FAQ Category: Lumbar Spine

There is a new device that can be slipped under the skin and in between two vertebral bones to help prop them open. This keeps the spinal canal and spaces for the spinal nerve roots open. It’s called an interspinous process decompression (IPD) system.

The patient doesn’t need to be under general anesthesia. A local anesthetic is all that’s required. It’s not necessary to remove any bone so it’s a minimally invasive surgery (MIS).

The patient has very little pain with this operation. There is very little blood loss and a faster recovery is possible.

Odds ratios for workers’ comp (WC) patients with back pain are extremely difficult to predict. Studies show varying results. There is a general trend toward poor results after spinal fusion for WC patients.

In a preliminary study from Ohio, out of 725 WC patients who had lumbar fusion, only six per cent were back on the job after a full year. Almost one-third of the group ended up having a second operation. And the use of narcotics for pain control was very high (90 per cent).

Doctors aren’t sure what is the problem. Perhaps it’s just part of the WC dilemma. Or maybe there’s something about the surgery itself that leads to such a poor result. Social, psychologic, and behavioral factors can’t be ignored.

Smaller studies report disability rates as high as 25 per cent after a single-level fusion. Disability rates went up for WC patients having two- or three-level fusions. There was 100 per cent disability reported for the group having a three-level fusion.

It’s possible that results improve over time. Longer studies are needed to report the results of spinal fusion after two, five, and 10 years. Your motivation to get back to the job may also be a positive factor in your own case.

You’ve come upon a major dilemma when it comes to health care, technology, and costs. There are many experts who don’t advocate the use of treatment just because it’s available. The rising costs of health care make it necessary to find out who can benefit most from each type of treatment.

The artificial disc replacements (ADRs) are new enough that we still don’t know for sure who can benefit most. There may be some patients who truly would do better with a lumbar fusion instead of an ADR. The opposite may be equally true.

Third party payers (insurance companies, Medicare) want to know that ADRs have been proven superior to other treatments known to be effective. How reliable is the data collected on results if the companies who designed the new ADRs do all the research?

There are many questions that remain to be answered before insurance companies can or will approve the use of ADRs in patients with disc problems. How long will the implant last? Will patients end up having a spinal fusion anyway if the ADR fails?

Will patients gain more function and/or have less pain with an ADR compared with spinal fusion? If the ADRs are approved but a patient still wants a fusion, will it be covered? Many more studies must be done to provide reliable and valid results before these questions will be finally answered.

Low back pain (LBP) is the most commonly reported type of pain in adults. This statement is supported by results of several national surveys taken over the past 30 years in the U.S.

Studies repeatedly show that 80 per cent of all adults will experience LBP sometime in their lives. At any one time, about half of adults age 18 and older in the United States have LBP during any given year.

About one-fourth of the American adult population have had at least one day of LBP during the last three months. A smaller portion (15 per cent) report back pain lasting more than two weeks each year.

The number of people visiting their doctors for back pain has remained steady over the last 30 years. However, the number of people seeking treatment for their LBP has increased. There are more surgeries being done but LBP patients are also more likely to look for conservative treatment.

Back pain is extremely common and always has been. Studies over the years have made it clear that the majority of healthy adults will have a day or two of back pain now and then.

We know that in 80 per cent of the people with occasional back pain, the symptoms will go away in less than a week to 10 days. Rest is okay for the first day but activity is always much better.

With acute low back pain, you can use an ice pack to help reduce the muscle spasm. Then while it’s numb from the cold, do some walking around the house. Alternate periods of rest and inactivity with movement and activity.

Be aware of your breathing. Many people in pain feel anxious about their situation. It’s very easy to hold your body stiff against the pain. You start to take infrequent or shallow breaths when you really need to take slow, deep breaths often. Breathing will help you and your muscles relax and reduce pain intensity.

If there are no medical precautions, you can use over-the-counter pain relievers for a few days. However, if you experience a sudden fever, blood in your urine or stool, or other more serious symptoms, check with your doctor. In a very small number of cases, back pain is caused by infection or other systemic disease.

