My wife is being treated for a sudden problem with low back pain. It just came out of the blue without an injury or warning. I’m worried it might be something serious. The doctor doesn’t seem too concerned that it’s anything like cancer. How can they know for sure?

Fracture, infection, or tumors are always a possibility with sudden onset of low back pain. The doctor will look for risk factors that raise the suspicion of a more serious problem.

For example a previous history of cancer such as breast, lung, or colon cancer increases the concern over new onset of back pain. The doctor will also take into consideration red flags such as age over 50, constant pain, and elevated sed rate (lab test).

Most of the time the doctor can tell by the patient’s history and clinical presentation what’s going on. The doctor looks at what makes the pain or symptoms better or worse. Herniated discs present one way and spinal stenosis another. Back pain from a mechanical or nonspecific origin looks different from either of these problems.

The diagnosis is often confirmed by time. If the patient gets better with the prescribed treatment, then no further tests are ordered. But if the patient doesn’t get better with conservative care or gets worse, then X-rays or other imaging tests may be needed.

My mother-in-law has leg and back pain from spinal stenosis. There’s been some talk about surgery for this problem. Is the risk of developing other problems from the surgery worth taking a chance to get some pain relief? We don’t know what to tell her.

Spinal stenosis is the narrowing of the spinal canal that often occurs with aging. Pain is worse when standing or walking and better when sitting. Unfortunately this can lead to deconditioning and weakness in older adults. The risk of falls increases under these circumstances. So finding a way to get relief from pain and improve function is important.

Older adults are also at greater risk of complications and problems related to the surgery. This is especially true if they have other health problems such as diabetes or high blood pressure.

Studies show that results from surgery for spinal stenosis are better if the patient has more leg pain compared to back pain. Overall results show success in about three-fourths of the older patients who have surgery for this problem. This means three out of four patients do well with surgery. There’s no clear distinction to predict which patients won’t do well.

A simple laminectomy to remove part of the bone may be all that’s needed to help your mother-in-law get back on her feet again. With or without surgery, a good rehab program is advised. Consider making an appointment with the surgeon and discuss the pros and cons of surgery, the risks, and other possible treatment options available.

I’ve accepted the fact that I have chronic low back pain. When I went to see the doctor for this last bout of back pain the report listed “subacute chronic back pain.” What does this new label mean?

Chronic pain is defined differently by different people. For the most part, everyone agrees that pain lasting past the expected time for physical healing is called chronic. Most soft tissue and bone injuries recover in six to eight weeks’ time. Factors like poor health, diabetes, and tobacco use can delay normal healing.

According to most research, pain that persists beyond the expected time becomes ‘chronic’ after three to six months. The doctor’s exam must identify whether this is a new (acute) injury or a recurrence of the old injury.

Subacute chronic pain suggests a new episode of back pain that is in the healing phase. Acute means it has recently happened (first one to two weeks). Subacute refers to the period of time from two to six weeks of the recovery process.

I just came back from the physical therapist’s office. I’m being treated for low back pain that started about three weeks ago. No one seems to know what’s causing the problem. How can they treat me if they don’t know what’s really wrong?

It sounds like you may be suffering from a bout of low back pain (LBP) called nonspecific LBP. Most likely it’s caused by some soft tissue problem but the exact mechanism of pain is unknown.

In cases like this the physical therapist relies on a classification method to decide on treatment. Treatment is determined based on your signs and symptoms. For example if you are 40 years old or younger with full hamstring motion and excess joint motion, then stabilization exercises may be best.

For patients with very recent symptoms and loss of joint motion, manipulation or manual therapy is advised. And for patients whose symptoms are better with certain motions and worse with others, specific exercises may be needed.

The therapist conducts an exam looking at all the various factors known to impact treatment. Specific treatment of this type often speeds up recovery. Once your symptoms start to improve you may be progressed to the next level of exercise.

A program of low-stress aerobic exercise on a bike or treadmill is common. At that point exercises to correct postural faults, muscle weakness, or inflexibility may help prevent future episodes of LBP.

I had a vaginal hysterectomy so no muscles were cut. Even so I’m having back pain and weakness. How do you explain this?

