FAQ Category: Lumbar Spine

Spinal instability can mean different things to different doctors. There isn’t complete agreement on one single definition. Some doctors use patients’ symptoms as a measure of spinal instability. Painful “catching” during movement, blocked movement, or just persistent pain over time can point to an unstable spine.

Others doctors take X-rays and look for too much slipping or tilting of the vertebrae during movement. If you talk to physical therapists and other exercise specialists, spinal instability is defined in terms of muscle control. Poor posture and weak core trunk and abdominal muscles lead to an unstable spine.

A recent study in Japan used side (sagittal) views of X-rays to measure two things. The measured how much the bones slip or move forward and back while the patient was bending and extending. This is called translation. They also looked at how much the vertebrae angle or tip forward and back during the same motion (angulation).

Then they compared these two measures with patient symptoms. They found that symptoms are worse when there’s too much translation. Too much angulation by itself doesn’t seem to make a difference. Too much of both movements is linked with chronic low back pain from instability.

Ask your doctor for his or her definition of instability to get a better understanding of your own case.

When a disc pushes out of the sac that holds it in place, it can press on the nerve root at that level as it leaves the spinal cord. Enough pressure can cause back pain that goes down the leg.

During the SLR test the patient is lying down on a table and one leg is lifted off the table. This movement stretches the nerve and reproduces the painful symptoms when there’s a disc problem.

The MRI helps show the exact spot and how big the bulge is. If the SLR is negative, further tests are done by the doctor in the office. The cost of the MRI is saved when no other tests point to a disc or spine problem. The MRI helps the doctor see how much pressure is on the spinal cord or nerve root. Too much pressure may require surgery to keep the patient from having permanent nerve damage.

Back pain affects most people at some time in their life–usually beginning in mid-life. When the pain isn’t caused by a single problem, it can pose a big mystery. About 80 percent of back pain sufferers get better and return to their previous activities.

Most of these folks are labeled with mechanical low back pain. This means that the bones and soft tissue structures of the low back area may not be lined up and/or are not moving properly. Usually it’s not something that shows up on an X-ray or MRI.

In cases like these, physical therapists categorize back pain based on which movements cause the pain. So if bending and twisting increases your pain, you may have a Rotation-Flexion problem. If rotation with extension is painful, you would have a Rotation-
Extension problem. Some patients only have pain with extension have an Extension Syndrome.

With this model, the one-size-fits-all notion doesn’t work. Treatment is individual to each specific movement problem.

More studies of this type are being done as the number of health care dollars shrinks. Sometimes it’s hard to compare patients because there are so many variables from patient to patient. A recent study of patients with disc-related back pain looked at one measure called the straight leg raise (SLR) test.

The private insurance company requires a positive SLR test before treatment is approved. They found some patients were up to 100 times more likely to have a positive SLR test if they were covered by a private manage care service. This was compared to patients in a worker’s compensation program where prior authorization isn’t needed.

It’s not clear yet whether the difference is related to the patient’s health, doctor’s exam, or insurance coverage. Maybe it’s some other factor altogether. More studies are underway to take a closer look.

You make a good point. Doctors may feel it’s necessary to document findings that aren’t really there in order to help patients get the care they need. This is especially true when preauthorization for treatment is required based on specific findings. If those findings aren’t there, then no treatment is allowed.

A recent study reported many doctors exaggerate the severity of patient’s symptoms. They may even report signs and symptoms that aren’t there. This deception is caused by the tension of what to do when the patient doesn’t have the exact problem covered by insurance.

Identifying the problem is the first step in changing these practice patterns. Helping patients get the services they need is called patient advocacy. More research is needed to support patients’ need for care while keeping costs down.

Spinal decompression is a way to remove bone from around the spinal cord or spinal nerves. It takes the pressure off these structures and reduces pain and other symptoms.

A recent study from the National Spine Network (NSN) reported patients have the best result after spinal decompression compared to other spine operations. First surgeries go better than repeat spinal operations.

Based on research, doctors suggest the following steps to a good result after spinal surgery:

You may be having what’s called referred pain. This means you are having pain in an area some distance away from the actual problem. The reason this happens has to do with the nerves and how they work.

pinal nerves leave the spinal cord and travel down the back to the buttocks, legs, and feet. Anything that can put pressure on the nerve can send pain messages down the nerve to areas further down.

The doctor can usually tell which nerve is aggravated based on the location of your symptoms. Pressure on the nerve can cause back, buttock, or leg pain. Usually the patient has back pain that goes down the leg. This is called radicular pain. But it’s possible to have just the leg pain without back pain from the same problem in ths spine.

