between the vertebrae. Bone chips are placed on either side of the wedge.

Some surgeons think the PLIF is better than the PLF for patients who have spondylolisthesis with sciatica. In theory, removing the disc should take pressure off the sciatic nerve and reduce or eliminate painful symptoms.

However, according to one study comparing PLF to PLIF, patients in the PLIF had more sciatica than patients in the PLF group. The researchers weren’t sure how to explain this result. They suggested it may be related to other factors such as how severe the spondylolisthesis was or how much spine degeneration had occurred.

Blood loss is a potential problem for anyone having surgery of any kind. Problems after spinal fusion surgery have been linked with excessive blood loss. Loss of blood is more likely to be a problem as the number of spinal levels fused increases.

The average number of lumbar segments fused for degenerative scoliosis is four. More than five segments fused is a risk factor for bleeding. Blood loss does not seem to be related to the patient’s age or other health problems.

Surgeons are finding more and more ways to prevent or minimize blood loss during surgery. This is called the bloddless technique. Careful surgical technique is an important part of this prevention. For example, avoiding cutting blood vessels can reduce blood loss.

Some surgeries can be done with a minimally invasive method. Blood loss is reduced with minimally invasive surgery. This is done by making a smaller incision and cutting through less soft tissue.

More advanced technology has also helped. This includes the gamma knife and harmonic scalpel. The surgeon can make more precise, smaller cuts causing less tissue damage.

There are also ways to save fluid and blood lost by the patient and return it to the same person. Since this is a closed circuit, it is usually acceptable to all religous groups. Ask your surgeon about the surgical technique used in your area. Find out if bloodless medicine is available for you.

You would have to ask your physician to explain what that means for you specifically. Some experts describe functional disability as difficulty with daily activities. For some patients this could include dressing, walking, or climbing stairs.

Others may describe a functional disability as the inability to sit or stand for long periods of time. This type of limitation can make some jobs difficult or impossible. Difficulty lifting, carrying heavy objects, or participating in an exercise or sports program can also be labelled a functional disability.

There are some standard tests that can be used to measure and quantify disability. Two of the more commonly used tools are the Disability Rating Index (DRI) and Oswestry Disability Index (ODI). Pain levels and measure of difficulty with a variety of tasks are measured.

These tools also take into consideration activities such as sleeping, sex, social life, and traveling. You may remember filling out some forms with questions about these activities. Ask your doctor to go over his or her test results with you to explain your type and degree of disability.

Several studies of twins have been done over the years. Some researchers have tried to compare the studies to find answers to questions like yours. But back pain isn’t always measured in the same way from study to study. So comparisons can be difficult.

Some studies include identical twins, while others have fraternal (not identical) twins. It’s possible there are differences in these two groups that haven’t been accounted for.

One study of male twins from Finland identified both genetic and environmental factors contributing to low back pain (LBP) in twins. They found that twins tend to seek similar occupational and job opportunities. And the data analysis showed a significant effect of genetics on disc narrowing and disc degeneration leading to back pain.

It is still suspected that other factors influence back pain as well. More studies are needed to identify all of the risk factors. There’s not much you can do about your genetic make-up. But other risk factors may be modifiable. Focusing on risk factors that can be changed may help reduce the incidence of LBP.

It’s clear from X-ray and MRI studies that degenerative disc disease (DDD) doesn’t always cause pain. And the amount of pain isn’t based on the severity of changes seen in the imaging studies.

Knowing this, researchers are looking for explanations for low back pain caused by DDD. Right now, all we have are theories to go on. Some of these theories include nerve entrapment from disc herniations and inflammatory responses of the tissue around the disc herniation.

Other experts propose that nerve ingrowth occurs after rupture of the outer surface of the disc. The same thing can happen when the endplate between the disc and the bone ruptures.

Any of these effects can also lead to changes in the biomechanics of the spine. Biomechanics refers to the position of the spinal parts. How each component of the vertebral segment moves and functions is also a part of biomechanics.

In the last 10 years, more studies have pointed to a possible genetic influence in low back pain. Genetics may be linked to the development of disc narrowing and disc degeneration. Genetics may even have an effect on types of jobs people choose and how they spend their leisure time. Back pain may be linked to these factors as well.

There isn’t a simple answer to your question just yet. More studies are needed to identify risk factors and predictive factors for disc degeneration and low back pain.

You ask a very good question. Many times, studies are set up with inclusion and exclusion criteria. This means that the subjects included must have certain characteristics to be included. And if they have others, they are excluded. Cognitive impairment and mental function is often on the list of exclusion criteria.

Many studies of older adults include tests to measure mental function and mood. The researchers may use the results to exclude subjects who aren’t appropriate for the study. In other cases, the results of such tests are an important part of the study.

