FAQ Category: Lumbar Spine

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.

Stenosis means closing in. Spinal stenosis describes a condition in which the nerves in the spinal canal are closed in, or compressed. The spinal canal is the hollow tube formed by the bones of the spinal column.

Anything that causes this bony tube to shrink can squeeze the nerves inside. As a result of many years of wear and tear on the parts of the spine, the tissues nearest the spinal canal sometimes collapse and press against the nerves.

This helps explain why lumbar spinal stenosis (stenosis of the low back) is a common cause of back problems in adults over 55 years old. Standing up straight or extending the spine closes the gap or hole where the spinal nerves leave the spinal cord. Bending forward opens this space a little, giving the neural tissue a little more room.

We call this positional-dependent spinal stenosis. There is treatment for this condition. Sometimes exercises to help open up the neural spaces can help the individual stand up straighter. Surgery may be needed to take pressure off the spinal nerves. In some cases, spinal fusion is required to stabilize the spine.

If your father is not under the care of an orthopedic surgeon, you may want to advise him to make an appointment for consultation and planning. A stooped over posture can cause a decline in function, altered breathing and digestion, and other problems that can be avoided.

Scientists have yet to unravel the mystery of scar tissue. Some people form lots and lots while others not enough. Too much scar tissue (as you have found out) can put pressure on the nearby tissues causing painful symptoms.

When the nerve is involved, nerve pain, numbness, tingling, and other symptoms of nerve involvement can become major problems. Removing scar tissue in a person whose body forms excess scar tissue may not be an acceptable solution to the problem.

In recent years, new research has been testing out the use of gels and fat grafts to prevent scar tissue formation. The early results have been very successful. But long-term results are very limited at this point in time.

Poor sleep quality and disrupted sleep have been linked with pain-related disability and depression. The consequences of poor sleep (fatigue, sleepiness during the day) can affect work and daily activities.

Pain management programs vary from clinic to clinic. Most provide a multidisciplinary approach. You may be taught energy conservation and pacing skills. Setting the right goals is important to avoid overdoing. Pacing your activities for the entire day, week, or even month is part of the management process.

Exercise including stretching, aerobics, and resistance training are usually a key feature of every pain management program. Exercise combined with medication (when needed) and counseling often work together to help improve sleep patterns and sleep quality.

Let your team manager know of your concerns about sleep problems and your desire to improve your overall sleep pattern. Sometimes making simple changes is all that’s needed. Each member of the pain management team may have something to offer.

You may be a good candidate for a treatment program called cognitive behavioral therapy (CBT). This is a form of patient education and counseling about pain and pain management. The counselor will teach and coach you in specific coping and relaxation techniques.

You will gain confidence that you can (and will) be able to manage your pain while taking care of yourself, taking care of things at home, and still working (if you have a job outside the home).

You will learn how to control and even turn off pain-related thoughts. The counselor will help you recognize if and when you are catastrophizing or expecting the worst.

Studies show that by reducing catastrophizing, patient’s function and pain levels improve. At the same time, there is decreased disability. Talk to your doctor about your concerns and questions. Ask if CBT or other treatment methods might help you.

Low back pain (LBP) that lasts more than three months is considered chronic. At this point, it’s likely that the soft tissues have healed as much as possible from the original injury. Scar tissue, disc degeneration, pressure on a nerve, or damage to the joints in the spine can cause continued symptoms.

Fear of re-injury or fear of increased pain can lead patients to alter the way they move. This phenomenon is called fear-avoidance behavior. Decreased motion actually makes the situation worse. Sometimes a multidisciplinary (team) approach is needed to get you out of the fear-avoidance/pain-spasm cycle.

A physical and/or occupational therapist will work with you to restore normal motion and movement. With specific, gradually increasing exercise, you will be shown how to increase your activity level with confidence and without increased symptoms.

Studies show that a multidisciplinary back training program is effective in getting patients back to work. There is usually an improved perception of quality of life, too. This is true even when symptoms aren’t better or the patient isn’t cured.

Ask your doctor about multidisciplinary team back training for you. Let him or her know of your desire to get back to work sooner than later.

