FAQ Category: Lumbar Spine

It seems to make sense that a back brace or support should help prevent or reduce low back injuries. But studies consistently report no difference in rates of injury or reinjury between workers who do or don’t use a back support.

It turns out that one of the biggest risk factors for low back pain (LBP) is a low level of physical (not mental) health. Current best advice today is to maintain a regular routine of physical activity and exercise.

When returning to the job after an injury, take time to review the training manual for job tasks. Based on research results of recurrent back injuries, this is good advice whether you are returning to your old job or starting a new task.

Tobacco use and especially cigarette smoking have been linked with delayed healing and poor wound healing in study after study. Nicotine is a vasoconstrictor, which means it causes blood vessels to narrow (constrict).

Smaller blood vessels deliver less blood, oxygen, and nutrients to injuries or surgical sites. Reduced blood flow also means less clearance of toxins and cell waste products.

In a recent study at the New York Upstate Medical University, smoking was a significant predictor of pain in the first 12 months after anterior spinal fusion with cages. Emotional health was the strongest predictor of results. There may be an association between poor mental health and smoking, but this was not part of the study.

Experts believe exercise can prevent low back pain. Specific exercises can be done to strengthen individual back muscles. Stretching exercises increase trunk flexibility, which is also important.

Physical activity and general movement helps increase blood supply to the muscles, joints, and discs. The belief is that improved circulation minimizes injury and enhances repair when microtrauma or other more serious injury does occur.

Studies of patients with low back disorders also show that active exercise is important in improving mood and decreasing stress. Both of these factors are linked with improved general health and preventing chronic back pain.

It’s not clear yet exactly which exercise is best — only that exercise in general seems to make a difference. More study is needed to sort out who should do what — both to prevent back pain and to recover from an episode of back pain.

Clearly, older people have less range of motion in all joints compared with young adults. The neck, back, hips, and shoulders seem affected most often.

Scientists think there are several factors to help explain what’s happening. First, as we age, the natural elastic tissue fibers called elastin are replaced by stiffer collagen fibers.

Not only that, but the older we get, the more collagen is formed. Cross-links between collagen fibers in the soft tissue of the spine increase stiffness and reduce elasticity or flexibility.

Women tend to have more flexibility but less strength in the spine compared to men. This is a consistent finding when lumbar range of motion and strength are measured across the decades.

All studies so far yield the same results: regular exercise and physical activity are essential to maintain strength and flexibility. Any gains made are quickly lost if the exercise or activity isn’t repeated.

Those statistics generally refer to low back pain, which may or may not have a known cause. Often the pain comes on without injury and is called mechanical low back pain.

This means it’s likely caused by one of the moving parts in the spine. This would be any of the soft tissues such as ligaments, joint capsule, or muscles. Tumors, infection, or fractures are not included in the mechanical category.

Some conditions seem more likely to occur depending on our age. Younger people are more likely to suffer from herniated discs. Older adults begin to get spinal stenosis, a narrowing of the spinal canal. An equal number of adults develop degenerative disc disease (DDD). DDD is more common with aging as the discs become thinner and give less support to the spine.

According to data gathered from the National Spine Network, these three conditions occur in nearly equal numbers across adults ages 30 to 55 years old. Less often but just as disabling are adults affected by spondylolisthesis.

Spondylolisthesis is a condition in which there’s a small fracture in the supporting column of the vertebra. This allows the body of the vertebra to slide forward. The result is a pulling on the soft tissues and joints at that segment. The spinal cord or spinal nerve at that level can get pinched or compressed causing neurologic problems.

You ask a very interesting question. Understanding the cause of back pain helps predict future events. Some (but not all) spinal disorders can follow us from young adulthood into our older years.

For example, spondylolysis can become spondylolisthesis and cause many problems. Spondylolysis is a condition in which the pars articularis, a supporting structure of the vertebral body gets a tiny crack or fracture. By itself, this may not be a problem. But if the fracture is enough that the body of the vertebra pulls forward (spondylolisthesis), then back pain and neurologic problems can occur.

