FAQ Category: Lumbar Spine

More and more experts are calling into question the use of powerful opioids for the treatment of chronic back pain. Studies aren’t supporting their long-term use. Patients may get some short-term pain relief, but there’s no change in their pain levels or function in the long run.

Patients such as yourself bring up a good point. What if you would be worse off without this painkiller? What if by not taking it, your pain level goes up while the quality of your life goes down? It’s possible the drug is helping you maintain your current level of function.

On the other hand, there is always the concern of addiction and other side effects from the long-term use of this drug. Sometimes a drug holiday is needed to find out where you are in the process and maybe even reset the system. Taking a break from the medication could be a very good idea.

It may be best to follow your doctor’s advice. He or she should help you slowly come off the drug to minimize the side effects of withdrawal. Other nonopioid medications for pain control can be used at the same time until you see how much more pain (if any) you are still having without the drug.

Many of the latest studies support the use of psychological care as a helpful treatment for chronic low back pain (LBP). There is plenty of evidence to show that this type of treatment reduces pain and improves function. In fact, disability and depression are also improved with psychological treatment.

The problem many patients have run into is much the same as yours. Third party payers and insurance companies are more willing to pay for an expensive surgery than for pscyhological counseling. And this is true despite the proof we now have for the benefits of behavioral counseling over surgery.

Education is the key. It may be helpful if your physician contacts your insurance company. Giving them an explanation for this recommendation and bringing them up to date on the latest research may be very helpful. A letter of justification from your doctor may be needed by the insurance company.

Many times a little information goes a long way. Don’t give up on this idea. You and your physician may be able to open the door for other patients in the same situation.

Many studies have supported the idea that psychological intervention is very effective in helping patients manage their chronic low back pain and disability. It’s not a magic cure but it can help reduce pain and improve function and quality of life.

Psychological interventions include cognitive behavioral therapy (CBT), relaxation therapy, biofeedback, and even hypnosis. CBT is based on the idea that our thoughts influence how we feel, think, and act. By changing how we think, we can positively influence how we feel both physically and emotionally.

Negative and especially negative, unrealistic thoughts cause distress and result in problems. Changing the way we think is done gradually through a series of steps. Patients keep a diary of events and feelings or thoughts. They learn how to see a better way to think through these events. They try out new ways of behaving and reacting.

Through CBT, chronic pain patients learn how to face activities they have been avoiding. Relaxation and distraction techniques are a key tool in this step.

Some patients may benefit from more than one method. Many patients may still need a multimodal treatment plan. This means many different methods of treatment combined together have the best effect.

Problems with low back pain (LBP) affect up to 80 per cent of the adult population sometime in their lives. Older adults are subject to degenerative changes from wear and tear. The discs, joints, and ligaments can be involved.

Narrowing of the spinal canal from age-related changes can cause a condition called spinal stenosis. Pressure on the spinal cord inside the canal leads to LBP that can travel down the legs. People with this problem have trouble walking and standing up straight.

Tumors, fractures, and infection are other causes of LBP. These are fairly rare and require treatment to get better. The majority of patients suffer from what’s called mechanical LBP. This means the moving parts and soft tissue structures are most likely the problem. We don’t always know exactly what those are for each person. These are the folks who seem to get better with time no matter what they do (or don’t do) to treat it.

Doctors and physical therapists are working together to find ways to classify back pain. The goal is to put patients into subgroups based on common features. Subgroups of people with LBP would help guide treatment based on each contributing factor. In the future we expect to see better ways to diagnose, classify, and treat LBP.

Many studies show that low back pain is linked with the timing and symmetry of hip and pelvic motion. Uneven motion from one side to the other is one factor. Too much or too little hip motion is another. Sometimes hip or pelvic rotation that starts too soon or too late can contribute to a problem with back pain.

The reason for this is the magnitude or amount of load on the spine with each hip or pelvic movement. Tissue stress starts to accumulate over time when loading is uneven or asymmetrical.

Some experts say that until the specific loss of motion is treated, your back pain won’t go away. If it does disappear, it’s likely to come back again later. The therapist’s task is to find out the most likely movement pattern causing your problem and restore normal motion.