For patients with low back pain (LBP) that doesn’t go away on its own or with months of conservative care, a multidisciplinary approach may be needed. Many studies show this method is effective.

Chronic LBP is thought to be more than just a back ache. There are psychologic and emotional factors involved. Patients’ attitudes, beliefs, and social background seem to be important, too.

The cost of missed work, surgery, and disability from LBP is enough to warrant a team approach for some patients. Usually, the goal isn’t to cure the pain. The goal of the team is to help the patient become more functional or active despite the pain. Pain relief along the way is possible but not always expected.

Your team should be made up of some, but not necessarily all of the following professionals: physician, social worker, psychologist, physical or occupational therapist, nurse, and vocational counselor. The goal is to get you back to full function at home and at work.

One out of every three workers report low back pain (LBP) at one time or another. This makes LBP the most common work-related health problem. Both men and women are affected but sometimes for different reasons.

A recent study of 2,556 middle-aged men and women helped identify some of those differences. Men were more likely to have LBP when they felt out of control at work. For example, low control over decisions and low social support at work were linked with LBP. Job insecurity was a better predictor of LBP for women.

When the results of multiple other studies are included, the evidence for gender differences is inconsistent. More studies in this area are needed. It has been suggested that worker response or reaction to work conditions may be more important than the actual work conditions.

And it’s likely that factors outside of work may be related to episodes of back pain. Anytime middle-aged or older adults report LBP, a physical exam with their medical doctor is a good idea. If there are no medical causes for their back pain, then a program of physical activity and exercise is advised. It may not change the work situation, but it can provide a stress release.

It is well known that lifting or handling high physical loads does put a worker at increased risk of low back pain (LBP). But other activities such as rapid body movement or changing body position frequently (especially if it involves twisting or turning) can increase the risk of back injury or back pain.

It’s also been shown that low control over work situations is linked with LBP. Reorganization and restructuring can cause a significant amount of work-related stress. Men are more susceptible to LBP when others make decisions that affect them. Women are more stressed by job insecurity. Back pain is linked with both of these factors.

You may be seeing the results of the change in physical as well as psychological stressors. Older workers with less education are more likely to drop out under these kinds of conditions. Drop out refers to quitting, retiring, or developing LBP or other health issues.

Information about spine healing is limited because it’s too expensive to do before and after MRIs on every back patient. Doctors must rely on the studies they do have. They especially find it useful to compare the results over time for patients who do have more than one MRI taken.

Changes in signal intensity are used to gauge what’s going on in the spine. For example, when bone marrow is replaced by fibrous tissue, the MRI shows decreased intensity of the signal. This is labeled as a Modic Type 1 (MT1) change and is considered unstable because changes are still occurring.

MT2 changes describe red bone marrow that has been completely replaced with fat (yellow marrow). There is a different (usually increased) MRI signal intensity with MT2 changes. MT2 changes are quiescent or quiet with no further changes expected.

Studies have documented changes in the spine based on serial MRI studies. MT1 (unstable, changing) can convert or transform to MT2 (stable, quiet, unchanging). This is the most likely change to occur. The situation doesn’t get better but it doesn’t get worse. The patient may not be aware of any changes going on as the painful symptoms remain the same.

Only a small number of cases have been documented of reverse transformation from an unstable to normal situation. Changes from stable to unstable are uncommon as well.

MRIs are just a small part of the diagnostic process. They don’t always correlate well with patient symptoms. Sometimes the MRI can show a large protruding disc and the patient feels just fine. In other cases, extreme pain may be present without any major changes seen on the MRI.

The decision to repeat the MRI should be made with your physician. He or she will use what was seen in the first MRI, along with your history, and a physical exam to advise you as to the next best step.

If you are a candidate for surgery, a repeat MRI may be helpful. New MR images can show changes that have occurred over the past six months. The type of changes and extent of these changes can help guide the doctor in determining the best treatment approach.

The Bodyblade is a thin, flexible foil measuring about 30 inches long. It has a molded grip in the center for your hand. It can be held (and used) in the vertical, horizontal, or diagonal direction.

Depending on how you hold it and the position you’re in, you can activate different muscle groups. The blade oscillates (moves back and forth) at a natural frequency of 4.5 times each second.

