FAQ Category: Lumbar Spine

People often refer to a disc herniation as a slipped disc. The disc doesn’t actually slip out of place. Rather, the term herniation means that the material at the center of the disc has squeezed out of its normal space.

Between the vertebral bones of the spine is an intervertebral disc. The discs provide a cushion or shock absorber for the spine. Each disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus. The annulus is a series of strong ligament rings around the nucleus.

Herniation occurs when the nucleus in the center of the disc pushes or protrudes out of its normal space. The nucleus presses against the annulus, causing the disc to bulge or prolapse outward. The bulged disc material is still contained within the annulus.

But in some cases, the nucleus pushes completely through the annulus and squeezes out of the disc. This is called a disc herniation or protrusion. Herniation and protrusion are two words for the same thing.

If a piece of the disc breaks off, it’s called a sequestered fragment. Surgery is almost always needed for sequestration. The loose piece can enter the spinal canal and put pressure on the spinal cord or spinal nerve roots causing serious problems.

A lumbar fusion is done to keep a segment of your spine from moving too much and causing pain. To do this, your surgeon adds a bone graft to stabilize the segment where the injured discs are causing the problem. The bone graft grows, effectively blocking movement or motion. The surgery can be done in one segment or more, but the standard is one segment only as research shows that this is likely the most effective.

Recovery from spinal fusion surgery can be slow. Some patients use a back brace for a few weeks or months while others don’t. This is generally due to doctor preference. Because recovery is slow, it may not seem right away that your surgery has been effective, so it’s important to be patient. Your back pain may not ever disappear completely, but a successful surgery can be a significant reduction in pain and a renewed ability to move about freely.

Only your doctor can tell you what you can and cannot do following surgery so always follow his or her guidelines. If you have been given the go-ahead to exercise, ask specifically what you should be doing. The better shape that your whole body is in, the better it is for your back, but you must be careful and only do what you have been told you may do.

That being said, usually a good exercise for your whole body is something like swimming, walking or bike riding. These exercises work out muscles throughout your body without added strain to your back. Unless given the ok from your doctor, avoid exercises that do strain the back. These include high-impact exercises like running, jumping, climbing or lifting weights.

Finally, don’t underestimate the importance of stretching. Good stretching allows for the muscles to work effectively.

The question of using epidural steroid injections (ESIs) for patients with sciatica is still a hotly debated topic. Studies report results on both sides: the injection helps or the injection doesn’t help. Patients are saved from surgery. Or patients still have the surgery anyway.

The reason there are such differences in opinions may have to do with the quality of the studies. Experts who take a step back and review all the research report that the design of many studies is poor. The results can’t really be trusted without better research methods.

Looking at the big picture, patients who need surgery are going to need it with or without the injection. But it isn’t always easy to tell who’s going to need an operation. So sometimes patients opt to try the injections first. They do provide fast relief from the pain. And the pain relief can last up to three months.

The injections don’t necessarily change your ability to function. That’s when surgery is needed. Removing the disc that’s pressing on the nerve may be the only way to calm down the painful symptoms and restore full function.

It looks like mild disc protrusion responds well to ESI without the need for surgery. With a disc protrusion, the disc is bulging but still intact. The inner core or nucleus of the disc has not pushed through the outer covering around the disc.

With a herniated disc, the outer covering has a crack or hole in it and the disc material is oozing out. If you have a herniated disc, then surgery is recommended sooner than later.

Although this is rare, it can happen. If you had an epidural steroid injection, the needle goes through the skin so that the tip of the needle is in the epidural space. This space is the area between the bony ring of the spine and the covering of the spine called the dura. The dura is the sac that encloses the spinal fluid and nerves of the spine.

Once the needle is in place, a liquid mixture of cortisone and lidocaine (a type of novacaine) is injected. The epidural space is normally filled with fat and blood vessels. Fluid such as the lidocaine and cortisone flows up and down the spine and inside the epidural space. It coats the nerves that run inside the spinal canal.

The result is to reduce inflammation and swelling. Pain relief is the goal.

But there are potential complications. Anytime a hole is punctured in the protective lining of the spinal canal, bacteria can be introduced. Local infection with an abscess can occur. Or a more serious systemic infection such as meningitis can develop.

