FAQ Category: Lumbar Spine

The possibility of human error always exists in any operation. But surgeons who have advanced to the level of training required to perform artificial disc replacements (ADRs) rarely have these kinds of problems.

Complications such as bleeding, blood clots, or infection can occur in anyone having any type of surgery. Most of the time, the problems that develop after ADRs include slipping or sinking of the device.

Occasionally movement of the implant can be traced to improper locking at the time of the operation. Most of the time there’s no way to predict or prevent migration.

Rarely a technical error such as putting the implant device in place backwards can occur. In such cases a second operation is needed to remove and replace the ADR. Implants come in different sizes (up to 12 for some devices). In a small number of patients, even the smallest implant can still be too large. In such cases, the implant may have to be removed and the spine fused instead.

You’ll want to have confidence in your surgeon before having this operation. Don’t hesitate to share your concerns. Ask him or her what to expect and even what kinds of complications other patients have had with this procedure.

Studies show a high rate of patient satisfaction with this treatment. The majority of patients report less pain, improved function, and decreased disability. And keeping spinal range of motion is the best advantage over having a spinal fusion.

These are both very good questions, and ones you will want to bring up with the surgeon at the next pre-op visit. Artificial disc replacements do come in different sizes, shapes, and styles. They can be made of metal, ceramic, or plastic. Cobalt chromium alloy is a safe material that has been used for many years in replacement joints for the hip and knee.

A plastic (polyethylene) core fits in between the two metal endplates. The core acts as a spacer. It is shaped so that the endplates pivot in a way that imitates normal motion of the two vertebrae. There are small prongs or teeth on one side of each endplate. The teeth help anchor the endplate to the surface of the vertebral body.

Another way of anchoring the artificial disc replacement is the central keel or fin design you described. The implant is secured to the vertebral end plates by a thin, upright piece of metal that looks like the rudder on a boat or a shark’s fin.

The surgeon uses a special method of X-ray imaging called fluoroscopy to guide the implant into place. Before the device is installed, the old, damaged disc is removed. Any bone spurs in the area are removed and the bone is smoothed out.

A special slot is chiseled out for the keel. The surgeon slides the implant into place making sure the keel goes in the slot properly. Once in place, the implant can’t rotate or slip sideways out of the slot.

During this part of the operation, the surgeon also tries different sizes of implants to find the right one for each patient. Some companies have as many as 12 different sizes to choose from. It’s important to avoid an implant that is too large or too small. In rare cases, even the smallest implant may be too large for the patient. If the results are not satisfactory, the implant can be removed and the spine fused.

Degenerative conditions of the spine affecting the discs and bones is fairly common in adults over the age of 65. Narrowing of the neural arch where the spinal cord is located or the foraminal spaces where the spinal nerves exit can cause significant back and leg pain.

Age-related disc problems are usually called degnerative disc disease. The condition that causes narrowing of the spaces is called spinal stenosis. Many adults over the age of 85 have both conditions.

Recent research has shown that young adults can have one or both of these problems, too. They get the same symptoms of back and/or leg pain. Advances in imaging with MRIs now make it possible to identify these conditions in much younger patients.

Several studies have been done now to show that young adults with chronic low back and/or leg pain can have spinal stenosis. And the pictures from the MRIs provide convincing evidence that the stenosis is congenital (present at birth).

How this develops and what hereditary patterns are present remain unknown. It could be an abnormal gene that control collagen fibers that make up the soft tissues around the spine. Or it could be a shortening of the columns of bone called pedicles that help give the vertebral bones heighth. More study is needed to find out the factors, causes, and mechanics of this condition.

Most experts suggest a course of conservative care for back pain before surgery. This is true even if there has been known injury or disc protrusion. Antiinflammatories, exercise, and physical therapy should be given a fair trial before turning to surgery.

If it’s been at least six months with nonoperative care and you’re still no better, then surgery may be an option. But any back surgery has its risks. With open back surgery, a large incision is made through the skin and soft tissues. Special tools called retractors are used to pull the muscles and soft tissue aside. This gives the surgeon a clear view and access to the spine.