For example, a recent study on the impact of low back pain on older adults was done. They found that depression had a major impact on disability. Decreased function from chronic pain leads to a decline in quality of life. Depression may naturally follow.

You can certainly discuss your concerns with the people running the study. But you may find that your father will still remain part of the study. They may be looking for people just like your father as part of the study. If not, statistical analysis will take care to explain skewed results from subjects who are outside the norm.

Others have noticed this difference in response to pain between older and younger adults. Yet studies show that chronic pain is a common symptom in adults over the age of 65. And pain interferes with daily life more as we get older.

Not much study has been done to explain the impact of pain on behavior and function in older adults. Much more focus has been placed on working-aged adults. This is most likely because of the costs linked with work-related disability.

A recent study from the University of Pittsburgh focused on adults aged 65 to 84. Half the group had chronic (daily) pain lasting at least three months. The other half didn’t have any pain. Everyone was tested using 22 different measures of physical and mental health.

It turns out our elders are affected by pain more than it would seem. But they often have so many other problems that it’s not clear what impacts their pain the most. Sleep disturbances, mood disorders such as depression, and the effects of medications top the list of other factors impacting their health.

And older adults have had more time to get used to the increased aches and pains that develop over the years. They may be able to cope better with pain because they expect it as part of the aging process.

Both of these factors together may account for why older adults move and function more normally than younger adults with similar symptoms.

Both of these spine conditions lead to irritation or compression of the spinal nerves. Spondylolisthesis is the forward movement of one vertebra over another. Spinal stenosis is a narrowing of the openings for the spinal cord or spinal nerves.

Aging and the associated degenerative changes in the spine that come with aging are common causes of both problems. Treatment usually begins with conservative care. This means a nonsurgical approach.

Your father’s doctor may prescribe physical therapy, acupuncture, or pain relievers at first. Sometimes patients try all three. The symptoms of back and leg pain can be very disabling. Physical function declines and so does quality of life.

Surgery is an option for some patients when conservative care doesn’t relieve the symptoms. But in an older adult, the complications of surgery can outweigh the benefits. In such cases, a series of epidural steroid injections (ESIs) can be helpful.

Once again, the surgeon may suggest a patient combine ESIs with other modalities such as analgesics or exercise. It may take a period of weeks to months to find the right combination or steps in treatment that really help. There doesn’t seem to be a one answer fits all patients with these conditions.

There are actually several different types of operations that can be done for this problem. But most surgeons advise a three to six month trial of nonoperative care first before surgery is done.

Anti-inflammatories and analgesics (pain relievers) are used first. Physical therapy to help with pain, improve motion, and function may be helpful. Some patients are good candidates for epidural steroid injections.

Many patients try other alternative forms of treatment such as chiropractic, osteopathy, acupuncture, massage, and so on. Sometimes the pain can be decreased enough to improve walking and daily activities of living.

When nothing else helps, surgery may be considered. There are several different procedures that can be used. Decompression and spinal fusion are the two most common operations. The surgeon may or may not use posterior instrumentation.

Instrumentation refers to the use of metal plates, screws, rods, or wires to hold the bones in position. Posterior just means the surgeon performs the operation from the back rather than from the front of the body.

Studies have not been able to pinpoint the best treatment for this condition. Surgery seems to help patients the most who have severe, disabling pain. But which operation should be used is still based on the surgeon’s preference rather than solid evidence of which operation is best for each patient.

Complications are common and older patients may not tolerate those well.

Actually, there is a connection. About 30 years ago, the hip-spine syndrome was reported by two orthopedic surgeons. No further studies have been done on the topic until recently.

A group of surgeons in Tel-Aviv, Israel studied 25 patients having hip replacements. They observed that low back pain (LBP) in this group was almost as bad as their hip pain. After the surgery, hip pain and function improved. But so did the LBP.

The group reported the most improvement in LBP by three months after the hip replacement. They didn’t gain any further change in their back symptoms. But at the end of two years, the changes were still maintained.

Patients reported being able to stand, balance, and walk better as a result of the hip replacement. The authors concluded that total hip replacement does have a positive effect on spinal posture and symptoms.

There is a unique blending here between industrial business and health care. Injury or chronic pain can lead to reduced physical capacity and long-term disability.

For a long time, our country has supported work disability benefit programs. Generous early retirement packages almost put an end to workers returning to the job.

But the discovery of a new approach using a functional restoration program has brought many changes in the past 20 years. Researchers published the results of a landmark study in 1985 that changed how chronic pain is viewed in the work place. This new approach focused on rehab activities that simulated the work environment.

Workers were given specific exercises and tasks to do that would prepare them for an eventual return to their former jobs. This type of exercise was called work hardening.