Pressure on the nerve can also cause numbness, tingling, or an electric shock sensation. Let your doctor know if you develop these or any other symptoms. Early treatment is the key to a good result.

You didn’t say what kind of surgery you had in the past or plan to have in the future. Results do vary depending on the type of operation. For example, a recent study of over 3,000 patients who had back surgery did better when the operation was a spinal decompression instead of a spinal fusion.Decompression takes the pressure off spinal nerves.

Studies show that most patients do better after their first back operation. A second or third surgery doesn’t have the same chance as the first one for an equally good result. In fact less than half the patients who’ve had surgery before report improvement after the second operation.

This information doesn’t mean you shouldn’t have the operation. Research shows that patients who have good rehab have the best results. Your rehab program should include management of your physical, social, and psychologic well-being. Talk to your doctor about getting a referral to a rehab program after your next operation.

<Many doctors, dentists, and even massage therapists have started using an automated patient reminder service. A computer software program dials patients' phone numbers and leaves a prerecorded message about the next scheduled appointment. The service usually occurs about 24 hours before the next appointment.

There is a high dropout rate for back pain patients in treatment. Some, like you, have trouble making the appointments for a variety of reasons. Others get better and get back to work and daily activities without completing the program. Since there’s a high rate of back pain recurrence, patients are strongly advised to finish their rehab and practice good back care for the rest of their lives.

There are even some people who propose giving monetary incentives. This may help patients take better care of themselves. We don’t know if that will happen anytime soon, but it can’t hurt to ask your therapist for a reminder call for the rest of your visits.

Interferential therapy (IFT) is a form of electrical stimulation. Two or three currents of differing frequencies are used. Each one is slightly out of phase. When they get mixed together it makes a low frequency current. By doing this, there’s less resistance within the tissues so it can go deeper, and it’s more comfortable for the patient. These frequencies slow down or stop pain messages at the spinal cord level.

IFT is a popular method of treatment for low back pain in the British Isles. It’s used by many physical therapists (called physiotherapists) there for pain relief. The electric current is delivered to the tissues through patches or electrodes. The electrical device is a small, handheld, battery operated unit.

IFT has been in use for many years. Some recent studies on a similar form of electrical stimulation (called TENS) have brought the use of electrical stimulation under fire. The debate about the use of this treatment for low back pain hasn’t been settled yet.

There isn’t a simple answer to this question. Both types of surgery are being used today. Big changes have occurred in how both operations are done. Short- and long-term
results are being studied.

Fusion is meant to stop all motion in the spine at the level of the fusion. It doesn’t really change the original problem. For example if a fusion was needed because there’s degeneration, fusion only masks the true disease process. It doesn’t get rid of the
original problem.

Fusion works best when motion is causing the pain. The segment gets fused and can no longer move so the pain is gone. Fusion can cause increased motion at the level above or below the fused site. This may increase damage faster and sooner at those levels.

Disc replacement corrects the abnormal motion. The space between the vertebra is kept
open. The patient gets pain relief and return of function. Problems can occur if the artificial disc isn’t put in place just right. The disc can also crack or break. They don’t last forever and may only hold up 10 to 20 years.

Studies comparing fusion to implants have mixed results. The best patient for a disc replacement seems to be someone with only problems at one level in the low back area. The doctor must have good training and experience to get the best results.

Disc replacements or artificial discs are fairly new on the scene. The idea has been around for 35 years, but most designs have never made it to the market. Of the ones that have been made, used, and studied, results are limited to the past 10 years.

In Europe where artificial discs have been used longer than in the United States, plastic implants show little to no wear after 10 years. Researchers estimate the discs will last longer than total hips or total knees. Motion in the disc is far less than what’s present
in the hip or knee joint. This may account for the minimal wear seen.

One disc implant called the Charité artificial disc has specially coated plates to help bone grow around the plate. This will help hold it firmly in place. The plates come in five shapes to match the patient more closely.

Special moveable parts allow it to slide forward and back slightly during motion. This helps in case the implant is positioned just slightly off center at the time of the operation when it’s put in place.

All of these features will help disc replacements last 20 years or more–perhaps even for a lifetime!

The debate over heat versus cold is an old one. Cold is still the number one choice for an acute injury–that means during the first two or three days. This helps slow down the amount of swelling and inflammation at the site of the injury.

Heat after that can help carry away waste products and debris that’s building up from the inflammatory process. Heat can also relax muscles, thus reducing pain from spasm. For
chronic injuries, aches and pains, patients are often advised to use whatever makes them feel better.