Darvon is an opioid used for the relief of mild to moderate pain. It’s been on the market since 1957 and is considered a weak narcotic. Other similar drugs include tramadol and codeine. Darvon is about one-third to one-half the strength of codeine. A 65 mg dosage is equal in pain relief to about 600 mg of aspirin but without the acid content of aspirin at that dosage.

Opioids such as Darvon are advised for short-term use (several weeks up to several months) for pain control. Long-term use over years may result in the opposite effect: increased pain with other side effects. This turn around in pain relief is referred to as the downward spiral.

Pain starts to increase while taking the same drug that formerly brought pain relief. The patient finds that he or she needs more and more of the same drug (or a stronger drug) to get the same pain relief. This first step is called tolerance.

As part of the downward spiral, addiction can occur. A red flag sign of addiction occurs when the patient starts to experience symptoms of drug withdrawal without the drug. The person’s activity level, outlook on life, and sense of well-being start to decline. Depression and anxiety can become additional problems the patient must now cope with.

Contact your doctor immediately if you find yourself experiencing any of these effects. Narcotics for pain relief should never be used alone. Exercise, physical therapy, behavioral or cognitive therapy, acupuncture, and other alternative methods of pain control should be part of a total treatment plan.

Right now surgeons are trying artificial disc replacements (ADRs) in patients like yourself. The goal is to limit how much force is put on segments adjacent to the fusion. This is especially important for patients with multisegmental level fusions (in other words, long fusions over several segments).

No one is sure yet just what will happen in the long run with this type of surgery. The ADR may restore or preserve motion at that level, but what happens then at the next level? Can adjacent level degeneration following fusion be stopped with a single-level ADR? Does it take a two-level ADR to have the best results?

Bioengineers at the University of Toledo Spine Research Center are using computer-simulated models to study this problem. Most recently, they compared two different models and measured the results in terms of motion, load, and stress on the spine. The first model had a two-level ADR. The second model was a L5-S1 fusion using a cage and pedicle screw system along with an ADR at the L45 level.

The results varied and the researchers were unable to say one method worked better than the other. They each had their advantages and disadvantages. The bottom-line answer to your question is: more study is needed before anyone will know!

Discs are made up of two parts. There is the center or core, a soft gel-like substance called the nucleus pulposus (NP). The NP is surrounded by a fibrous covering called the annulus.

Fissures are cracks in the surface of the annulus. They can occur as a result of gradual wear and tear associated with aging and the degenerative process. Or they can develop as a result of an acute injury.

In either case, it’s possible for the body to repair the damage itself. No treatment (outside of good nutrition and avoiding extreme contact sports) may be needed. If you had an MRI during the healing phase, the image might show a bright annular signal indicating inflammation. Over time, the signal might return to normal as the healing process takes place.

If the tear extends into the center of the disc called the nucleus propulsus, then disc protrusion and eventual herniation may develop. Initial treatment may be the same for either type of injury with a wait-and-see approach. Many people can recover from this with conservative care.

Your orthopedic surgeon can review with you all of your options. Most doctors advise conservative care for at least six months before more invasive treatment (such as surgery) is considered.

X-rays and magnetic resonance imaging (MRI) are common tests for first-time episodes of low back pain (LBP). It’s easy to think that changes seen are the cause of new symptoms. Doctors know this isn’t always true because many people with even worse-looking imaging studies can have no symptoms at all.

Some doctors prefer to treat the problem symptomatically. Then if the pain doesn’t go away, further testing can be done. It’s possible that early stages of inflammation won’t show up on the MRI anyway so waiting six weeks or more may actually show a more accurate picture.

A recent study from the University of Hawaii took baseline X-rays and MRIs of 200 subjects without back pain. Anyone who developed first-time back pain was then re-tested. The idea was to see if changes associated with the trauma would be apparent on the new MRIs.

Less than five per cent of the follow-up MR scans showed relevant new findings. Even with an episode of trauma, changes on MRIs were few and far between. Given the high cost of MRIs, they are not advised for routine exam of LBP. MRIs may be advised for patients who have been treated conservatively without improvement.