Using the lower leg to measure hip lateral (outward rotation) is a standard test. The fact that you were improved just with the motion suggests your hip is involved. Whether the problem started with the hip and went to the back or vice versa requires further testing. Sometimes there’s no way to tell. The therapist must treat one thing at a time and see what makes it better in order to find out what is the underlying cause.

Fusion disease is a complication from spinal fusion surgery. Spinal instability from a variety of problems and conditions may need surgical treatment. The standard operation is a spinal fusion. The disc is removed along with some pieces of bone putting pressure on the spinal nerves.

The now empty disc space is filled with bone graft and a tiny cage filled with bone graft material. Metal screws or a metal plate and screws may be used to hold the spine stable until the bone fusion heals.

This operation can be done in one of two ways. The surgeon can make a large incision, cut through the muscles, and use retractors to pull the soft tissue out of the way. That is the traditional or standard method. A newer approach is called minially invasive surgery (MIS). With MIS, the surgeon makes a tiny incision and uses a microscope to see inside. Retraction is not needed.

It’s the cutting of the muscles called dissection and the use of retraction that can cause fusion disease. Damage to the muscles along the spine and to the nerves to those muscles can result in muscle atropy and weakness. Despite the fusion, the patient may develop an unstable spine from muscle weakness.

This condition can be temporary or permanent. It depends on how much nerve damage occurs. Nerves can heal but it takes time.

Adjacent segment degeneration (ASD) has been reported after spinal fusion in many studies. Scientists are trying to sort out the cause from the effect. Is ASD the result of decreased motion at one segment putting increased stress and load on the next level?

Would the next level have worn out anyway? Is ASD caused by the number of levels fused? What about position of the fusion? If there’s too much curve in the lower spinal curve does it transfer increased load to the next level?

Right now there are more questions than answers. A recent study from Spain may help us understand what’s going on. Researchers used computer analysis of X-rays taken before and after lumbar spinal fusion. Patients were followed up to seven and a half years later.

What they found was a uniform narrowing of the disc spaces in all the vetebral segments. It wasn’t just at the level next to the fusion. It’s looking more and more like widespread changes occur because of the natural aging process.

If this is true, fusion won’t make the next segment any better or worse. In other words, having a second fusion may help your symptoms but won’t keep the next level from developing problems later.

There is a concern that the motion segment above and below the fusion site can start to break down. This may appear on X-rays as increased degeneration called accelerated segment degeneration (ASD).

The patients start to have new symptoms at the level above the fusion. This occurs after a quiet period without symptoms after spinal fusion. The new symptoms may signal a transition from a normal to abnormal motion segment. Transitional syndrome doesn’t usually happen right away. The average period of time reported is between three and 13 years after the first fusion.

Patients with more than one level fused are more likely to develop transitional syndrome. Factors that put you at increased risk for transitional syndrome include osteopororis (brittle bones), fusions at more than two levels, and generalized (usually age-related) disc disease.

Spinal stenosis is a narrowing of the space around the spinal nerves in the low back area. Pressure on the nerve tissue can cause disabling back pain and other symptoms in older adults.

Newly published research shows that moderate spinal stenosis can be treated effectively with nonoperative care. Moderate stenosis was defined as back pain that travels down into the buttocks and leg(s). Some patients had a loss of sensation in the legs. Symptoms were made worse by walking.

In this study, nonoperative care included pain relievers and exercises. The exercises were prescribed and supervised by a physical therapist. When a six-month trial of nonoperative care was unsuccessful, surgery was advised.

The surgical group made better progress at first. But after two years, the exercise group and the surgical group had similar results. The decision to have surgery for this condition should be made after at least a six-month trial of conservative care.

Surgery may still be needed and a valuable tool to reduce pain and disability even in the short term. A two-year reprieve from painful symptoms and loss of function in an 82-year old adult may be worth having the surgery.

About one-third of the bone grafts used in the United States come from donors. This type of graft is called an allograft. Screening for disease is a very important part of the process before the graft material is released for use by patients.

There is a risk of bacterial or viral infection from bone graft but the number of cases reported are very small. Most allografts are frozen and stored at temperatures below minus 60-degrees Celsius (minus 76-degrees Fahrenheit). Fresh (unfrozen and unprocessed) allografts are muchmore likely to transmit infection.

The freezing process destroys bone growing cells and leaves behind cells that help other bone cells grow. During the process the allograft is also sterilized. These steps reduce but do not eliminate all risk of infection. For this reason, the FDA requires specific testing for HIV and hepatitis.