There are several things to consider when looking at this question. First, is it true that back pain is increasing? How was this information determined? Good quality research studies have not been able to consistently come up with the same results when studying this problem.

Anytime a press release reports a trend of this kind, it’s wise to look a little deeper. What is the basis for the claims? In this case, it turns out that the National Pain Foundation was presenting the results of two surveys paid for by a drug company. A drug company that just happens to have a pill to offer for chronic pain.

Always look for research results that have actually been published. And it’s best if the studies are from peer-reviewed journals. This means the articles are read and approved by experts in the field. The research methods used in doing the study are examined carefully.

In today’s market, it appears that survey science is being replaced by clever marketing. While there’s no doubt that many American workers are getting older, there’s no proof that this is the cause of increased back pain. It could be that today’s baby boomers are more willing to report their aches and pains than previous generations.

There’s been some concern that the number of people in the United States suffering from daily back pain is on the rise. And it looks like more folks are choosing to show up at work rather than use sick leave and stay home.

So much so that this concept has gained a new name: presenteeism instead of absenteeism.

This may not be a bad idea since doctors routinely tell patients with back pain to keep moving or stay active. But there is some concern about the loss of productivity on the job. And there may be some safety issues if one worker is carrying the load for another.

Right now there aren’t enough good studies to prove or disprove the idea that chronic pain in the workplace is rising. The few studies out there have conflicting results. And two surveys often used to show a steady increase in the problem were actually paid for by a pharmaceutical (drug) company. They may have a special interest since they produce and sell medications for pain relief.

All indications are that a healthy diet and regular exercise is the best prevention for many health problems, including back pain. Experts suggest moderate exercise for at least 30 minutes a day, four or five times a week.

As you suggest, it is clear now that chronic back pain affects more than just the spinal joints and muscles. Newer, more advanced imaging studies have shown that chronic pain results in changes seen in the spinal cord and brain. This new information helps confirm that chronic pain is a neurologic, not a psychologic problem.

Having said that, we are also aware that there are psychologic effects of chronic pain. Patients in pain stop moving. They are afraid to move in the ways and patterns that they know will increase their pain. This is called fear avoidance behavior (FAB).

Decreased motion will actually cause even more pain. New ideas for treatment include helping patients overcome FAB and resume more normal motion. Physical therapists and behavioral psychologists work together to retrain patients to move and think differently.

Whether or not this method will result in a return to normal in the spinal cord and brain remains to be seen. We now have the technology and research skills to conduct large studies that will answer some of these questions.

There may be some patients and some situations where the idea is still used that it has to hurt to work. In general, we have discovered that pain is a signal to change or stop what we are doing in order to avoid injury or damage to the tissues.

But sometimes the system goes haywire. Pain becomes chronic. When patients with chronic pain stop moving, then a syndrome of disuse occurs. A second saying, motion is lotion is still very true. Without movement, we become stiff, less flexible, and muscles atrophy and weaken. All of these effects lead to more pain.

New imaging studies of the brain and spinal cord have helped us see that changes occur in these structures with prolonged pain. New therapies to help reverse these changes are being tried.

One method that has been partially successful is called deep learning therapy (DLT). With DLT, patients are encouraged to work toward improving function, not pain. This may be what you are experiencing. The goal is to be more active and do more even if the pain doesn’t change.

There is hope that by retraining the body to move and function as it did before the pain, the nervous system can be reset. Helping patients break the hold that fear and anxiety have over them is part of that process.

From all the studies comparing workers who see private versus occupational specialists, it looks like how you are treated is more important than who treats you. To be a little more specific, we now know some specific treatment methods that work well to restore workers to health without back pain.

What are the secret methods? First, stay active. Allow only one or two days of rest and inactivity for back pain. After that, keep moving.

It’s natural to feel anxious and fearful when you are in pain. Back pain sufferers seem especially prone to fear-avoidance behaviors. This means they let the back pain dictate what they do and how they move. If it hurts when they move in a particular direction, then they stop moving that way. In a short amount of time, the loss of fluid motion sets up an even greater pain-spasm cycle.

Second, the physician should offer reassurance that recovery is possible and very likely if you follow the right steps. Your doctor should explain the likely cause of your back pain and what you can expect. The natural history of back pain is that 80 per cent of affected people get better in a couple weeks.