With advances in surgical technique many pelvic and abdominal surgeries can be done without cutting muscles or nerves. The surgeon may be able to use special tools to remove tissue through small puncture holes in the abdomen or through the vaginal canal.

Injuries or just effects of surgery can affect muscle strength and function. Stretching or compression can occur when the soft tissues are pulled out of the way, a process called retraction. Ischemia or temporary decrease in blood supply during surgery can also affect the soft tissues.

Injuries of this type can cause biomechanical changes. Sometimes the recovery of normal motor function isn’t automatic. The muscles don’t contract together at the right time to stabilize the trunk and spine. Pain may be another factor affecting how and when muscles function.

More and more research is showing the positive value of core training to ‘reset’ spinal stability. Physical therapists teach patients specific exercises for the abdomen and trunk. This kind of rehab program may be helpful for you.

My gynecologist suggested I try core stabilization exercises to help prevent back pain after a hysterectomy. How do I get started?

Research has shown that normal muscle activity between the abdominal muscles and trunk muscles is needed to provide core stability. Stiffness, support, and strength of the trunk and spine are another way to define “core stability”.

These muscles must contract with strength but at the right time and in the right sequence for each movement. That requires strength as well as proper motor control. Back pain can occur when deep abdominal and pelvic floor muscles are either not contracting or are not in sync with one another.

Spinal stabilization exercises are often called core training. Programs offering core training, Pilates, or spinal stabilization come in a wide variety of choices. Local health clubs often provide core training or pilates classes. You may be able to find some videos at your public library with any of these titles.

Two very popular and easy-to-follow books are available for the average consumer. The Core Program and Instant Relief were both written by a physical therapist (Peggy Brill) who has devoted her professional life to developing an exercise program for women. These are available at: www.brillpt.com.

Men and women are both finding the benefits of core training for many problems including pelvic pain, back pain, and incontinence.

I had my first baby six weeks ago. I had back pain all through the last trimester. I thought by now my back pain would have gone away. Does this mean I’ll have it the rest of my life?

About half of all new mothers report low back pain after childbirth. Another 25 percent report problems with leaking urine called incontinence. Both of these conditions are caused by pelvic and abdominal muscle weakness.

There may be motor control problems too. The muscles may contract too late for the motion. In normal muscle function, some muscles start to contract as soon as the person thinks about doing a movement. The muscles start stabilizing and preparing the body for movement before the person starts moving.

Most of these symptoms go away for first-time mothers. Women who have had more than one pregnancy are more likely to have chronic problems with back pain and pelvic dysfunction.

New research shows that an exercise program to restore muscle strength and motor control can help take care of these problems. You may have heard of core training, Pilates, or stabilization exercises. Ask your doctor if you are safe to begin such a program.

A physical therapist can help you get started and then you can continue on your own at home. This type of exercise program is especially important if you are planning on having any other children.

I’ve been labelled a chronic pain patient. After six months of treatment and rehab, my back pain is no better. I’m looking at surgery as my next option. Are there any statistics on how low back pain patients like me do after surgery?

There are many ways to measure success of an operation. Pain relief is one. Many patients are expecting complete pain relief when often there is only partial relief or none at all.
Some patients even report more pain after surgery.

Quality of life (QOL) is another measure. If pain relief isn’t delivered, then QOL often goes down. Disability goes up as pain levels increase and function goes down.

In a recent study at the Productive Rehabilitation Institute of Dallas for Ergonomics (PRIDE), patients with extreme pain after rehab were more likely to seek further medical care. The risk of post-rehab surgery was 11 times greater in this group compared to patients with mild pain.

The authors of the study pointed out that chronic pain patients with work-related injuries were less likely to return to work after surgery if their pain level was ‘extreme.’ This was especially true for patients who were disabled for one to two years.

They suggested taking a careful look before doing surgery on anyone with extreme chronic low back pain.

I’m a little more than worried about myself. Four months ago I had a work-related injury. I still have low back and leg pain. Some days it’s very severe. Other days it’s milder. The doctor expected the pain to go away with healing and says healing has taken place now. Could I still get better? Or is this “as good as it gets”?