Studies now show that using the retractors for too long can contribute to the increased back pain some patients reported after spinal fusion. A new method of releasing the retractors for five minutes every hour is being tried with animals. So far the resuls have been good.

With periodic retraction release, there is less pressure on the muscle. The result is less muscle injury and fewer problems with back pain afterwards. Talk to your surgeon about your concerns. Bring up your pain experience from the last surgery. Ask about possible alternatives to help keep this from happening again.

This is a common problem faced by many of today’s seniors. Besides pain, level of disability and fear-avoidance behavior are important factors. Studies show that the person’s perceived disability is a more powerful factor than even the amount of pain they are having.

Level of perceived disability is linked with fear-avoidance behavior (FAB). FAB refers to the fact that the person is afraid it’s going to hurt, so first they slow down. Eventually they may even stop moving in one or more direction. They change the way they move to avoid pain but also because they are afraid it will hurt.

As you have suggested, cecreased activity is the first step toward increased stiffness, loss of flexibility, and more pain for those who already have pain. Increasing physical activity and exercise is highly recommended, both for this age group and also for this problem.

Take stock of your community resources. For example, is there a walking group at the mall your father could join? Many older adults find this a good way to increase activity safely. They can walk as far as it’s comfortable and sit down to rest as often as needed.

What about a membership in a health club? Many older adults get a lot of help by being with other active adults. They can take advantage of the pool or hot tub. There may be yoga or fitness classes geared toward seniors. If finances are a problem, maybe the family can pitch in together and purchase a membership as a gift.

At the same time, find out if there is any medical treatment that can help. Sometimes analgesics for pain or antiinflammatories can help this condition. If he has not been seen by a physician lately, make an appointment to review the possible options for pain control.

It sounds like he may be referring to the X Stop device. This small implant is made of titanium. It fits between the spinous processes of two vertebral bones. The spinous process is the bony knob you feel along the back of your spine.

The X Stop holds the vertebra in a slightly flexed position. It keeps the spine from extending at that level. Flexion opens up the spinal canal, the area where the spinal cord or spinal nerves are located. Extension closes down this space.

With spinal stenosis, there is a narrowing of the spinal canal from a variety of age-related changes in the spine. Anything that narrows the spinal canal puts pressure on the nerve tissue.

Since a flexed position of the spine causes painful symptoms to increase, patients end up stooped over in an attempt to relieve the pain. They are unable to comfortably stand up straight. The X Stop puts the affected spinal level in the flexed position and holds it there. The patient can stand up freely without fear of symptoms coming on or getting worse. And it helps them avoid the stooped that is so characteristic of someone with spinal stenosis.

The X Stop in a tiny device that is implanted between the spinous processes of two vertebrae. The spinous process is the knobby projection that comes off the back of the spine. This is where many muscles and ligaments attach.

By putting this device in place, the spinal segment is held in a position that decompresses or takes pressure off the spinal nerves. It is a minimally invasive procedure. There is very little blood loss. The muscles are not cut open so the recovery time is fairly rapid.

In some centers, patients are admitted the night before and go home the next day (day of the operation). In other surgical centers, the patient is in and out the same day (within 23 hours).

If they feel up to it, patients are allowed to walk right away. Many people start getting up and moving about the next day. It’s usually safe to go home if someone is there to assist the patient. They really shouldn’t go home alone the first day.

Unless there are some unusual complications, you can expect to see your wife getting up and moving about freely the day after the operation. Patients are free to resume normal activities, as they are able. Motion is not limited but lifting is restricted.

Osteoporosis causes 1.5 million fractures every year. These are called fragility fractures. They are caused by weakened bone with a loss of bone density or mass. The most common fragility fracture is a vertebral compression fracture (VCF).

The fracture can occur with just regular movement or after only a minor injury. The pain is made worse by standing up straight or extending the spine. The patient becomes more stooped over. This position puts even more pressure on the spinal bones and decreases lung capacity.

Conservative care such as your aunt is receiving is the first step for many patients. Bracing, activity changes, and pain medications help a large number of people with this condition. For those who can only tolerate bed rest, there is a concern about the effects of immobility. The risk of pneumonia, bed sores, and blood clots goes up for the bed bound patient.