Flexibility in the forward bending position doesn’t all come from motion at one lower lumbar segment. The length (tightness) of the hamstrings is an important factor.

And when motion at one segment is decreased, the other spinal segments may compensate to make up the loss. This means that increased motion in the upper (thoracic) spine and even in the upper level of the lumbar spine helps make up the difference.

The fusion is considered a failure only if segmental movement is seen on flexion-extension X-rays.

The condition you describe is called spondylolisthesis and can range from mild to severe. The degree of severity is based on how far forward the vertebra has slipped. More than a 50 per cent slip is called a high-grade spondylolisthesis.

Fusion of the spine is needed in high-grade cases to prevent or stop pain and disability. Further slippage is called slip progression. If this happens after the fusion, it’s referred to as settling rather than slip progression.

A small amount of slippage or settling is common. It’s not considered a failed fusion if there is no movement seen on dynamic X-rays. The X-rays must be taken as the patient bends forward and straightens into a slightly extended position of the spine.

Further slippage is not expected. In rare cases, a second revision operation may be needed.

Not according to a recent study from Finland. Patients with moderate spinal stenosis were divided into two treatment groups. One group was treated with pain relievers and exercise. The second group had surgery to take pressure off the spinal nerves.

The operation is called a segmental decompression. Bone is cut away from around the nerve. In some cases, spinal fusion was also needed to stabilize the spine.

The two groups were compared over the next two years. Pain and other symptoms, along with function were measured. The exercise group made steady improvements. But early results were better for the operative group. They had less pain and better function. Both groups were able to walk about the same distance.

It may be worth it to some people to have the surgery in order to reduce painful symptoms. There is no known disadvantage in delaying surgery. Patients who wait to have the surgery seem to have the same results later after surgery.

Ergonomics literally means the law of work. It is the study of human factors affecting work. This includes physical, psychologic, and social factors. In recent years, the term ergonomics has been closely linked with matching the work place and its tools to the human body for the purpose of preventing injury and disability.

But a series of studies on ways to decrease stress on the spine hasn’t proven that proper ergonomics prevents back injuries. Studies in automobile manufacturing plants did not show any fewer sick days due to low back pain than before ergonomics were started.

In fact, a study of Boeing factory workers in Seattle, Washington showed that psychosocial factors played a big part in back pain. It appears that the physical stresses of work weren’t as disabling as the psychosocial stresses. These findings have been repeated in study after study.

So, the emphasis on ergonomics is less today for two reasons. One, many more people have already adopted ergonomically sound concepts at home and at work. And secondly, there is less focus on the topic in general because of these research findings.

The intervertebral discs between the bones of your spine are your main shock absorbers. They have to withstand thousands of pounds of load and repeated stresses with every step, twist, and turn that you take. Proper nutrition is essential to the disc’s health and repair processes needed on a daily basis.

Nutrition as your physician used the term is referring to the blood supply to the disc. A good blood flow brings oxygen and nutrients needed for discs to remain healthy and in good repair.

Studies show that low levels of oxygen to the disc results in low pH balance. pH is a measure of the acid-base levels in the body. Discs with low disc ph build up high levels of lactates. The combination of breakdown in disc nutrition and high biomechanical loads on the discs may be what leads to disc degeneration.

Exercise increases blood flow, which in turn helps wash away lactates and other byproducts of cellular metabolism. The increased blood supply also brings fresh oxygen to restore the disc.

Although what you eat and the nutrition you get from food is important, in this case the nutrition your physician mentioned is most likely to come from daily exercise. Just what is the best exercise remains unknown. All studies so far point to almost any kind of exercise as helpful so long as it raises your heart rate and increases your blood flow.

A recent study using digital fluoroscopic video (DFV) may have some answers to your question. DFV is a type of X-ray that allows us to see the spine move. Rate, speed, and angle of motion can be captured on video and measured.

DFV images can be taken in normal adults without low back pain and compared to the same movement pattern in patients with low back pain. By finding out exactly what’s going wrong, treatment can be directed to restore normal motion.

The catching or slipping you describe has been seen in DVRs of patients with abnormal neuromuscular control. This means the muscles aren’t contracting when and how they should. Movement occurs at the wrong time, such as too late in the flexion-extension cycle.

