FAQ Category: Lumbar Spine

The long-term benefits and results of interbody cage lumbar fusion (ICLF) are largely unknown. Research is limited. Much of what has been reported so far comes from the companies that designed and made the cages.

Doctors at Duke University recently reported on a group of 56 ICLF patients two years after the operation. The results were similar to low back pain patients who had other kinds of operations. They found the fusion worked just fine but the patients often had more pain and less function afterwards. Even two years later, a large number of patients were disabled and unhappy with the results.

The study found a strong link between surgery results and psychosocial factors. Depression, smoking, and a pending lawsuit are three factors most likely to cause poor results after spinal fusion. The researchers suggested patients who smoke or who are depressed should get treatment for these issues before surgery.

There are different ways to look at patient satisfaction. Is the quality of life better after the operation? Does the patient have less pain? More function? If they had to do it all over, would they have the same operation again? These are some common measures of patient satisfaction.

A recent study at Duke University of results after fusion reported many patients were more disabled after the operation. All patients had a spinal fusion using interbody fusion cages. Even so 64 percent of the patients said they would have the same operation again.

Researchers find this outcome puzzling. They suggest patients are so distressed by the time and money spent on the surgery, they feel obliged to say they would do it again. Or perhaps the results of the operation were disappointing but it was better than doing nothing about the problem.

A history of low back pain is really the most powerful predictor of future episodes. If you haven’t had back pain yourself yet, that’s a good sign. Whether there’s a genetic component to back pain or not remains unknown.

There are other risk factors to consider. Many studies now show social and psychological factors are the most important. These may be even more important than the condition of your spine.

People who are depressed or who tend to “feel” their pain more than others (called amplification) have more back pain. This is true in the short-term as well as over a longer period of time.

Findings on X-rays, CT scans, and MRIs don’t always match up with patient’s symptoms. Many times the spine is in a state of moderate to severe degeneration and the patient is pain free. Other times the patient is disabled with only mild degenerative changes in the spine.

Good posture, proper lifting, and daily activity and exercise are still the best prescription for preventing back problems.

Discography is used to see if the disc is the source of pain in patients with neck or back or pain. During discography, a dye is injected into the disc. The patient’s response to the injection is observed. Pain that is similar to the patient’s back or neck pain suggests that the disc might the source of the pain. Computed tomography (CT) is usually done after discography to look for actual changes in the disc.

The main reason to have a provocative discography is to find out if a patient with chronic back pain needs a spinal fusion. This is done in someone who has failed all efforts at conservative care. The results from discography are an important part of the preoperative evaluation for most patients. However what makes for a “positive” test isn’t always clear.

A recent study at Stanford University showed provocative discography can’t predict the future. Some patients with a positive discography never had any more episodes of back pain. Others with a negative discography developed back pain lasting as long as one year. This second group had other psychological problems.

Discography is just one of many tests used to help doctors and patients make decisions about back pain care and management.

Studies suggest it may be a little bit of both. Heavy lifting is a predictor of future episodes of back pain. This could be the case of mechanical overload: lifting more than the spine is designed to handlt. Back pain is more likely to go away and stay away when there’s a decrease in the workload.

There may be a fear factor here in that a person’s back starts to hurt when the person avoids certain movements in order to prevent injury. Studies show greater psychologic distress in patients doing heavy work compared to part-time workers or workers on light duty.

In a recent study from the Perth Pain Management Centre in Australia, researchers made some surprising findings about back pain sufferers. After successful treatment of disc problems, patients still used the same amount of medication. Like your husband, the patients did not return to work as expected.

These two findings prompted the researchers to make two suggestions. First, chronic pain
sufferers may have some drug behaviors that require medical or psychologic treatment. Second, there might be factors besides pain and physical function keeping patients from
returning to work. Again, psychologic or behavioral intervention may be the best way to approach this problem.

Conscious sedation means you are awake but calm and free of fear or anxiety. This type of sedation occurs with the use of oral sedative agents. The result is to reduce pain and discomfort. The patient is able to speak and respond to any requests made by the surgeon. If any pain occurs the patient is able to report changes to the surgeon.

Conscious sedation is used when minor operations are performed. In the case of disc surgery, sometimes the surgeon needs to know if the nerve is being touched or pressed. The patient is awake and alert enough to report any increased pain sensation.

