FAQ Category: Lumbar Spine

Medicalizing a problem means giving a patient the idea that a problem can be “fixed” or “cured” by someone else. The patient takes a very passive role in his or her own health care and recovery.

In the medicalization model the patient takes very little responsibility. When treatment is stopped, the symptoms come back or the patient gets worse.

The best program for most back pain is one that promotes patient confidence in movement. Fear of pain can result in avoiding certain movements. This sets the patient up for more pain and creates a vicious cycle of inactivity and pain.

Information and advice about back pain, back care, and exercise seems to be the most effective for acute back pain. The more a patient can do for him or herself, the better.

Using the “better,” “same,” or “worse” method is actually a good tool if you think of these three places on a line or a continuum from left to right with ‘better’ at one end, ‘worse’ at the other end, and ‘same’ in the middle. It gives the health care professional an idea if you are headed in the right direction (better) or not.

There are many other tools available to use. One is called the numerical pain rating scale or NPRS. It’s a line just like the better-same-worse scale. On the left of the scale is the number zero (0) indicating no pain. The numbers go up as you move to the right with the number 10 at the far right showing “worst pain” imaginable.

The NPRS has been tested many times and found to be reliable and valid for use with patients in the clinic or with research. You may have seen a similar scale using faces to show how the patient feels. At one end is a happy face. At the opposite end is a sad, painful face. There are several faces in between. This scale was always used with children but it’s become very popular with adults, too.

The real key is to use the same scale each time to assess for change. Moving in the wrong direction (worse) is a signal that something isn’t right. Moving two points toward higher pain or worse function should be examined more closely.

The scale you’re using is called the numeric pain rating scale (NPRS). It’s a valid way to measure pain and change in pain, especially after treatment.

Patients who improve by two points or more can give the credit to the treatment, the passage of time, or both. A change for the worse by two points or more is a sign that you need to check back in with your nurse or doctor.

It may be you just need a change in medication. Or perhaps you overdid it and are suffering the fallout for a few days. But any worsening of symptoms without an apparent cause is reason enough to go in for a recheck.

Don’t throw the scale away. It’s a good way to judge what’s going on and what to do next.

It wouldn’t be surprising either way at this point: improvement or no improvement. Getting “better” can be gauged in different ways. Do you have less pain? Can you sleep through the night? Can you get in and out of a car easily and without pain?

Measures of pain, motion, and function may vary from day to day but overall are you seeing some change? Some health care professionals like to use the numerical pain rating scale (NPRS) to measure change.

The patient circles a number on a straight line from zero (no pain) to 10 (worst pain). This can be done before treatment begins and then everyday, every week, or every month after for comparison.

The amount of change expected may depend on what kind of injury you had. Most soft tissue injuries heal completely in four to six weeks. The first 10 days are usually the most painful with a slow improvement from there.

Patients with chronic pain lasting more than two or three months from the time of injury may not see a change in pain on the scale. They would do better to look for change in function by asking, “What can I do now that I couldn’t do yesterday? Last week? Last month?”

Spinal fusion grafts the two vertebral bones together so they don’t move. Motion is lost but the segment is stabilized. This helps reduce pain. The main problem with fusion is degeneration at the next level (either the level above or the level below).

On the other hand, lumbar disc replacement (LDR) preserves motion. The idea is to prevent adjacent level degeneration and prevent future recurrence of pain. Often a fusion at one level requires a fusion later at another level. The LDR may prevent that from happening.

We say “may” because long-term results aren’t available yet. Some studies have data up to eight years. There are no studies yet that follow patients for the life of the implant
(15 years).

That’s a good question. There are two kinds of motion to consider. The first is the exact amount of increased motion that occurs in the vertebra because of the new disc. Then how much does this motion translate into actual bending forward or backwards?

Studies are just coming out with some long-term results of motion and function. A recent study from France linked increased motion with improved function. Patients were followed for 8.6 years, which is about the halfway mark for the life of the implant. Increased motion ranged from two degrees to 18 degrees.

It remains to be seen how patients fare after that. It could be that the increased spinal motion at the disc-vertebral interface helps protect and preserve the spine. It may be that given enough time, there will be degeneration caused by the increased motion. At this point, we just don’t know what’s the ideal amount of motion after LDR.

It’s true that some patients have more motion than others after a total disc replacement (TDR). Doctors and researchers aren’t sure why this happens. It’s widely known that different people have different motion. In fact, different spinal levels within the same person have different amounts of motion, too. Maybe these two factors make a difference.