There’s something else to consider with low back pain (LBP). Studies show that younger people are more likely to have severe LBP. They have less energy and more fatigue. LBP has a bigger impact on their social lives. They are more likely to report the back pain has a negative effect on their overall physical health.

Your grandson’s current LBP may not have any bearing on his future back condition. On the other hand, all aging adults are at risk for spinal stenosis. This is a narrowing of the spinal canal. It’s caused by age-related changes in the spine. Previous back injuries or back pain is not clearly linked with spinal stenosis.

Most lumbar nerve blocks are done on an out-patient basis. If there aren’t any major problems, the patient goes home the same day.

In this procedure the surgeon places a long, thin needle into the intervertebral foramen. This is the space where the spinal nerve exits the spinal canal and travels down the spine. A special X-ray called fluoroscopy is used to guide the needle to the right spot.

Once the needle-tip is in position, an injection of anesthetic and corticosteroid is given. The mixture goes into the area around the nerve root and can bring immediate pain relief. For some patients the pressure of the fluid around the irritated nerve makes the pain worse but this doesn’t usually last. Once the numbing agent starts to work, pain is reduced.

Nerve blocks are good for patients with chemical irritation of the nerve from disc degeneration. Mechanical pain from stretch or pressure on the nerve is not likely to respond to a nerve block.

Usually a synovial cyst of this type looks like a separate structure with clear margins. It’s located outside or next to a facet joint in the spine. The cyst is filled with a clear fluid.

The MRI has a hard time telling the difference between fluid in the spinal column, joint fluid, or hemorrhage. An abnormal signal may be all that’s recorded for tumors, cysts, or other soft tissue masses.

The doctors rely on the patient’s history, symptoms, clinical exam, and the imaging studies to make a diagnosis. The final diagnosis is made during the operation when the mass is clearly identified or removed and sent to pathology.

Lumbar nerve root blocks have become a very popular treatment for back and leg pain that doesn’t respond to pain relievers or physical therapy. A steroid mixed with a numbing agent like novacaine is injected as close to the nerve root as possible.

The idea is to decrease the chemical irritation of the nerve from the disc. Studies show that degenerated vertebral discs have enzymes that release chemicals. An inflammatory response is set up and pain is the result. Usually only one injection is needed for pain relief. Sometimes a second or third injection is required before the patient gets the desired results.

In a small number of patients (five percent) new pain or leg numbness or weakness occurs with nerve root blocks. They may have some lightheadedness. These minor problems are temporary. More serious problems are less common but can happen. Paralysis, headache, and increased pain are some of the major complications reported.

Most patients report immediate improvement or pain relief within the first 24 hours.

Adequate pain control after spinal surgery has been an age-old problem. Nurses can’t always respond right away to patients’ requests for pain relievers. When this happens, pain can escalate and get out of hand.

Studies show that nurses often underestimate pain intensity of patients after surgery. The nurse’s assessment of the patient’s pain and the patient’s self-report may be very different. Nurses are concerned about drug tolerance or drug dependency and tend to err on the side of caution.

Sometimes patients’ anxiety gets in the way. Worry and fatigue can increase a patient’s pain perception. There may be other factors influencing pain frequency, intensity, or duration.

It can be helpful to keep a chart of your mother’s pain levels. Ask her to rate her pain from zero (no pain) to 10 (worst pain). Monitor her levels before and after she receives any drugs for pain. This will help show if the medication is working. Perhaps she just needs a change in dosage. Or she may need a different drug altogether.

Check with the doctor to make sure he or she is tuned into your mother’s pain levels. It’s always helpful when a family member can let the nurse or doctor know when the patient’s pain levels seem out of control.

Nerve blocks involve injecting a steroid drug and a local anesthetic into the spine near the spinal nerve. Surgeons use fluoroscopic imaging to guide the needle to the right spot. Usually they are aiming for a spot called Bogduk’s safe triangle. This is a triangular area that seems to prevent complications like nerve damage.