Surgery isn’t always possible because of how fragile and weak the bones are. The forces and stresses put on them during a fusion operation may be too much to even attempt.

A newer method called vertebroplasty may help a small number of carefully selected patients. In this procedure, cement is injected into the collapsed vertebra to help fill in the cracks and strengthen it.

Recovery from VCFs depends on the general health and motivation of the patient. It is a painful condition, and that factor alone can keep even the most motivated person from making progress.

However, once the pain is under control, your aunt should be under the guidance of a physical therapist who can help her get her strength and function back. Depending on her health and personal factors, she may be able to progress through the program and return home within days to weeks.

You may be referring to a large randomized study called the SPORT study. SPORT stands for Spine Patient Outcomes Research Trial. The study was supposed to report on the results of patients treated for lumbar disc herniation. Results from surgery were compared with results from nonoperative care.

The reported results may have been a bit misleading. And the study design may have been a bit off as well, according to Dr. Paul McCormick, a neurosurgeon from Columbia University. Dr. McCormick published a thorough review of the study.

He pointed out that it’s not really possible to get a Yes or No answer to the question of whether having surgery is better than not having surgery for this condition. Not all disc herniations are the same. Not all patients are the same.

And even if the answer turned out to be that surgery was better for herniated discs, it still doesn’t mean everyone with a disc problem should have surgery. If it turned out that conservative care was better, would anyone be allowed to have surgery? Of course…so the findings as presented were a bit misleading.

The biggest misunderstanding occurred because some patients assigned to the surgical group decided not to have the operation after all. And some patients in the nonoperative group decided to crossover to the surgical group. But the results in the end were still reported as if they were part of the group they started in, not the group they ended up in.

The crossover rate was high in this study. This factor reduced the study’s ability to detect a difference between the two types of treatment. Patients with severe symptoms who have surgery often get pain relief quickly. The results measured by pain levels, function, and disability may not be much different from those who didn’t have surgery.

But from the SPORT study, we know that patients with mild symptoms gravitate toward conservative care. They don’t really need surgery. It takes a little longer to recover but the final results are often the same compared to patients with severe pain from lumbar disc herniation treated surgically.

The current standard for treating lumbar disc herniation is conservative care first for at least six weeks. Some doctors prefer a longer trial before sending patients for surgery.

Conservative care consists of staying active but avoiding those motions and activities that cause pain. A program of physical therapy will help you maintain your motion and strength during the healing process. You will be taught how to avoid developing bad posture or unhealthy movement patterns often caused by painful symptoms.

You will be shown how to use proper breathing and movement patterns to restore all movements in a painfree manner. The therapist will also help you explore factors that may be adding to your back problems. Changes can be made in your workstation, sleeping habits,and psychosocial stressors that may be making your pain worse.

If, after a reasonable amount of time and effort, you are no better (or even worse), then surgery becomes a possible option. Even before surgery, the doctor may want to do an epidural injection. This is an injection of a steroid (antiinflammatory) and lidocaine (numbing agent) around the spinal nerve root for pain control.

Surgery does have the possible benefit of quick pain relief. But not all patients have speedy results with surgery. And surgery comes with its own set of complications and possible problems. Studies do show that patients with the worst pain and disability seem to do better with surgery. But people with moderate to severe lumbar disc herniation do get good results with nonoperative care. It’s always worth a try first before taking a more invasive approach.

Recurrence of back pain after a discectomy (disc removal) is not uncommon. And it can even happen after a long period of pain-free living. There are several possible reasons for this.

The first possible cause is that a disc at a different level can start to protrude causing pain. Or sometimes scar tissue from the previous surgery builds up in the space around the spinal cord or spinal nerve bringing on painful symptoms. Scar tissue has also been shown to develop as a result of an ongoing inflammatory process. This may have happened before the disc was removed.

Another possible cause of painful recurrence is if all of the disc material wasn’t removed. Sometimes the surgeon is unable to see the complete disc space. Or sometimes the detached pieces of disc material move to the front of the disc space and are hidden or unreachable without causing damage to the nerve tissue.