The Food and Drug Administration (FDA) has only approved the use of artificial disc replacement (ADR) for one-level lumbar disc replacement. Two-level ADR are undergoing studies now.

It will be quite some time before long-term results are really known for this new treatment. Scientists say there are many variables to be studied and defined. How long do the implant components last? What’s the effect on the segments above and below? In particular, what happens at the joints, discs, and soft tissues above and below the ADR? Does load increase or decrease? Does the motion increase, decrease, or stay the same?

Right now computer simulations are being used to test results using one- versus two-level ADRs. Various studies are also looking at what happens when a patient has a spinal fusion at one level and goes back later for an ADR at the next level. How does this compare to someone who had two ADRs and no fusion?

With new technology and improved implant designs, these (and many other) questions will be answered in time. For now your orthopedic surgeon can advise you as to what is best for your situation.

Steroid injections into the epidural space of the lumbar spine have been around since the early 1950s. The epidural 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.

Many surgeons use steroid injections as a means of managing the problem. Patients often get good relief from pain and other symptoms. As with any invasive procedure, problems can develop. In about five per cent of patients, headache, hemorrhage (bleeding), or spinal meningitis (infection) occur.

If you have tried physical therapy, activity modification, and medications such as antiinflammatories and analgesics for pain without success, then steroid injection may be a good next step for you.

Talk to an orthopedic surgeon about this and other options before making a final decision.

Studies show it’s not uncommon for patients and surgeons to disagree about the results of spinal fusion. Your surgeon may be looking at X-ray results or other imaging studies and seeing a solid fusion. When there’s no motion and no sign of instability, the fusion may be considered perfect.

At the same time, you feel the results are unsatisfactory due to minimal change in your painful symptoms. A patient’s preoperative expectations may affect the level of satisfaction after surgery.

If you expected complete pain relief, you might be disapointed with anything less. If you hoped the symptoms wouldn’t get worse, then your satisfaction goes up when the symptoms improve even slightly.

It may be a good idea to let your surgeon know how you feel and discuss this situation. There may be other treatment options available that could enhance your results. It’s also possible that you will continue to see improvement over the next six months.

You didn’t say why your operation was a failure. Are there signs on X-ray that the fusion didn’t take? Is there still motion at that segment? Or are you having persistent pain and decreased function despite good X-ray findings?

Either of these situations occurs in up to one-third of all spinal fusion patients. Further testing may be needed to get to the root cause of the problem. Myelography may be done.

The myelogram is an X-ray of the spinal cord and the space around it. A needle is inserted into this space to inject a special dye. Myelography can show changes in the normal shape of the spinal cord, spinal canal, and spinal nerve roots. It is a good way to find spinal lesions caused by disease or trauma.

Your doctor may also order an MRI. Studies show that MRI may be better than a myelogram to show the different changes in the spine. MRI can show fibrosis and disc problems. Ask your surgeon what he or she would recommend as a next step for you based on results so far.

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 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. Sometimes people are born with a narrow spinal canal. The aging process speeds up the start of any problems.

But usually it’s wear and tear on the spine from aging and from repeated stresses and strains that cause many problems in the lumbar spine. As we age, the intervertebral disc begin to collapse. The space between each vertebrae starts to shrinks.

Bone spurs may form that stick into the spinal canal and reduce the space available for the spinal nerves. The ligaments that hold the vertebrae together get thicker and push into the spinal canal. All of these things together cause the spinal canal to narrow.

Lumbar spinal stenosis (LSS) is a common problem in older adults. LSS is a narrowing of the spinal canal and compression of the openings in the vertebral bones where the spinal nerves exit the spinal canal. It can be a very disabling condition. It’s the most common reason older adults have back surgery.

Studies show that the number of spinal fusion surgeries for this problem has grown steadily in the last two decades. Most patients are advised to try conservative care before having surgery. This could include medications, physical therapy (PT), and/or bracing.