The ligaments have to hold on to prevent too much motion at the wrong time. The disruption in the normal timing and amount of motion may be what’s causing the catching sensation. You should consult with an orthopedic surgeon to be certain there isn’t something else going on in your situation.

Clinical practice guidelines (CPGs) are suggestions or guidelines for health care professionals to use when treating someone with a specific condition. CPGs are usually developed by a group of people reaching agreement or consensus about how and when to treat the condition.

The decision is based on results of research published on the topic. This provides a baseline for making evidence-based treatment decisions, rather than just trying different things or doing what seems to work best without really knowing.

CPGs also helps insure that patients with the same problem are treated the same or equally based on current, available scientific data.

A clinical prediction rule (CPR) is a way to test patients to find out who can benefit from a particular treatment. For example, in 2005, a group of physical therapists (PTs) developed a CPR for low back pain (LBP) patients. They were able to identify four things that would predict success or failure in treating LBP patients with stabilization exercises.

This type of classification system is very practical and based on scientific data from research. We may expect to see more CPGs and CPRs for various problems, including acute and chronic low back pain.

Walking or biking are the two most common and probably easiest forms of exercise to engage in. Very little equipment or expense is involved. A good pair of walking shoes is advised.

If you have access to a treadmill or stationary bike, you can exercise year-round with no interruptions due to weather. This type of equipment also makes it possible to keep track of your exercise program.

But even without the equipment, you can walk outdoors or in a mall and keep track of the time and distance. Intensity can be gauged by your heart rate or rate of perceived exertion (RPE). The short-form of the RPE scale goes from zero to 10.

Zero is for no exertion at all. Ten is for maximal exertion (working very hard). So for example, a rating of two means you are working a little with mild exertion. Four is somewhat hard. Seven is rated as very hard. At seven, you are breathing hard and you’ve probably broken a sweat.

For an aerobic program, you should be between five and seven. If you haven’t exercised before, it may take a few weeks to a few months to get to this level. Since your doctor has approved you for aerobic activity, you can start at a comfortable level and gradually increase the intensity and duration (how long) you exercise.

The goal is to be consistent and to stick with it. You will have to decide what works best for you. Usually a daily program of 30 to 40 minutes of moderately intense exercise is advised. This will improve your overall health and may decrease your back pain at the same time.

Exercise has been shown to increase endorphins, natural pain killers and cortisol, a stress hormone. The exercise must be at a high enough intensity to change blood chemisty, but how intense may vary from person to person. Anxiety and depression are known to be improved with regular moderately-intense exercise.

Many studies show that activity vigorous enough to get your heart rate up for at least 20 minutes or more is best. The basic formula used to calculate the intensity of the exercise is 220 minus your age then multiplied by 60% (or 0.6). That gives you an idea of the minimum heart rate needed to exercise at a moderate rate.

You should not go above 85 per cent of your maximum heart rate. And if you have any health concerns, it’s best to see your doctor before beginning an exercise program. There really isn’t something like a happy pill. The most powerful drug we know for chronic pain and many other conditions is exercise.

Regular exercise is advised for everyone based on many studies showing the positive benefits on health and mood. You may benefit from an antidepressant if exercise does not prove helpful.

The word neurogenic simply refers to nerves, implying the the problem is nerve-related. Claudication means limping. Some people who limp also have leg pain or cramping discomfort in the calf, so they think claudication refers to their pain. They will be half right because what they usually have is limping from pain or discomfort.

There are different kinds of claudication. Each one is named for the underlying cause. For example, if blood circulation is cut off to the lower leg because of clogged arteries, the patient has vascular claudication.

Vascular claudication comes on with activity when the heart is asked to deliver more oxygen to the legs. But the blood can’t get past the clogged arteries. Pain or discomfort from a lack of blood occurs. As might be expected, vascular claudication goes away by stopping the activity (standing still) or with rest.

Spinal or neurogenic claudication is not due to lack of blood supply. It is the same kind of pain caused by nerve root compression, usually from a degenerative spine.

This type of claudication is often relieved by rest but position is even more important. Any position that puts pressure on the spinal nerve(s) will increase the painful symptoms. And a change in position to relieve the pressure can reduce the symptoms. Bending forward usually reduces the symptoms of neurogenic claudication. Standing up straight or extending the spine makes the symptoms worse.