Employers were aware of the high cost of retraining staff and became more willing to take back previously injured workers. They discovered that even working part-time with a reduced load, having their former employees back improved productivity and saved money.

It sounds like you are right in step with today’s knowledge of injury and disability. Injury prevention is the first step and the key to the success of any industrial business. But once injury occurs, patient education is equally important. Return to work is not only possible for most workers, it is the goal.

Lumbrosacral refers to the lower part of the spine where the lumbar vertebrae meet the sacrum. Radicular in this context is a term to describe nerve pain that travels from the low back down the leg.

Syndrome lets you know that there are two or more symptoms commonly associated with this condition. A simpler, more familiar term for lumbrosacral radicular syndrome (LRS) is sciatica.

Tension or pressure on the nerve root is the most common cause of sciatica or LRS. Disc problems, tumors, and stenosis (narrowing of the spinal canal) are the most likely sources of nerve impingement causing sciatica.

Sciatica is a condition involving the nerve, so some people see a neurologist for a second opinion. Others seeking surgery may choose an orthopedic surgeon.

The standard practice for treatment of sciatica involves a minimum of six months of conservative care before considering surgery. Nonsurgical care can range from pain meds to acupuncture to chiropractic care. Physical therapy is also a common way to treat sciatica.

Treatment can be specific once the cause of the problem is identified. Sometimes postural changes contribute to this painful condition. A prolapsed or herniated disc can also lead to sciatica. In both cases, exercises prescribed by the therapist can be helpful.

Inflammation and irritation of the nerve for an unidentified reason may respond best to acupuncture. If spinal alignment is a possible cause, then chiropractic care may be advised.

Work with your doctor to find out what is causing the problem. Ask about the best alternate approach since the problem has not resolved after so much time. It may take awhile to find the right combination of treatment to obtain the relief you seek from your symptoms.

The FDA has approved two lumbar disc replacements. There is the CHARITÉ artificial disc and the PRO-DISC-L total disc replacement (TDR). Both have been tested on humans in clinical trials. The results are not perfect yet but various studies report good results. Pain is relieved and motion is restored.

Your choice of disc implant may be determined by your surgeon. Not all surgeons use both implants. By implanting the same type of disc each time, the surgeon increases his or her knowledge and expertise with that implant design.

Studies show that implant placement is important. If the TDR is placed too far forward or back from the central axis, the load on the joints is increased. And since the facet joints can be painful, the goal is to reduce the force and load placed on the joints.

Once you see a surgeon, you can ask which type of TDR he or she recommends. If you decide you prefer one design over another, then you may want to look for a surgeon who uses that type.

More and more younger adults are asking this very question. The manufacturers of the artificial disc replacements (ADRs) are working to find a design that will do many things. First, it must give relief from the painful symptoms. And it must restore normal motion. Then it should perform well under years of high demands.

We don’t have long-term studies to guide us yet in choosing the right implant for each person. Right now, there are two types of ADRs on the market. The CHARITÉ disc replacement has a mobile-core design. This means it has a moving center of rotation and mimics normal motion more closely than the fixed-core type. PRODISC-L is a fixed-core implant. The center is a ball and socket design. The vertebral body moves around a fixed center.

A recent study comparing these two implant designs has offered some new insights. It appears that the mobile-core design significantly reduces the load and force transferred through the facet (spinal) joints. And this type of implant design can be placed anywhere in the disc space and still function well.

The fixed-core type of implant is much less forgiving. Even when placed in the center where it belongs, it still results in an increased compressive stress on the joints. From this study, it looks like the mobile-core design has less risk of wear and may last longer than the fixed-core type.

You may want to ask your surgeon which type he or she prefers and/or advises for you. The surgeon’s preferences and skill also factors in the final results. Your activity level will likely make a difference in how long any artificial implant lasts. You may be advised to modify some of your activities with an ADR.

Disc degeneration and/or herniation is a common cause of symptoms painful enough to send a person to the doctor. Removing the disc is often the only way to stop the pain. When any tissue is removed from the body, it is automatically sent to the pathologist.

He or she prepares the tissue and then uses special techniques to examine it under a microscope. They look at the various components of the tissue and describe both normal and abnormal findings. They also grade or stage the tissue. This gives an idea of how far along the tissue was in the degenerative process.

Disc material can be graded using a scale called the Thompson grading system. Based on the amount of degeneration, the disc can receive a grade from I (mild changes) to IV (severe changes). A grade II suggests mild fibrous tissue has infiltrated the center of the disc. The outer covering also shows a mucous-like substance between the cells.

Studies show that crystal deposits also form in the discs. They appear to be age-related, meaning they form more often as we get older. These crystals disrupt the normal cell functions and flow of fluid within the disc. It’s likely that they also cause the degenerative process to go faster.