Based on studies of other joints and previous spine studies, it appears that patients with more motion before surgery have more motion and a better result after spinal surgery. Some research seems to suggest different TDR implants have different results, too. A slightly different design may make a difference in outcomes.

It’s also been shown that early movement without bracing results in greater spinal motion. Doctors want to get to whatever is causing the difference so they can give patients the best results possible. More research is needed to sort this all out.

There are several possible reasons for this difference. Sometimes it depends on the coding used to describe your condition. You may both have back pain but you may not have the same diagnosis. Cost and insurance coverage can vary depending on the problem being treated.

You insurance coverage may also determine what is billed and what is paid. Deductibles, copayments, and coinsurance can all make a difference in the final billing.

Costs can also vary based on how much time the patient is with the doctor. Extra tests such as X-rays, MRIs, or CT scans may add to the total bill for one patient but not another.

To know for sure, you’ll need to talk to the billing staff in the doctor’s office. Don’t hesitate to call and check it out.

The abdominal muscles are targeted with this exercise. In particular, the transverse abdominis (TrA) is contracting. Studies show that in normal movement the TrA contracts first before the arms and legs move. It’s likely that the TrA is stabilizing the spine during active movement.

Research has also shown that patients with low back pain (LBP) have a delay in TrA muscle contraction compared to people without LBP. Rehab to regain normal muscle contraction helps decrease LBP.

There is a series of lumbar spinal stabilization exercises. You might be ready for the next level. Let your therapist know the exercises seem easy and see if you’re ready to move on.

At each level in the spine there are a pair of small joints called facet joints (25 pairs in total). The facet joints allow movement between two (or more) vertebrae. The shape and direction of these joints changes in different parts of the spine making different types of local movement possible (bending, extending, twisting).

Arthrosis means joint disease. Inflamed osteoarthritic joints can cause low back pain (LBP). This occurs most commonly at L4/5 and L5/S1 in the lumbar spine. Scientists have shown that facet joints are usually not the single or primary cause of LBP. Disc disease and degeneration can also cause low back pain. Sometimes people have both.

Lysis means to break down. Nucleolysis refers to breaking down the contents of the center or nucleus of the disc. Various methods of nucleolysis have been tried and tested around
the world.

Chemonucleolysis is the injection of an enzyme into the disc. This enzyme called chemopapain causes the proteoglycan to shrink. The proteoglycan is a jelly-like substance that allows the disc to hold water. When the proteoglycan can’t hold water, it
shrinks. Less fluid in the disc takes pressure off the nearby spinal nerves.

The chemopapain had side effects in a small number of patients. The treatment isn’t used
as much anymore. Ozone therapy was the next idea tried. Ozone has three oxygen atoms. It’s injected into the disc through a narrower needle than chemopapain. There are fewer problems. The period of discomfort after treatment is shorter.

Thermal nucleolysis can be done by heating the nucleus of the disc with high-intensity ultrasound (US). Another form of heat-induced nucleolysis uses a carbon dioxide laser beam. About 75 percent of the patients who had this type of vaporization nucleolysis got
better.

Consider a total disc replacement if nucleolysis fails to improve your symptoms or function. The damaged disc is removed and the implant is placed between the two vertebrae. Your motion is restored with reduction of pain. If for some reason you don’t get the relief you hoped for, a spinal fusion is always a final option.

This is a very good question, and one you’ll need to ask your surgeon. There are many factors here. The position you’re in for the operation is certainly an important one. In some cases the patient is on his or her back with the legs apart (flexed and separated). The surgeon actually stands between the patient’s legs looking toward the patient’s face.

Your hip range of motion will be greater under the influence of the anesthesia than it is when you are moving it yourself. But there’s a danger of hip dislocation if the hip isn’t
supported or if the hip is moved too far out.

The surgeon will test your hip motion and check the joint for stability before doing any surgery with extreme positions. Still, it’s always a good idea to remind the doctor of any special considerations.

That’s a good question considering hip pain is rarely treated by fusion and that’s been the treatment for disc degeneration. Disc replacements actually date back to the late 1950s. The results weren’t that good. Without today’s advanced imaging, doctors didn’t know why.

Artificial disc replacements (ADRs) have made a come back recently. This is due, in part, to new understanding of how the spine works. Spinal motion occurs because of two joints and the disc. The spine bends forwards and backwards and sideways. Twisting to the right and left also occurs in the spine. Designing a disc that can do all those motions has taken quite a while.

