FAQ Category: General Spine

When a doctor advises you to participate or not participate in certain types of activities, it’s always best to speak with the doctor to clarify what he or she means and to understand in the reasoning behind the suggestion.

It is possible that the exercise you are used to doing will place additional strain on your back and will affect or delay healing. However, there are usually activities and exercises people can do even if they do have chronic lower back pain.

To learn what type of exercises you can do, either speak with your doctor or a physiotherapist who can explain to you what types of movements you can do and what types you should avoid.

Back care education is often a large part of rehabilitation and treatment following a back injury. The type of education that is the most effective has been the subject of studies, but no firm outcome has been determined.

Employers whose employees do activities that can result in back injuries often have back injury prevention information available, however, that may not be enough. The general public can ask their physicians or at a local physiotherapist for literature or information on preventing back injuries. There is also a great deal of information on back injury prevention available on-line on the Internet.

Surgeons are on the hotseat (so-to-speak) these days. Insurance and third party payers are demanding proof that the intended surgery is likely to be successful. After the fact, if it’s not, payment may not be made to the doctor.

Providing evidence or proof that the operation is warranted and likely to be successful is a new requirement in the quest for evidence-based medicine. If there’s no evidence (or not enough evidence) that a procedure works, then patients may be denied pre-approval.

In an effort to identify patients at risk for a poor result after surgery, a biopsychosocial exam may be needed. A psychologist or psychiatrist conducts a complete exam of all potential surgical candidates before surgery can take place.

If the patient tests out at low risk, then surgery can proceed as planned. But if the patient’s test scores show he or she is at high risk for failure after surgery, then a pre-surgical rehab program is advised. Patients who do well and pass this phase can be rescheduled for surgery.

Patients who remain at high (or uncertain) risk may be required to complete both a pre- and a post-surgical rehab program. In some cases, surgery may be denied if the risk appears too great.

Both procedures are used to remove herniated disc material. In both operations, the surgeon uses a special microscope to guide the surgical instruments. With microdiscectomy, the herniated disc is removed along with the rest of the disc material. The surgeon uses a special tool to reach inside the disc space and pull the tissue out.

In the case of sequestrectomy, the surgeon does not enter the disc space at all. Only loose disc fragments in the intervertebral space are removed.

The short-term results of both procedures are similar. Patients have decreased pain and improved symptoms. However, by entering the disc space, discectomy may cause further damage to the disc. The result can be reherniation.

Studies are starting to show the superiority of sequestrectomy over discectomy. Over time, patients who have a sequestrectomy have better functional outcomes. Segmental deterioration occurs more often after discectomy.

Manual laborers may have an increased risk of on-the-job injury compared to workers with desk jobs. Accidents and injuries can be costly. Many work place settings have their own safety measures. So be sure and ask what safety standards are already in place and follow these closely.

Being afraid of a back injury can actually be a risk factor of its own. Scientists have found that people who believe they might hurt themselves if they perform certain movements or job tasks have fear-avoidance behaviors (FABs). Anyone with FABs may experience delays in getting back to work after a work-related injury. And they may be at risk for chronic disability after an acute episode of low back pain (LBP).

Educate yourself about LBP. Talk to your doctor or a physical therapist about ways to decrease FABs. There are educational, behavioral, and exercise strategies to overcome this problem. You will be able to perform your job tasks and duties safely. you will learn to do your job without avoiding movements and activities that you might have previously considered off limits or likely to cause another injury.

Yes, one place to start is with definitions. In 2006, a group querried researchers from 12 different countries and came up with two definitions of low back pain. One definition was a minimal definition, the other was an optimal definition to be used in epidemiological studies. The hope is that dissemination and use among researchers will be of benefit when comparing studies on low back pain.

Spinal manipulation should only be performed by trained professionals, such as chiropractors. There are some doctors of osteopathy who are qualified to do the procedure, but you should be certain that the person who is treating you is qualified.

To perform a manipulation, the chiropractor should evaluate the patient thoroughly to be sure there are no medical issues that would contraindicate (go against) a spinal manipulation. Once the evaluation is done and the chiropractor knows what he or she wants to do, the patient is placed in the appropriate position for the maneuver.

Using the “treating” hand, the chiropractor places the hand over or under the target vertebrae (spinal bone), using a slow strong force. He or she then thrusts quickly as hard as necessary to make the adjustment.

There may be a popping sound in the joint cavity with the thrust.