This would be a good time for a follow-up visit with the surgeon. Early treatment may give your husband the best results and possibly avoid a second surgery.

Degenerative disc disease is the main reason total disc replacements (TDRs) were developed. Before that, spinal fusion was a patient’s only choice. With the TDR, the patient can experience rapid pain relief and faster recovery compared to spinal fusion.

Not only that, but motion is preserved. Patients are happier with the outcomes and complication rates are lower with TDR compared with spinal fusion.

Deciding who is a good candidate for TDR and the best time to do it are still under considerable study. Long-term results are just becoming available. It looks like there may be some problems with disc and joint degeneration at the level above the implant.

Until these kinds of problems are ironed out, TDR will probably remain at a single level for now. Deciding which level to replace is also under debate. Many surgeons use provocative discography to find the most painful level. This test is somewhat painful itself so it is not used routinely. However, it is fairly accurate in identifying the most problematic area.

Other imaging studies such as CT scans and MRIs may be used along with the patient’s report of symptoms to identify the best disc to replace.

Subsidence is the term used to describe this problem. It can occur whenever an implant of any kind is used in the body. The reason why subsidence occurs isn’t entirely clear yet.

It may be understandable in patients who have changes in the bone such as osteopenia or osteoporosis. But it can happen to patients without these problems as well. And with a total disc replacements, the implant design may be at fault. Subsidence seems to occur more often with implants that have a central keel to hold them in place. Studies are ongoing to find out what can be done to prevent this and other problems.

Treatment varies depending on many factors. Careful observation may be all that’s needed when the patient doesn’t have any symptoms. But there are several options for the patient with severe back pain. First, the implant can be removed and replaced with another implant. Or it can just be taken out and spinal fusion done instead.

Vertebroplasty has been used by some surgeons to prevent further sinking of the device. A long, thin needle is inserted into the disc area. Glue is injected through the needle to help support the area. The glue dries and acts like cement.

The problem of TDR subsidence is fairly new and doesn’t happen very often. A clear solution hasn’t been determined yet. Each surgeon may approach the problem based on the individual patient and his or her circumstances.

Sciatic pain can be caused by several things, so it isn’t uncommon. It can be caused by a slipped disk in the back (also called a herniated, bulging, or ruptured disks), trauma to the back, buttocks, or pelvis, or pressure directly to the nerve. Sometimes, the doctors don’t know what caused it.

The symptoms of sciatica can be different from person to person. They include: tingling or pins and needles down one or both legs, changes in sensation to the legs, pain in the buttock area radiating up or down, difficulty walking, and in severe cases, difficulty moving the affected leg or foot.

Your second question can only be answered by you and your doctor. Ask your doctor what he or she thinks about you returning to work. Make sure that your doctor knows and understands what it is that you do throughout your day.

Unfortunately, there isn’t any one thing that you can do to be sure that your back pain doesn’t return or get worse when you are at work. There are some things that you can do to reduce the chances of that happening though. For some suggestions, you may have to get your employer on board. Hopefully, once your bosses understand the reasons behind the suggestions, they will see why it’s important for not only you, but all employees to have a safe work
environment.

First, if you sit most of the time at your job, you need to make sure that
your work station is set up correctly to promote good posture and body mechanics. Is your seat high enough or is it too high? Your feet should be able to sit flat on the ground in a comfortable position. If your seat is too high and you can’t lower it, you need a foot rest that can put your feet in the right position.

Is your chair good for your back? Is there lumbar (lower back) support? Is it
comfortable to sit on? Are you sitting at your desk in such a way that you
don’t have to stretch or twist your back to reach things?

If you have to do any lifting, are you lifting correctly? Do you need a support belt for your back? Are you using proper body mechanics? Proper body
mechanics involve never bending and lifting with your back. Always squat and
bend at the knees, using your leg muscles to lift.

If you’re at a job where you have to stand all day, is there a step or
footrest where you can place one leg, taking the load off your back? Are you
wearing good shoes to support your body?