Another reason ADRs are being tried again is the increased experience surgeons have gathered over the last 10 years with spine surgeries. Fusions and cage implants from the front of the spine (anterior approach) have shown that implants can be placed easily and safely.

Some doctors say ADRs are the wave of the future for the treatment of spine problems.

When you think about it, back pain from degenerating discs should be treated the same way hip or knee pain from arthritis is treated: joint replacement. It’s a rare patient that would have hip or knee fusion for joint damage from arthritis.

Fusion stops motion whereas an implant restores motion. The problems with fusion are usually related to increased movement at the level above or below the fusion. That won’t happen after disc replacement. Sometimes fusions fail because the graft doesn’t take and the spine still has motion. Up to half of all patients with a fusion still have pain.

As with any implant there’s always a chance for wear debris to cause problems. The implant can come loose or get infected. In time we will know better what problems to expect with artificial disc replacements. For now the results are very favorable.

The weight of the book gives an outside cue to “wake up” the abdominal muscles. They pay a little more attention when there’s an added stimulus. The book weight combined with the pull of gravity in this position work together to improve your muscle contraction.

Sometimes people start with a fairly heavy book. Over time the book is traded for a lighter one while still contracting the muscles with the same vigor. The goal is to be able to contract the abdominal muscles fully on your own without the added help.

A few cues may help you. With your spine level, take a deep breath in. As you let the air out, pull your belly button up and in. Think about touching the back of your spine with your belly. Think, “belly in, breath out.”

It’s a little like patting your head and rubbing your belly at the same time. It does take some time and practice to do it naturally without the verbal reminders.

As you bring your belly button up and in towards the spine you are actually contracting the abdominal muscles. These particular muscles help stabilize the spine. Coordinating the breathing helps keep the respiratory muscles from working against the abdominal muscles.

Your therapist should be asking you each time he or she sees you how you are doing (better, same, or worse). This information is used to progress or alter your treatment program. Let your therapist know right away what’s happening (or not happening) with you.

Research on traction has not shown it to be a reliable and effective form of treatment for low back pain (LBP). A recent review of the traction studies showed the fault may lie with research methods rather than the traction. More studies are needed to find out which patients (if any) get the best results with traction.

Based on clinical practice (what seems to work) rather than evidence-based practice (what has been proven effective) traction should have a lasting effect within the first four weeks.

Please make sure your therapist knows you’re having headaches. There may be a simple reason for this such as head and neck position during the lumbar traction. Headache as a side effect of traction is common in a small number of people.

Most of the time the effect is not serious or long-lasting. You shouldn’t really have to have pain or discomfort in another area of your body to help the problem area heal. Your therapist should review your case carefully. He or she will also help you weigh the pros and cons of traction versus other treatment.

Traction is used most often by physical therapists for the relief of neck and arm pain or low back pain with leg pain from nerve irritation. The traction is usually motorized in the clinic.

The patient lies down on a table and either the head or the pelvis is secured in the traction. As the motor runs, the table is pulled apart and traction is applied to the joints. The position is held for a short time and then gently released. The cycle of traction – hold – release is repeated during a 10 to 20 minute period of time. Weight applied varies according to the patient size and symptoms.

Traction can be used at home with a pulley and weight system for the head and neck. This is a form of gravitational traction. The patient is sitting or lying down with a traction sling around the base of the skull. The sling is attached to a rope that goes through a pulley above the patient’s head. Weights are placed at the bottom of the pulley to apply a downward pull thus putting traction on the head and neck.

You may have seen machines advertised on TV that allow you to hang upside down for relief of back pain or to keep your back healthy. This is another type of gravitational traction.

Autotraction is another type of traction. Basically, the patient exerts the force on him or herself by pushing or pulling on the device. The therapist can also apply manual traction using his or her hands to apply a pulling force on your head or pelvis.

There are four different artificial disc replacements (ADRs) today. They can be divided into two groups based on the materials they’re made of. One group has metal-on-plastic surfaces. The second group is metal-on-metal.

The second way to classify ADRs is by their movement. The normal, healthy spine has six separate motions. Compression and load are two other forces put on the spine with everyday movement. ADRs can be “constrained” or “unconstrained” depending on any restrictions in normal motion.

As to the actual device, some ADRs are made up of a single piece press-fitted together. Others have two or three separate pieces with a ball and socket design. The end plates are secured to the bone by spikes sticking out of the top and bottom pieces.

It’s likely that ADRs will continue to evolve and change as research finds out what works best for patients.