In a recent study of 1200 cases of spinal nerve block, scientists showed that precise needle tip position doesn’t affect outcomes. Patients had pain relief regardless of the exact location of the injection.

It is possible that your nerve pain is coming from a nerve at a different spinal level. It’s also possible that your pain isn’t coming from the nerve at all. There is still much we don’t know about back pain with nerve symptoms. Sometimes patients get pain relief right away. Others seem to get better over time with or without the injection.

Make sure you follow-up with your doctor. There may be other treatment options to consider. You may need a second nerve block either at the same place or in another location to get the best results.

Spinal nerve blocks can cause sharp radicular pain at the time of the injection. This happens when the needle tip comes close to the nerve root. When this happens, the surgeon will pull the needle back and readjust the needle tip position.

In the past, surgeons weren’t sure of the best location for steroid injections. Some tried to get as close as possible to the nerve without causing increased pain. Others used a spot called the safe triangle — an area known to avoid any nerve complications.

If the nerve is the cause of the pain, then injection of a local anesthetic and steroid will give the patient immediate pain relief. Thanks to a recent study at several large hospitals, we now know that the injection doesn’t have to get so close to the nerve.

It’s hoped that the results of this study will help surgeons find a standard method to give future patients the most pain relief possible with this treatment.

Right now there isn’t a lot of agreement among surgeons about spinal fusion. Studies clearly show fusion is a good option for spondylolisthesis.

Spondylolisthesis is a condition in which a fracture occurs in the vertebrae causing the main body to slip forward over the vertebrae below. Pressure on the spinal cord or spinal nerves occurs. Fusion helps hold the bone in place and prevent any neurologic damage.

Other reasons for fusion are much less clear-cut. Fusion may be considered for deformity from scoliosis (curvature of the spine). Degenerative disc disease is another reason surgeons think about fusion as a possible treatment option.

In a recent study at the Leatherman Spine Center in Kentucky a group of 19 surgeons reviewed 32 cases of lumbar degeneration. A model for choosing reasons for fusion was used by each surgeon. Five different indications were offered. The goal was to see how much agreement there was among surgeons.

The results showed only moderate agreement — not enough to adopt the classification model for general use in the clinic. More work is needed to find a way to help doctors select patients for fusion based on the same criteria.

‘Spondylo’ is a term used to describe the vertebral bones in the spine. ‘Spondylosis’ refers to stiffness or changes in the motion at the joints of the spine.

Anything that changes the motion at each spinal segment can cause spondylosis. For example a narrowed disc space compresses or pushes the joint surfaces together. Joint motion can be limited and painful in such cases.

Bone spurs or other arthritic changes around the edges of the vertebral (facet) joints can also cause spondylosis.

Discogenic disease refers to changes in the discs that cause pain. This could be disc protrusion or herniation. In such cases, nothing shows up on X-rays. MRIs or discography is usually needed to pinpoint the disc as the cause.

It sounds like your discs are fine but there may be a problem at one or more of the vertebral joints. Be sure and ask your doctor to go over the X-rays and results with you for a better understanding of your own spine.

Before starting or increasing a weight-training program, it’s advised that all adults over 65 have a physical exam and their doctor’s approval. Hidden effects of atherosclerosis and coronary artery disease can lead to problems with this type of exercise.

Once you’ve been cleared, then try and work with an athletic trainer, physical therapist, or exercise physiologist. A supervised program is always a good idea in the beginning. It’s best to develop a regimen you can stick with over a long period of time.

Try to work all areas of the body including the arms, legs, calves, and abdominal and low back muscles. Most researchers advise training at least three times a week but not more than six. If you are using resistance-training equipment, then allow for a two-minute rest period between each machine.

Training the low back muscles once a week seems to be just as effective as doing it more often. Doing eight to 13 repetitions at 50 to 80 percent of your one-repetition maximum is best. Your trainer can help you find your one-rep max.

It takes six to eight weeks to change muscle fibers and build strength. You can continue increasing that strength by doing the exercises a full 20-weeks. The final goal should be to have a consistent exercise program that you can do week in and week out for years (the rest of your life!).