These are a few of the many situations that should be addressed if you want to
make your work place as back friendly as possible.

It can be confusing when you hear different terms being used for the same
thing. Bulging, slipped and herniated disks are all the same thing. Other names used are: compressed, prolapsed, and ruptured disks.

Your backbone is made up of small bones called vertebrae. There is a gel-like substance between the disks that cushion them and keep them in place. Sometimes, a back injury results in a disk moving and pressing on a nerve. That’s what causes the pain.

When acute back pain doesn’t respond to modified activity, exercise, or mild analgesic drugs for pain, then a second look may be needed. You should make an appointment with your medical doctor again. You may need some additional testing to check for something more serious.

Constant pain that gets worse at night or worse in general is a red flag. Numbness in the groin area, blood in the urine, and muscular weakness that is getting worse are also warning signs. Fever, sweats, nausea, and unexpected weight loss should be reported to the physician.

If, after further testing, you get a clean bill of health, then you may need some additional treatment. Acupuncture and chiropractic care have been proven helpful for some patients. Physical therapy to help you change movement patterns and improve muscular coordination and fitness may be needed.

Your doctor is the best one to advise you on the next step. Understanding your condition, what to expect, and what you can do are all important in avoiding chronic back pain.

Scientists have not been able to pinpoint exactly what factors can turn a case of acute low back pain into a chronic condition. Studies show conflicting results. We do now for sure that movement and activity are the best way to manage acute low back pain. Advice to keep moving and stay active is the best thing any kind of doctor can give patients with acute low back pain.

Over the last 20 years, the idea that bed rest can help has been put to rest. There is no evidence that bed rest will result in fewer cases of chronic back pain. Other treatments such as injections, drug therapy, or biofeedback remain hotly debated.

Chiropractic adjustments have been shown effective in some, but not all, studies. It appears that chiropractors do a good job helping patients understand their back pain and how to get rid of it. Explaining the mechanics of back pain and giving patients an idea what to expect go a long way in helping patients recover.

Although the cause of your symptoms is different (diabetes versus stenosis), the symptoms are both coming from the peripheral nervous system. With diabetes, it’s known that high levels of sugar in the body can cause damage to the small blood vessels and nerves. The result is a condition called diabetic neuropathy.

Experts aren’t sure why stenosis causes nerve problems. Narrowing of the spinal canal from the stenosis can put pressure on the nerves. But it’s likely that a decrease in blood flow to the nerves is also part of the problem.

Studies have been done of the damaged nerves in patients with stenosis. When put under a microscope, swelling and scarring called fibrosis is seen. They have also seen a breakdown of the lining around the nerves. The tissue along the outside of nerves is called the nerve sheath. Breakdown of the nerve sheath is called demyelination.

Taking Neurontin has been shown to help some patients with stenosis. When compared with patients who were not taking Neurontin, the patients with stenosis who took the drug could walk farther with less pain. They also had less numbness and tingling in the feet. The exact mechanism for these effects is unknown.

It’s always wise to talk with your doctor before trying a new medication. Some people are tempted to try a few pills from their friends or family. This is never a good idea. There could be serious, unexpected side effects that could have been avoided with medical supervision.

Disability prevention programs often include improving workers’ work stations. Decreasing the physical workload by providing lifting devices is often part of the plan. But research has not been able to prove that these factors really make a difference in back pain or injuries.

It looks like there may be many factors that must be addressed. The problem is, it also looks like each person is unique and has his or her own needs. Changing the work place for one employee may not be as helpful as some other change.

Scientists are working to gather together enough information to be able to predict who needs what for a successful outcome. These are called predictive factors. It’s not guaranteed that a patient with one set of predictive factors will have 100% success. But the chances of a good result go up or down based on positive or negative predictive factors.

Although it makes common sense that an appropriate work station will reduce work-related injuries, there just isn’t enough scientific proof to support the idea. You may have your best results by putting together a list of logical and reasonable reasons for your request.

Increased job satisfaction has been linked with improved work performance. If changing your work station and decreasing your lifting load will improve your outlook at work, then your request may be seen as reasonable.