Ankylosing spondylitis (AS) is a chronic inflammatory condition in a group of diseases called spondyloarthropathies. Young men in their teen years or early 20s are affected most often. Back pain, stiffness, and postural changes are common.

There is no cure for AS. Treatment is centered around patient education and managing symptoms. Because of the inflammation, the first line of treatment is usually non-steroidal anti-inflammatory drugs (NSAIDs).

Physical therapy is a central part of the management program. The patient is set up with a home program of spinal extension exercises, deep breathing, and range of motion exercises. Strength training for core muscles of the trunk are also important. The patient is advised to do these exercises routinely (daily if possible).

More recently, biologic agents called tumor necrosis factor alpha inhibitors (TNF-a inhibitors) have been used with AS. These drugs are very effective in reducing inflammation and preventing flareups. Patients experience decreased pain and increased motion, which results in improved function.

A rheumatologist may be the best doctor to consult with about the best way to treat your nephew. Each patient must be evaluated individually. Finding the right drug at the proper dosage can take a bit of trial and error before the best results are obtained.

Patient satisfaction may be measured and compared in studies using different standards. Many times, more than one criteria are used. Sometimes pain levels are compared before and after the operation. Often, pain and function are reported. There are some specific tests to rate disability before and after.

Patients usually use their own means of determining satisfaction. For some, pain relief is the main goal. For others, getting back to work is important. Age may make a difference in satisfaction. Younger, more active adults may expect to resume all previous work and recreational activities. Older adults may be happy to be able to independently perform activities of daily living.

Surgeons often view the success or failure of a procedure differently than a patient. The surgeon uses X-rays to look at alignment of the bones and joints as one measure. Operative time, blood loss, and wound infections may be another group of variables used to determine success versus failure. Studies often include number of days in the hospital or total cost as measures. Some patients may include these in their assessment of satisfaction, but the majority rely on pain, function, and return to work status as their main measures of success.

Some sources use pain persisting beyond six weeks, others use three months as the required duration before calling a condition chronic.

The latest low back pain guidelines recommend that imaging should not be obtained for non-specific low back pain. The imaging could expose you to unnecessary radiation, and likely will not show any significant abnormalities.

You will want to discuss this with your surgeon for sure. Never take old, outdated medications for any reason without asking your doctor first. And never use a drug for more than one problem without consulting your doctor.

The use of nonsteroidal antiinflammatory drugs (NSAIDs) after a discectomy (removal of the disc) may be more effective when combined with a pain reliever such as morphine.

According to a study comparing patients having three different types of spine surgery, NSAIDs alone or morphine alone don’t work as well as putting them together. And the drug combination was only needed for the first 48 hours. After that, the drugs were discontinued.

There was no difference in adverse effects between the two groups. So, combining the two drugs together did not cause additional problems compared with just taking the morphine. And the pain relief was much better using the combination drug.

Your surgeon will have a standard protocol for pain control after discectomy. Ask what this is and how it might be used in your case. Bring all discarded or unused medications with you for review at your next appointment. Follow your doctor’s advice careful and throw anything away that should no longer be used.

In the normal spine, there is a disc between each of the vertebral bones. This intervertebral disc separates, supports, and cushions the vertebral bones. Each disc is made up of two basic parts. There is a gel-like center called the nucleus pulposus. The nucleus is surrounded by a stronger fibrous structure called the annulus.

Fissures or cracks can occur in the outer covering. If the tear goes deep enough, the contents of the nucleus can seep out through the annulus. This condition is referred to as a herniated disc. Pressure from the protruding disc material on nearby spinal nerve roots can cause back and/or leg pain.

If conservative care does not help reduce pain and other symptoms, then surgery may be needed. A partial or total discectomy may be done. If the entire disc is removed, disc reherniation is not possible. The surgeon may replace it with an artificial disc replacement (ADR). If the patient is not a good candidate for an ADR, then a spinal fusion is an option.

Disc reherniation can occur when only a portion of the disc is removed. If only the torn fragments of the nucleus are taken out, then it’s possible for the rest of the disc to herniate again. Sometimes the remaining disc protrudes in a different direction.

Disc reherniation isn’t a common problem. Often there is a traumatic event that occurs before the patient notices new symptoms. This could be a car accident, twisting or bending injury, fall, or other event.

Surgical site infections occur fairly often after spinal operations. Signs of infection often develop in the early days after surgery. Infections that occur in the hospital are called nosocomial. They are also known as hospital-acquired infections.

Proper handwashing goes a long way to prevent infections. But patients often bring their own risk factors when they come. Obesity, diabetes, or elevated blood sugars (pre-diabetes) are major risk factors for infection after spinal surgery.