Workers are encouraged to stay active and remain on the job. Workplace modifications may be needed in some cases. Modified duties may help you to return to full duties faster than if you have to cover the entire workload while in pain.

Studies of patients who follow this model get better. This was true for those who saw the occupational specialist and for those who pursued private medical care. In fact, the results were equally favorable for a third group — those who saw the occupational specialist and then went to their own doctors as well.

You didn’t mention what kind of work you do or the type of workplace you’re in. Making the transition back to work may depend on these two factors. Modified duties may be helpful if you are engaged in repetitive activities, prolonged postures, or required to lift heavy loads frequently.

A workplace evaluation may be needed to help you decide what’s needed. If your physician is an occupational specialist, then he or she can help you with this. Otherwise, you may need a physical therapist to help you set up the necessary changes.

Sometimes it’s just a matter of resuming your job by starting out with reduced work hours. If no other modifications are needed, you can begin with a two hour shift and add one to two hours each day until you are back full-time.

Of course, all of these ideas require the cooperation of your employer. If you feel confident approaching your manager about this, try to make arrangements yourself. If not, you may need to visit with your doctor and ask for some help. In many cases, a letter from the physician outlining the steps needed is all that’s required.

According to all the experts and the results of many studies, your physician’s advice is right on. Most back pain is mechanical (muscles, joints) and will get better on its own without treatment.

The doctor’s first task is to make sure you don’t have something seriously wrong. Once he or she rules out infection, fracture, or cancer, then reassurance is the next step.

Established clinical practice guidelines recommend doctors tell their back pain patients to rest for a day or two. But then you should keep moving and get back into the swing of things.

Hand holding should take the form of decreasing patient fears and increasing your understanding of the problem. The doctor should give you the reassurance that you will recover. Eighty per cent of back pain sufferers can expect to recover within two to four weeks.

You may need further medical help if your symptoms change or get worse. Going back to your family doctor is still a good idea. He or she has a baseline of your symptoms from the start of the problem and will know what’s the next step to take. If you need further testing or a referral to a specialist, then the process goes much faster with your doctor behind the plan.

It’s very easy to hurt your back while lifting or moving heavy objects. The pain is a warning to you that there is something wrong in your back. Unfortunately, if you injure your back but there’s no pain at first, you could cause more damage because you don’t stop your activity.

Your pain could be caused by a few things, although if you are having a lot of pain, if one or both legs is numb, if you lose control of your bladder or bowels, or if you really have a hard time moving, you should call your doctor for an evaluation.

It can take a few days for the pain to build up from a back injury. Or, some people experience a cumulative injury or trauma. This means that you are doing the same thing frequently, such as lifting the wrong way or twisting, and eventually after you’ve done it for so many times, you back starts to hurt.

If I have injured my back in a work accident, does that mean it’s easier for me to hurt my back again?

It seems that if you have injured your back, you do have a higher risk of re-injuring it at some point in your life. If your doctor has given you the ok, you could begin building up your strength and flexibility. By being fit, the job of standing upright, moving and lifting is taken off your back and put on to the stronger body muscles.

Any exercise you enjoy would do the trick to start if it gets the heart going and the muscles working, like walking, cycling or swimming. Avoid the types of exercise that can jar the back and involve jumping, for example. Also avoid ones that strain your back, like weight lifting.

Finally, be sure to use proper body mechanics when moving and lifting heavy objects. Remember to always bend at the knees when picking something off the floor, even a piece of paper. Your leg muscles then take the weight off your upper body and the object you’re lifting. If the object you are carrying is heavy, hold it as close to your body as possible, keeping your elbows bent. Finally, always move straight ahead, never turn at the waist when holding something heavy.

Your spine is made up of small bones or your vertebrae, disks, gel between the disks, and nerves, among other things. With spinal stenosis, the spaces in the spine get smaller and can press on the cord itself or on the nerves, causing pain. While it’s found mostly in older people, especially women over 50 years old, young people can get it too.

Spinal stenosis can be caused by a spine that isn’t formed properly or a degenerative condition, meaning the spine is breaking down. Diseases like arthritis can also cause spinal stenosis, as can trauma to the back from injuries or tumors, to name just a few.

There are two ways to treat spinal stenosis, through surgery or non-surgical treatment. Your grandmother’s doctor will likely want to try the non-surgical techniques first. They can include back bracing; epidural steroids (medication injected directly into the spinal cord); medications such as analgesics (pain medications), anti-inflammatory drugs, and muscle relaxants; spinal manipulation; and weight loss, if necessary.