For most soft tissue or bone problems healing does take place in six to eight weeks. Pain, swelling, and loss of motion usually resolve by the end of this time. The patient can get back to work or regular activities.

Recovery may take longer if there is nerve damage. And sometimes the pain cycle gets turned on and the body can’t turn it off. Scientists aren’t really sure what happens in cases like this. Pain becomes chronic and can be mild, moderate, or severe.

Studies show a better result for patients who have rehab. A multimodal form of rehab is best. This means the patient is evaluated very careful from a physical, social, and psychologic point of view. Rehab to address needs in all three of these areas is advised.

Patients do better in the long-run if rehab has included patient education, fitness, and counseling. Both occupational and physical therapists provide exercises and management techniques. Close supervision over a longer period of time is also linked with better results. For patients who have extreme chronic pain, early treatment is better than waiting for months before getting started.

Several years ago I had a fusion of my lumbar spine at L45. The surgeon used a posterior approach called PLIF. Now I’m going in for a second fusion at L34. This one’s called a TLIF. What’s the difference and why is it better?

TLIF stands for Transforaminal lumber interbody fusion. The surgeon goes in from an angle from the back and side. The entire disc can be removed from one side with TLIF. Other methods like the posterior lumbar interbody fusion (PLIF) require two incisions and entry into the disc space from both sides of the midline.

With TLIF there is less blood loss, less chance of nerve injury, and a shorter operative time. Only one side of the spine is weakened using the TLIF to remove the bone that protects the disc. Other methods compromise the stability of both sides of the spine. Likewise the soft tissues (muscles and ligaments) are only disrupted on one side with TLIF compared to PLIF.

The goal is to reduce complications and improve recovery time. The surgeon is able to use a minimally invasive operation and still get a good fusion for the patient.

I’m 77-years old and have terrible back pain. I can’t garden, play golf, or even go outside for a walk. The doctor wants to do a new fusion called MaXcess TLIF. What are other patients saying about the recovery time for this operation?

MaXcess Transforaminal Lumbar Interbody Fusion (TLIF) uses a special retractor system to give the surgeon access to the spine. The surgeon can use a small incision with minimal disruption to the muscle tissue while still being able to see what he or she is doing.

Time in the hospital may be much shorter with MaXcess TLIF (one day compared to three to five with traditional spinal fusion). Physical recovery is about the same (or faster) for the MaXcess TLIF compared to the other methods of TLIF. Patients report being pain free and back on their feet in a few days. It takes about four to six weeks to recover fully.

My doctor is going to do a minimally invasive operation to fuse my spine. It’s called a TLIF. I saw the special tools that will be used. Doesn’t it seem like with all of today’s technology they should be able to come up with some way to minimize damage to the patient but still let the doctor see what he or she is doing?

The surgeons would like this too. Using an arthroscope or endoscope to see inside the spine while viewing a computer screen is a challenge. The surgeon must move the tools without damaging nearby nerves and blood vessels. They must avoid cutting through soft tissues such as muscles and ligaments as much as possible.

A new retractor system is being tested for use with transforaminal lumbar interbody fusion (TLIF). With the minimally invasive operations, the surgeon inserts tiny tubes through the skin down to the bone. Special tools are then slid through the tube to remove the disc and nearby bone.

The MaXcess blade retractor slides down over the outside of the tube forming what’s called an operative corridor. The blades of the retractor then move the tissue out of the way so the surgeon can see what he or she is doing. Only a small incision is needed but the surgeon gets the full view without using microscopes.

I have a lumbar spine problem called spondylolisthesis. Is it safe to do aerobic exercise with this condition?

Yes but your doctor will need to clear you for this kind of activity. About 85 percent of adults with spondylolisthesis are treated with physical therapy including exercise — both specific exercises and aerobic exercise.

Spondylolisthesis is a condition in which one lumbar vertebra breaks loose from the spinal column and starts moving or slipping forward. X-rays are used to grade spondylolisthesis from one to four (mild to severe). The grades are based on how far forward the vertebra has moved.

If you have a mild to moderate case, then conservative care is advised. This can include steroid injections, physical therapy, and homeopathic remedies.