Doctors use information published in studies of normal ranges for strength and motion for men and women. These norms do change as people age but that’s taken into consideration, too. Doctors also rely on patients to tell them what’s normal for them.

A decrease of 20 percent or more for any motion (forward, backward, sideways) is considered a “positive” sign. The doctor’s exam also looks for other changes such as spinal curvature (scoliosis), leg length differences, or sensory loss.

Doctors are trained to look for red flags that point to serious problems like infection, fracture, or tumor. Most of the time, the cause of back pain is unknown. Changes in the soft tissues (muscles, ligaments, tendons) or joints can cause pain that’s referred to as mechanical.

Your doctor’s proposed treatment suggests a diagnosis of mechanical low back pain. Follow her advice and the chances are very good you’ll have a full recovery. If pain persists or you get worse, make a follow-up appointment for further testing.

With the rising cost of health care, doctors are taking a second look at advanced imaging studies like CT scans or MRIs. Research shows over and over again that imaging studies aren’t that helpful.

Many patients with acute low back pain (LBP) have normal X-rays. In a recent study of 100 LBP patients everyone had a normal X-ray. CT scans were also done. Only six of the patients had clinical symptoms that matched the CT scan for disc bulging. In fact, one-third of the patients with signs of disc problems on the CT scan didn’t have any symptoms of disc problems. And half of the patients who did have disc symptoms didn’t have any sign of a disc problem on the CT scan.

Almost all acute LBP patients get better with the advice your wife’s doctor gave her. Advanced imaging and more aggressive treatment are used when a patient doesn’t get better or gets worse instead.

Best practice right now says to follow the doctor’s advice and see what happens in the next 10 to 14 days. It may mean a few days of back discomfort but it will save your pocketbook from hurting unnecessarily.

Discography is often used in making a final diagnosis of low back pain. A dye is injected into the disc causing immediate pain when there’s a problem. But there are no set and fast guidelines for what is a “true positive” or “true negative” test.

In fact, a recent study of discography showed 25 percent of the population tested had a false-positive when they weren’t even having back problems. That same study found a high correlation between psychologic factors and false-positive discography results.

It seems there may be some people who are just more sensitive to anything that can cause pain even if there’s nothing wrong. You may be one of those people. There are other explanations offered for false-positive discography, but the bottom line is that better, more accurate tests are needed to identify the cause of low back pain.

The nature of the discography test is to find the disc that’s causing your painful symptoms. A long, thin needle is inserted into the disc and a contrast dye is injected into the disc.

A local, numbing agent or anesthetic is used before inserting the needle through the back so that part isn’t painful. It’s when the pressure of the liquid dye increases enough in the disc causing pain receptors to respond that you may feel disc pain. The surgeon carefully monitors your response and stops the test as soon as it’s positive.

If there’s nothing wrong with the disc, then the test should be negative and you won’t feel a thing. Whether the test is positive or not, after the test, you may feel some mild to moderate muscle discomfort. Usually the doctor will give you some medications to help ease any painful symptoms over the next few days.

Although 75 percent of the results are accurate, this still leaves a one in four chance that you can have a false-positive response. This means that you test positive for a disc problem when the disc is perfectly fine. So far we don’t have any way to predict who might fall into this group.

The test does offer good information to help in the decision-making process. A negative test means surgery isn’t needed. A true-positive test is a green light to proceed with surgery.

It is well-known that body size and strength go hand in hand. The larger the body size, the greater the strength. Larger people can produce more force.

A better way to answer this question is to compare people of different sizes by comparing muscle mass. This leaves out the nonactive tissue otherwise known as adipose tissue or fat. Who’s stronger muscle by muscle?

When using this approach overweight or obese adults have weaker handgrip, leg, and trunk strength. In some studies obese adults have higher knee extension strength. Scientists think this may be explained by the training effect of just carrying around more weight.

The differences in strength between obese and nonobese people probably have to do with metabolism of muscle cells. Further research is needed to understand this more clearly.