Resonance at this frequency challenges trunk muscle strength, endurance, and coordination. When used properly, the Bodyblade enhances spinal stability. The opposite is also true: lumbar compression may be increased with the Bodyblade. Such a result is not desirable for patients with lumbar spine pathology.

Studies show when used properly the Bodyblade is very effective in recruiting the abdominal muscles and trunk stabilizing muscles. The goal is to increase stiffness on both sides of the spine equally. The stiffness combined with coordinated muscle activation has been shown to improve spine stability.

Lumbar artificial disc replacements (ADRs) have been used in Europe for 20 years now, but they are relatively new in the United States. Long-term studies aren’t available yet, but a few reports of early failure such as you describe have been published.

From studies of the implants removed and from analyzing the nearby tissue, here’s what we know so far. Tiny particles of material from the plastic part of the implant flake off. This is called wear debris.

The wear debris sets up an inflammatory response in the nearby tissue. Scar tissue forms and the implant starts to loosen. The plastic can deform or become smooth and polished. It depends on the forces applied to it.

For example, if the bone around the implant softens and dissolves, the implant sinks down. This sinking process is called subsidence. Now the ADR rubs against the ends of the vertebral bodies forming a flat area that looks polished.

If the ADR is not placed correctly, uneven wear can occur. Scratches in all directions have been seen in some implants that were removed. In a few cases, the plastic core of the implant has even fractured.

The exact causes for implant failure are unknown. As mentioned, poor positioning and wear debris can contribute to the problem. But some ADRs fail without these factors. More research is needed to get to the bottom of this problem and to find ways to keep it from happening.

Experts did think that lumbar artificial disc replacements (ADRs) might last longer than the 10 to 15 years of hip or knee replacements. With less motion in the spine (compared to a hip or knee joint) and no synovium in the spine, there was hope that the ADRs would last much longer. Synovium is the soft tissue which lines the surfaces inside some joints.

Early studies of ADR failure have disproved this idea. Tiny particles called wear debris flake off the implant causing an inflammatory reaction. The result can be loosening and failure of the implant.

The surgeon will use X-rays and other imaging studies to assess the damage before surgery. Most likely the implant will be removed and examined. Once the surgeon can see the condition of the implant and the surrounding tissue,the cause of the problem may be identified.

It’s possible you could get another ADR to replace the first one. In cases where this won’t work, the surgeon may have to fuse your spine. Lumbar spine fusion can be done in several different ways. This may be decided based on your age, the condition of your spine, and the density of your bones.

Ossification is the process of bone or bone-like formation in connective tissues, such as cartilage or muscle. The ossified tissue has blood vessels that bring minerals like calcium and deposit it in the ossifying tissue.

Usually ossification occurs in damaged or injured muscles. The thigh (quadriceps muscle) and arm (triceps or biceps muscle) are affected most often. For some people, this process can happen without trauma or injury. In such cases, there may be a hereditary link.

A recent study at the Scoliosis and Spine Center of Maryland compared patients with and without ossification after a total disc replacement (TDR). They were unable to find any differences between the two groups even after two years. Range of motion was equally good and definitely improved over the pre-operative motion.

Further study is needed to investigate any long-term changes that may occur two or three decades from now. TDRs are too new to have this kind of data yet.

There are many ways to measure the results of treatment for conditions like low back pain. Patient satisfaction is one of the most important. Is the patient satisfied with the outcome of treatment? If not, then it may be time to reevaluate the goals and program approach.

Other measures of change or improvement may include pain severity, frequency, and duration. In other words, has the pain level changed? Does the pain come as often or more often? Does it go away sooner or last longer than before treatment?

Symptoms other than pain should be evaluated, too. Did the patient have numbness or tingling in the legs before treatment? Is it better, same, or worse after treatment? The same question can be asked about weakness in the legs, trouble sleeping at night, or bowel and bladder function.

Function and disability are two other items that can be looked at to measure success or progress in treatment. Patients compare what kinds of activities they could or couldn’t do before treatment with their current abilities. Have they been able to get back to work? Do more at home and at work? Engage in sexual activity? Enjoy leisure activities that were impossible before treatment?