The therapist will teach you how to use your core muscles to stabilize the spine. You can do this during standing, activities, and exercise. The goal is to strengthen the muscles around the spine to help hold the spine in place. This is called spinal stabilization. Another newer term for this is core training. The effect is to “stiffen” the spine and keep it from slipping and sliding.

Once you’ve mastered the idea of spinal stability, then the next step is to start aerobic exercise. You’ll have to keep the spine in good alignment at the same time you’re doing the aerobics. Any change in your symptoms or increase in pain, numbness, or weakness should be reported to your physician. Further examination may be needed before continuing or resuming exercise.

I had a spinal fusion at L34 for a slipped vertebra. The X-ray shows it didn’t take. The doctor says I have a “pseudofusion.” Will I have to have the surgery again?

It’s a little difficult to answer this question directly without more information. You’ll probably want to ask your surgeon this question.

If you have a condition called spondylolisthesis, then one vertebra in the lumbar spine has slipped forward over another. This is usually given a grade from one to four to indicate how far it’s slipped forward.

Surgery to remove pressure from the spinal cord and to stabilize the spine is called a decompression with fusion. There are different ways to do the fusion. Sometimes the surgeon places a bone graft just along the back or posterior spine. Fusion may take place from both the front (anterior) and back. And the surgeon may use plates and screws to help hold everything together until the fusion is solid.

If the fusion isn’t solid then there may still be some motion at that segment. This is called a pseudoarthrosis. It means “like a joint”. Instead of a solid, strong bony fusion there is a fibrous union that still allows some motion.

Studies show that a fibrous union may still give the spine enough stability to prevent the vertebra from slipping. Pseudoarthrosis doesn’t always affect the outcome negatively.

Your surgeon may want to use a “wait-and-see” approach. Further surgery may be needed but it’s not a given. Signs and symptoms of serious neurologic injury would point to the need for immediate surgery. This could include loss of bowel or bladder control or paralysis of the legs.

Do I have to go to Europe if I want to have a disc replacement instead of a spinal fusion? I hear they’ve done thousands of these operations over there.

The first artificial disc replacement (ADR) was invented by a French doctor in the 1980s. It wasn’t until the late 1990s that the device was widely used in humans. In Europe over 5,000 ADRs have been implanted.

Use of the ADR has been a little slower in the United States. The first cases were done in 2001. Reports of results are starting to trickle in. There are a limited number of surgeons and centers where this type of surgery is done in the United States.

There have been cases of patients going to Europe to have the disc implanted. So far only one report of failure has been published. An American had two disc replacements done in Europe. One ADR slipped forward and cut off the circulation to his leg. By that time he was back in the U.S. A U.S. surgeon found the problem and corrected it by removing the implanted device and fusing the spine.

Wherever you decide to go (U.S. or Europe) ask about the number of cases done and the incidence of any problems or complications. These are the early years of a new treatment. Caution is always advised until the device and surgical technique have been perfected.

I have a grade 3 spondylolisthesis that causes me a lot of pain. I have trouble doing simple tasks sometimes like getting in and out of the car. The doctor wants me to have surgery but I’m just not sure. What should I do?

Spondylolisthesis is a problem that can be corrected with surgery. The lumbar vertebra has a small fracture in the bone allowing the body of the vertebra to slip forward away from the back half of the bone.

This may not seem like much of a problem but when the bone moves forward, the soft tissues that are attached get pulled and stretched, too. Pressure is put on the spinal cord or spinal nerves. There is a potential for serious neurologic problems.

The goals of surgery are to stabilize the spine. The result is to reduce pain and neurologic symptoms. Improved quality of life usually follows. The surgeon may see it as a simple decision. It isn’t always so easy for the patient.

Research show if you have had conservative (nonoperative) care for six months or more and still have symptoms, then surgery is advised. If the surgeon doesn’t think surgery will help, then patients must continue with conservative care and manage the symptoms. Loss of bladder or bowel control is a clear sign that surgery is needed.

I saw a news report that you can have a disc replacement now … just like a joint replacement. What holds the new disc in place? Seems like as soon as you bend over it would push out of the disc space.