For some that’s a heating pad. Others still prefer a cold pack. Neither one should be left on for more than 20 minutes at a time. So to answer your question: who’s right? You both are: ice for acute injury, ice or heat for a chronic problem like back pain.

And to throw a monkey wrench in at the end: movement, physical activity, and exercise are still the best treatment for chronic low back pain. So for the best results, once you’ve used your heating pad, get up and go for a walk or engage in some other form of exercise.

Obesity has been linked with more problems after surgery–even sudden death from a heart attack. Wound infections and blood clots are two other big concerns. The effect of obesity on results after lumbar surgery has been reported.

Four spinal surgeons reported on the results of lumbar surgery in 298 patients. Obese patients didn’t get as much pain relief. More obese patients were unhappy with the results. But many obese patients said they were ‘somewhat satisfied’ or ‘very satisfied.’

The authors of that study suggest obesity doesn’t always keep patients from getting the operation they need. The doctor must think about all the other factors before making a final decision. This includes the patient’s age, and overall general health. The presence of other medical conditions and health concerns is also important.

There are mixed results from research today on this topic. Not all studies agree that obesity is automatically linked with problems after an operation. Some complications depend on the patient’s age. For example urinary tract problems are more common in older men with prostate problems.

Women who are obese who have diabetes and peripheral vascular disease are more likely to have a poor result. This can range from no change in function to death from heart attack. Wound infection, heart failure, and blood loss are just a few of the other possible problems.

That’s a very practical way to look at things. Countries with national health insurance do withhold care of this kind for patients over a certain age. Even in the United States, some treatment isn’t always advised based on age.

For example treatment for some kinds of leukemia in an adult over age 70 doesn’t increase life expectancy. Therefore it isn’t recommended for most patients in that age group. But when it comes to orthopedic surgery, advanced age isn’t always a problem. In fact, the rates of surgery have almost doubled in the last 20 years.

Poor health or other medical problems are more likely to increase a patient’s risk of problems after an operation. Heart disease, diabetes, and obesity are the top problems to consider. Since an 86-year old in good health could live another five to 10 years or more, surgery isn’t withheld on the basis of age.

You’ve made a good observation. Finding what makes your pain better or worse can help the doctor or physical therapist diagnose the problem. The next step is applying the right treatment for the problem.

What you’ve described could be caused by one of several things. There could be a muscle imbalance in your back, trunk, buttocks, or legs. There could be a problem with the alignment of the bones in your spine, pelvis, or hips. It’s possible that this movement problem doesn’t have anything to do with your back pain.

The best way to find out is to have an exam. If your pain and rotation don’t go away within two to four weeks, have someone take a look. Try to find an orthopedic doctor or physical therapist who specializes in back problems. Write down any other things you notice about your pain and movement. This can be very helpful for the examiner.

Artificial discs have been around long enough to go through several changes. Research is ongoing. As a result sizes, shapes, and materials keep changing for the better. As you say, the materials are metal, plastic, or ceramic.

Each disc is made up of two or three moveable parts. This could be metal on metal, metal and ceramic parts, or metal/plastic design. The all-metal implants can rub and cause tiny
flecks of metal debris. Problems can develop as a result.

The ceramic parts can shatter or break without warning. Plastic wears out sooner than metal or ceramic. The good news is that discs last much longer than hip or knee replacements. It has freer motion in the spine with less stress.

Ask your doctor for his or her opinion as well. Many doctors tend to use one material more than another and have some experience with long-term results.

Back pain still outnumbers neck pain. At least eight out of 10 adults (80 percent) suffer back pain some time in their lives. This compares to about 67 percent of adults who report neck pain. But you’re right about the rise of neck pain with computer use.

As Americans sit more and become less active, neck and back problems continue to rise in number. Finding ways to prevent this problem is the first step. After that, fast relief of symptoms will reduce suffering and lost time at work.

There’s an even greater problem in all this. Recurrent symptoms (either back or neck pain) are common. That’s all the more reason why scientists are interested in finding ways to prevent the problem in the first place.

Sudden pain upon awakening may be nothing more than staying in one position too long. Do you tend to sleep on one side for a long time? Does the pain go away once you start moving around?

A quick way to find out if position is the problem is to put a pillow between your legs. It must be fat enough and firm enough to hold your legs hip width apart. Make sure your knees and your ankles are supported by the pillow. This will keep one leg from hanging
down over the other leg, a position that puts hip muscles on stretch.

You may change positions in your sleep and lose the pillow. Just put it back between your legs if you wake up any time during the night. If your symptoms persist or you develop other symptoms, make an appointment with your medical doctor. If there’s nothing seriously wrong, seeing a physical therapist or a chiropractor may be the next step.