Sometimes the fact that the patient sees the doctor less often, takes fewer pain medications, or feels less jittery or restless and tense are ways to measure results of treatment.

The health care delivery system is taking a new approach to treatment these days. The focus is increasingly on what’s called evidence-based medicine. The idea is to show proof that the treatment used for a condition such as back pain is effective. Why spend time and money on something that may feel good at the moment but doesn’t really make any difference in the long-run?

One way to assess the effects of treatment is through the use of surveys taken before and after treatment. Various factors known to be part of the chronic back pain picture can be measured. These might include patient satisfaction, symptoms, function, disability, and psychologic state.

Depression and anxiety are common features of chronic pain patients. Many people know they are depressed while others do not. Measuring change in mood can be difficult without a survey of some type to identify change. Most change occurs slowly enough that the patient isn’t really aware of how much he or she has improved. When asked directly, the answer might not be the same as when tested formally.

Depending on what’s been done already, your surgeon may order a couple more tests before proceeding with surgery. MRI of your lumbar spine may be one of those tests. Discography may be another. Discography is used to see if the disk is the true source of your pain.

With discography, a dye is injected into the disc. Increased pain occurs because of increased pressure within the disc. If there are any cracks, fissures, or openings in the outer covering of the disc, the dye will ooze or seep out into the epidural space.

The surgeon uses a special X-ray machine called a fluoroscope to guide the procedure and see if the dye moves out of the disc. If surgery is indeed indicated for you, then there are several options to choose from.

The standard operation is an open discectomy. The surgeon makes an incision through the back of your spine and removes any disc fragments or even the entire disc. Less invasive methods such as chemonucleolysis, laser discectomy, electrothermal therapy, and percutaneous nucleoplasty are possibilities.

Once you see a surgeon and find out if you are a good candidate for discectomy, he or she will discuss what options are the best for you.

You may have had a procedure for your shoulder called radiofrequency (RF) thermal shrinkage. RF heats up the soft tissues in the shoulder, which then shrink as the tissues cool down.

The heat is not high enough to destroy tissue. It just changes the mechanical properties of the cartilage and ligaments. The goal is to increase shoulder joint stability by tightening up the ligaments and capsule. This may keep the shoulder from dislocating.

RF heat used with disc protrusion is called nucleoplasty. The RF used is the same energy source used with thermal capsular shrinkage but it’s high enough to destroy the tissue. A curved probe is advanced in and pulled out of the disc creating channels. As the probe goes forward, the tissue is heated and destroyed. Although the disc isn’t being shrunk, removing some of the disc helps take pressure off the nerve.

Nucleoplasty using RF energy for the treatment of sciatica caused by disc protrusion is a fairly new procedure still undergoing study. It has been used successfully in patients with one or two small- to medium-sized disc protrusions with an intact annulus fibrosis. The annulus is the outer covering of the disc material.

Other, more conservative care is always advised first before having surgery of any kind. Physical therapy to correct posture and stretch the sciatic nerve and muscles around it should be part of the early treatment process. Many patients with sciatica have improved symptoms or complete resolution of pain without surgical intervention.

It’s always helpful to see a health care professional who understands your medical and treatment history. When you return for follow-up, that individual may be able to save time and see the big picture of what happened to you and what has been tried.

But sometimes seeing a different person offers new insight or ideas. There’s nothing wrong with that! And, it’s possible your new treatment program is based on your condition and not the person prescribing it.

For example, doctors and therapists know from research studies that acute episodes of low back pain are best treated by reassurance, activity, short term pain relievers, and antiinflammatory drugs.

When pain persists longer than expected and if it lasts more than three months, it’s labelled chronic pain. Chronic low back pain is more likely to be treated with exercise therapy, behavioral treatment, and a multidisciplinary management approach.

With this kind of care, you’re more likely to have a medical doctor, physical therapist, social worker, psychologist, and nurse on your team. You may or may not get further improvement in your painful symptoms. But with proper management, you’ll be able to do more within the confines of your pain. The goal is to increase function even if you still have back pain.

Don’t hesitate to ask your therapist about your treatment and what is the long-range plan. Let him know what worked the first time in case it might be helpful information this time. And don’t be surprised if those treatments aren’t advised for a chronic condition.