You’re right, of course. The disc implant must be anchored in place just like a total hip or total knee replacement.

Some of the steps used to hold the implant in place depend on the type of artificial disc replacement (ADR) used. For some, the surgeon chisels out a groove in the bone. A special anchoring keel in the center of the ADR settles into the groove. Bone grows around it to hold it in place.

Other ADRs have a different locking mechanism to hold it in place. Special “teeth” on the outside of each part dig down into the bone to hold it in place. A small amount of motion of the implant is needed to allow normal spinal movement. If the ADR is implanted too tightly, then shear forces may cause a problem. The locking mechanism can break or the implant can come loose.

Researchers are still working to tweak the design of their ADRs. Each new problem (or success) helps them decide how to improve the implant. Early on there were many problems with plates breaking or moving. New designs seem to have taken care of these problems. For now there are very few reports of implant migration. In the short run, it appears they are holding in place just fine. Long-term studies are next.

If I have an artificial disc replacement and something goes wrong, what happens then? Can I get a second replacement?

Artificial disc replacement (ADR) is a fairly new treatment for disc problems of the low back or lumbar spine. As with any surgery, problems can occur. Nerves or blood vessels can get damaged during the operation. The implant itself can break or sink down too far into the bone. In a small number of cases, the implant has reportedly moved out of the disc space.

When a total hip or total knee replacement fails, the surgeon tries to revise the implant. Sometimes this means removing a portion of the new joint and replacing it. In some cases the entire joint must be taken out and a new one put in.

ADR is a little different in that it is a fairly new procedure. Long-term results from studies carried out over 10 or 20 years aren’t available yet. Indications for revision aren’t entirely clear yet. Some surgeons may be more likely to remove the implant and fuse the spine.

As time goes by and more studies are done, ADR revision will become more common. Surgical technique and instruments to do the revision will be developed. The implants will also continue to improve in design and use. Fewer problems will be encountered.

I’m going to have back surgery in the next few weeks. The surgeon has offered to just take out the problem disc. Another option is to remove the disk and take out a piece of the bone along the spine. Taking out the bone takes pressure off the nerves. I could have both operations at the same time and save myself the trouble later. What works best?

There’s a lot of confusion about spine surgery right now. There aren’t enough studies to show what works best or how long the results last.

Research does show that there’s a wide range around the country of what’s done and how successful it is. Some surgeons just do a discectomy. Others perform the decompressive laminectomy you described. A third option is to have a spinal fusion after discectomy. The idea is to reduce the need for a second operation later by doing both procedures now.

The problem is that studies show patients who have spinal fusion surgery aren’t less likely to have another operation. In fact, just having back surgery of any kind increases the risk of reoperation at a later date.

And the rate of complications goes up when discectomy is done with a spinal fusion compared to discectomy without fusion. Age is a factor, too. Older patients have a higher risk of problems after spine surgery. They are more likely to end up in a nursing home after a spinal fusion.

Talk to your doctor about your case before making a final decision. Take into consideration your general health, diagnosis, age, and research findings to date. So far it looks like the more conservative surgical approach is just as good as combining several operations together.

I live in a large city with several teaching hospitals around. I’ve been to several doctors in different clinics for my problem with back pain. Every one has a different idea of what to do. I can’t help but wonder if I lived out west in a small, rural town, what kind of treatment would I get there?

You might get exactly the same treatment you’ve received in the more urban populated area. A recent study of trends in treating back pain came up with some surprising findings.

For example, the rate of spine surgery is much higher in western states compared to the East Coast. There’s a wide range of treatment offered across the U.S. but the same is true just within individual states, too.

Overall trends show that spinal fusion has risen dramatically in the last 20 years. MRIs have made it possible to identify disc problems more readily. Along with this has come increased reliance on surgery to correct the problem.

In the U.S. the number of people with back pain is about the same as in other developed countries. The difference is that surgery is used two to five times more often here than in other countries like England or Scotland.

More studies are needed to find out what works and why. Choosing the right treatment for each patient and having the best outcome is the only way to solve the problem of overuse of surgery.