In deep sedation the patient is unable to breathe without help and unable to respond to physical stimulation or verbal commands. A general anesthetic given intravenously is used to achieve this state.

Many studies report up to 80 percent of all adults will have back pain at some time in their lives. Physically active and fit adults are less likely to have back pain.

Athletes do report low back pain from time to time. The rate of back pain is higher among athletes who are involved in several sports events. It’s lower than in the average adult population.

Triathletes involved in football, track and field events, distance running, tennis, weight lifting, skiing, gymnastics and/or wrestling have reported back pain in up to 63 percent of the athletes.

Back prevention is always a good idea in all ages and for all occupations. Physical activity and exercise, proper posture, and using safe ways to lift may help reduce back pain.

Physical activity and exercise are advised for back pain, but this usually refers to chronic back pain (lasting three months or more). In acute back pain following an accident or injury, rest and light activity are more appropriate.

Most ski instructors lift, carry, reach, bend, and push/pull equipment and people during work hours. In the acute phase of a back injury, any of these activities can lead to further injury. In addition, it’s common for some ski instructors to spend long periods of time standing. This type of inactivity can cause muscle spasm and increased symptoms.

You might want to take a day or two off if you have sick leave available. Rest and recover before hitting the slopes again. If possible ask for a reduced workload when you first come back. This may help ease you safely back into a full-day schedule. Take some time to get warmed up before jumping into your regular activities.

A study from the early 1980s reported back pain in about 66 percent of truck driver. This is less than the average of 80 percent in the general adult population. A more recent study in 2000 reported a 50 percent rate of back pain in over-the-road truck drivers. The reduced rate may be attributed to improved seat design in today’s modern trucks.

Fatigue, vibrations, and prolonged sitting are risk factors for back pain in truck drivers. There may be muscle or tendon damage rather than structural changes to the discs or spine. Drivers who are unhappy with their jobs are at increased risk for back pain.

Current thinking is that the back is protected by muscles whenever it is pushed off balance or overloaded. The concept of spinal stability, a “steady spine” is in the forefront of research today.

Injury can occur any time the muscles don’t protect the motion segments of the spine. Exercise is important for three reasons. It improves strength, endurance, and coordination of each muscle.

Recent attention has been placed on training the “core” muscles of the spine and pelvis. These include the abdominals, hip flexors, and back extensors. The jury is still out as to whether or not a core-training program really makes a difference. Studies are underway even now.

Even if the core training program doesn’t accomplish all three reasons for exercising, you’ll likely benefit in one or more ways. A physical therapist or qualified fitness professional can help you find areas of muscle weakness or imbalance and design a program to meet your specific needs.

Disc degeneration is a common and troublesome source of low back pain for many people. When conservative care fails, spinal fusion is often the next step. As you pointed out, there are many advantages to spinal fusion.

owever, sometimes it doesn’t work. In fact, up to half the spinal fusions fail to fuse leaving the patient in pain with ongoing disability. Pain at the donor site is a problem. Bone taken from the pelvic bone is often used in the fusion. Some patients have more pain along the donor site than where the fusion is done.

Other pitfalls include bone spurs around the area of fusion or disc degeneration above or below the level of fusion. An unstable spine may be the final result.

There are two main kinds of spinal fusion based on where the bone graft is placed. The first is a posterolateral fusion. Bone graft is placed along the back of the spine joining the transverse processes of two vertebrae. The transverse process is part of the
bone that sticks out to the side and attaches to the rib.

Screws and rods are used most often to hold the vertebrae together while this type of fusion is healing.

The second type of fusion is called an interbody spine fusion. In this fusion, the bone graft is placed in between the vertebral bodies. The disc is taken out and the bone graft goes in its place. This fuses one vertebral body to the other.

The graft can be placed in between the vertebral bodies from the front or the back of the body. Using an incision in the abdomen to get to the spine is called an anterior approach or anterior lumbar interbody fusion (ALIF). The graft can also be placed from a posterior approach through the back. This approach is called a posterior lumbar interbody fusion or PLIF.

Using both kinds of fusion at the same time increases the chances for a solid fusion. This type of surgery is referred to as a 360-degree fusion. It’s like using a belt and suspenders to hold the spine together.

Make an appointment to see the surgeon again. You’ll likely need an MRI to see what is going on. It could be a re-herniation. If that’s the case, then you may be a candidate for a discectomy–the removal of the rest of the disc.