Only a small number of patients actually pursue and complete a course of conservative care. From the research done so far, it looks like patients can get better without surgery. Pain levels can be reduced and function improved with overall increased patient satisfaction.

If your mother has not been treated by a physical therapist, this may be your next step. PTs are trying to find the best treatment for LSS. Results of studies so far show that flexion exercises and manual therapy do make a difference.

Many vertebral compression fractures (VCFs) are never diagnosed. The person doesn’t even know it’s happened until an X-ray shows the healed fracture at a later time. But for those patients with back pain, VCFs are usually treated nonsurgically.

Pain relievers are prescribed along with a wait-and-heal approach. This takes about six to eight weeks. It may take longer in patients who smoke, drink alcohol, or who are in poor health otherwise.

Some patients can benefit from an exercise program or bracing to help them keep an upright posture. If conservative measures don’t help, then surgery may be considered. Usually the surgeon waits until at least eight weeks after the fracture before suggesting a vertebroplasty or kyphoplasty procedure.

In these operations, a long, thin needle is inserted into the bone. Cement is delivered to the vertebral body through the needle. Once the cement hardens, the bone has increased strength. If your father has osteoporosis (likely at age 82), he may be at risk for future VCFs.

Doctors and therapists are aware of the need for a quick and easy method of assessing back pain patients. So far finding an ideal tool for testing has been difficult.

A recent study from Belgium may be what we’re looking for. It’s called the Backache Index (BAI). It takes about one to three minutes to conduct. Patients stay in one position (standing). Pain and motion are scored for five simple motions.

Bending forward is one of the movements. Side bending to each side is measured. Then side bending with extension is tested and that’s it.

The results of the BAI were compared against the results of four other standard back tests. Researchers conducting the tests found the BAI to be both reliable and accurate. More tests are needed to confirm these results but this may be just what’s needed for both patients and examiners.

As you point out, clinical practice guidelines (CPGs) for the treatment of acute LBP have been shown effective. Patients treated according to these guidelines get better faster and at a lower cost compared to patients who receive other treatment.

Despite the evidence that supports using these CPGs, less than half of all healthcare providers use them. Understanding why your staff doesn’t follow a clearly proven treatment plan is the first step. Since many patients with LBP get better without treatment, your staff may not see the need to follow all the steps in the CPG.

It’s important that everyone know what the CPGs say to do. Comparing current practice with the elements of the CPG may be helpful. Find any gaps between these two and develop a plan of action to close the gaps.

You’ll need some way to monitor and measure changes in practice. The Department of Defense developed something similar for use in the military healthcare system. You may find some of these materials useful. They can be downloaded from the Internet and printed from www.oqp.med.va.gov/cpg/LBP/LBP_base.htm.

You’re quite right! Factors like quality of life and personal satisfaction are very subjective measures. But studies show a direct link between patient satisfaction and improved outcomes from treatment so these elements are important.

Patient satisfaction may be what each person feels is important. In order to get some kind of measure, researchers devise a survey to include questions important to their study.

For example patients may be asked to rate the healthcare they received. They may be asked how difficult it was to see a specialist or if their care was delayed. Some patients rate their satisfaction with care strictly on the basis of how well the doctor listened or how much time the healthcare professional spent with them.

Sometimes patients are just given a scale from zero (no satisfaction) to 10 (complete satisfaction). Using this scale, they can say the number that best matches their own satisfaction however they define it.

There is still considerable debate about the existence of a problem called piriformis syndrome. With this syndrome, there is buttock and/or leg pain caused by irritation of the sciatic nerve.

It’s called piriformis syndrome because the sciatic nerve passes through the piriformis muscle. The piriformis muscle is located deep in the buttock. Muscle spasm, scar tissue, or other changes in the soft tissue put pressure on the nerve causing pain, numbness, tingling, and weakness.

Often nerve conduction velocity (NCV) tests and imaging studies are within normal limits. Since there’s no way to prove there is such a problem as piriformis syndrome, the diagnosis is still questioned by some experts. There’s no question the patient is having symptoms, but the cause of the problem isn’t always clear.