If she doesn’t get relief from these treatments, her doctor may consider surgery, depending on your grandmother’s overall health and her wishes.

Bad backs and lower back pain are very common. Some statistics indicate that we can have as high as an 85 percent chance of developing lower back pain during our lifetime. Of course, that also means that we have a chance of not developing lower back pain.

Being in shape is one way to help prevent injury to your back and onset of lower back pain. By keeping fit, you keep your muscles strong, taking the burden off your back. That being said, even fit people can injure their back if they don’t observe proper body mechanics. This means that you need to be aware of how you move, how you lift objects, and how you carry them. Contrary to what some people think, you don’t have to be lifting something heavy to injury your back. You could be bending over to pick up a pencil off the floor and still hurt yourself.

Remember to always bend at the knees when picking something off the floor, no matter how small. This way, your leg muscles will take the weight of your upper body and the object you are lifting. If the object you are carrying is heavy, bend at the elbows and hold it as close to you as you can. This, again, prevents your back from taking the weight of the object. Finally, always move in straight-ahead fashion while carrying something, do not turn at the waist. If you want to move a heavy object from a table in front of you to a counter beside you, pick up the object as described earlier. With your feet, turn your body so you are facing the counter and then lower the object on to it. If you must put the object on the floor, you must bend your knees as you should when lifting something.

Stenosis refers to a narrowing or closure of an opening. In the spine, this refers to a narrowing of the spinal canal around the spinal cord. It can also mean narrowing of the small hole in the bone where the spinal nerves pass through.

Anything that narrows these openings can put pressure on the sensitive nerve tissue. Back and leg pain are common with this condition. Difficulty standing up straight and walking are also part of the picture for many patients.

What happens over time with a condition like spinal stenosis is called the natural history. Researchers have not studied the long-term results of lumbar spinal stenosis. We don’t have a clear picture of the natural history for this problem.

There is treatment but we’re not sure who benefits the most from it or why. Nonsteroidal antiinflammatory drugs (NSAIDs) are usually used along with physical therapy. The therapist can help patients with pain management, posture, and exercises. Sometimes activity modification can help, too. The therapist advises each patient according to his or her own situation.

If conservative care fails, surgery can be done. The bone around the spinal cord or spinal nerve is removed in order to take the pressure off. This is called surgical decompression. It works well for some patients but not at all for others. Again, we don’t know who is most likely to have a good result. More study is needed in this area.

Narrowing of the vertebral canal puts pressure on the spinal nerve roots. This can cause microvascular injury and edema (swelling). The sensitive nerve endings respond to these changes with pain messages to the brain.

At the same time, increased blood flow and antiinflammatory cells rush to the area to help with healing and start to accumulate. This creates congestion around the nerve tissue amd adds to the problem.

Antiinflammatory drugs are often used first to help reduce the swelling. These drugs don’t make the actual opening any larger. But they do reduce the size of the soft tissues inside the opening, resulting in pain relief.

Epidural steroid injections (ESIs) work well for some patients. It makes sense that patients with the smallest canal openings would have the best results. But a recent study from the University of Louisville School of Medicine found this wasn’t true. Patients with large and small openings had the same results. Some got better with ESI and some didn’t.

It’s likely that other factors predict success of this treatment. More study is needed to find out what these are and plan treatment accordingly.

To know what’s causing your back pain, you would need to see your doctor, however, lower back pain is not just caused by lifting objects or moving the wrong way. This type of pain can also happen to people who sit for long periods, especially if their sitting arrangement isn’t well suited for them.

Make sure that your work station is comfortable and healthy for you. Use a chair that is low enough that your feet can sit flat on the floor. If this isn’t possible, use a foot stool for the same effect. Make sure that your chair has a curve in the lower part to support your back, the lumbar part. If your chair isn’t equipped with the lumbar support, you can buy a cushion that does that for you, or you can take a rolled towel and place it in the curve of your back. Try not to cross your legs when you are sitting. Change positions often, try to get up at least once an hour to walk around.

If you use a computer, be sure that your monitor is at a comfortable viewing level so you aren’t looking up or down, keeping your shoulders relaxed.