Treating disc herniation with conservative measures may be an option. Sometimes physical therapy and anti-inflammatories can help re-align the disc during the healing process. When these fail, then surgery is the next best option.

Back and leg pain with numbness and weakness are signs that the disc is pressing on the spinal nerve. See a doctor soon because nerve damage can cause permanent disability.

Actually, it is possible to have a sequestrectomy. That’s the medical term for taking out the free-floating disc fragments. This isn’t usually done because of the concern for a second herniation of the damaged disc.

But doctors are starting to re-think the standard discectomy or removal of the entire disc after herniation. Taking the whole disc leaves a narrow disc space. The ligaments and nearby capsule are affected by the change in disc height. The spine can become unstable without the disc.

A recent study compared discectomy with sequestrectomy. Patients with just the fragments removed were happier with the results. They also had fewer second herniations. More studies are needed to follow patients long-term before a change in treatment will be made.

Complete removal of all disc material is impossible. It’s true the surgeon will take out as much as possible, even scraping the endplates where the disc attaches to the bone.

A total discectomy is done to reduce the chances of another herniation. If any portion of the disc remains (even a small fragment or piece), problems can develop later. The disc fragment can move within the spinal canal or lodge against the spinal nerve causing nerve compression.

You may be having symptoms from disc re-herniation at the same level. You could be having problems with the disc above or below the previous level of herniation. The best way to find out what’s going on is to see your doctor. An exam and imaging studies will help clear up the cause of the problem. A new treatment plan may be needed.

All very good questions. Exercises using the Swiss ball have become very popular. Using the ball may help strengthen the core muscles. The core muscles hold the bones in the spine together. They are deep inside the trunk and give us stability rather than generating movement.

Core training is used by many people to prevent back injury. Athletes hope to improve performance by doing these same exercises. Patients with low back pain include them in their rehab program. The truth is there’s little proof that one type of exercise is better than another for acute or chronic low back pain.

Most studies support the benefits of a general exercise program. Unless you’re training for a specific sporting event, it’s best to engage in some kind of exercise on a regular basis. Find a form of exercise you like and vary your program. Your body and your health
will both benefit.

There are some studies that support the use of stabilization exercises for low back pain. Stabilization exercises are sometimes called core training. Specific muscles in the spine and abdomen are strengthened in this program. The data shows a reduced risk of repeated bouts of back pain after doing core exercises.

At the same time studies show that core training works better when combined with manipulative therapy. The patients who got the best results had a recent onset of back pain rather than long-term, ongoing back pain lasting months to years.

There are fewer episodes of repeated back pain when core training is used compared to medical treatment with advice and pain relievers. Core training compared to general exercises showed no difference in results.

For acute strain your best bet is to try both at the same time. For chronic, long-term pain that comes back often, try a program of general exercise on a regular basis.

This would be a good question to ask your physical therapist. Sometimes increased pain or discomfort in the central low back area is expected. Increased pain down the leg suggests the need for re-evaluation.

It’s important to make sure you’re doing the exercises correctly. Starting at a slow pace is often the best. Adding more exercises slowly over time can help you avoid re-injury. Most exercise programs start with easier exercises and then go to the harder exercises.

This type of graded approach can help reduce your fear of back pain with movements. It can also help ensure patients continue to do their exercise programs over time.

Exercise is known to help reduce back pain and disability. Don’t give up but don’t keep going until your therapist rechecks the way you are doing the exercises and your progress over time.

Some studies show the longer the fusion, the worse the results. Others claim that choosing the right patient determines the outcome. For a successful fusion of any length, there should be no history of psychologic problems. Patients with a spinal fracture, infection, or tumor should not be fused either.

There are two factors to look at: 1) patient satisfaction after the operation and 2) success rate of the fusion itself. Doctors agree that a successful fusion doesn’t always mean the patient is happy. Pain and loss of function can occur even when the fusion appears perfect. Quality of life (QOL) goes down for most patients in pain who can’t resume their normal activities.

A new study compared two groups of patients with lumbar spinal fusion. One group had a short fusion (one to two levels) while the second group had a long fusion (three to five levels). Both groups had the same good results when reporting on QOL. The long fusion
group had fewer successful fusions and needed a second surgery more often.