Patients are usually given a prophylactic (preventive) antibiotic to help prevent infections. The medication is best given within an hour of the surgeon making the first incision. Results are less than optimal when the antibiotic is given too soon or too late.

Patients blood glucose (sugar) levels should be monitored before and after surgery. Keeping blood glucose levels below 125 mg/dL is the goal. This is especially true for any one with diabetes or pre-diabetes.

Patients with complex surgeries may require the skills of more than one surgeon. The more people in contact with the patient and the longer the operation, the greater the risk of infection. Some of these factors just can’t be prevented.

These are all very good questions that should be asked of the hospital staff. If you are there when the surgeon comes in to check on your mother, then you can find out directly. If not, then check with the nursing staff or social worker assigned to your mother’s case.

Some of these questions may not have a specific answer. For example, the patient’s response to antibiotic treatment is a key factor. And this may depend on how deep the infection is and the general health of the patient. Matching the type of infection with the most appropriate antibiotic is also important.

Surgical site infections are treated first with intravenous (IV) antibiotics. In some cases, further surgery may be needed. The area of infection may have to be debrided. This means the infected or dead tissue is removed. The site is flushed clean with a saline (salt) solution.

If there was hardware such as metal plates, screws, or pins that are infected, these may have to be removed. The surgeon makes this decision after debriding the area.

Patient factors that can affect recovery include bowel or bladder incontinence (leaking or accidents), diabetes, and obesity. Although nutrition is important in wound healing, malnutrition before surgery does not seem to put patients at risk for infection.

Discectomy is the medical term for removal of the intervertebral disc. The disc is a soft, supportive cushion between two vertebral bones. Discectomy may be needed for patients who have a herniated disc that does not respond to conservative (nonsurgical) care.

There are several techniques surgeons can use to take the disc out. Some of the differences in the various procedures are in the amount of disc removed or how the disc material is taken out.

During a subtotal discectomy, the surgeon removes the entire soft nucleus (inner core) of the disc. Part of the vertebral bone called the lamina is removed first. This procedure is called a laminectomy. By removing a piece of the bone, the surgeon can gain access to the disc.

Microdiscectomy is done with an operating microscope. A hole is drilled in the lamina to allow the surgeon to insert small instruments into the area around the disc. Only fragments of the disc that are found are removed. The rest of the nucleus is left intact.

Both methods are acceptable ways to surgically treat this problem. The choice may depend on surgeon preference and experience.

Mobility is just another word for movement. In the case of the spine, there are six different motions involved. These include flexion (bending forward), extension (bending backward), sidebending (right and left), and rotation or twisting (right and left).

Total motion of all six directions reflect overall spinal mobility. But each individual spinal segment can also be assessed for mobility. Special tests can be done by the therapist to identify each segment as normal, hypomobile, or hypermobile. Hypomobile refers to a loss of motion. Hypermobile is a state of increased motion.

There is still quite a bit of debate over the concept of normal. What one examiner feels as normal may be labeled as hypomobile or hypermobile by someone else. Studies are underway to help therapists accurately identify spinal segments that fall into each of these three categories.

Dynamic MRIs are being used to measure the actual motion in the spine. These figures are compared with the therapist’s clinical judgment. A recent study done at USC (California) showed that spinal mobility testing seems to be most accurate in finding hypomobile segments. Hypermobile are more difficult to detect.

As you probably know, there are many tests available to measure outcomes of treatment for back pain. Some, like the Visual Analogue Scale (VAS) or the Numerical Rating Scale (NRS), measure pain levels. Others, such as the Short-Form Health Survey (SF-12 or SF-36) focus on general physical and mental health.

Specific back function and disability can also be measured before and after treatment. The Oswestry Disability Index (ODI), Roland Disability Questionnaire (RDI), and the Quebec Back Pain Disability Questionnaire work well for this type of assessment.

Each test has its own standard of measure but most of these are based on a range from zero to 100. There are no hard and fast cut-off points. And sometimes the test results suggest significant change but the patient’s level of satisfaction or clinical improvement is still low.

An international panel of experts met in June of 2006 to discuss this problem. Their task was to agree on a minimal important change (MIC) for pain and back specific function. They based their guidance on the five tests mentioned here.

They proposed absolute cut-off values for each test and suggested an MIC of 30 per cent from the baseline. These figures are only a guideline. Further studies are needed to verify it. As always, each patient’s case should be evaluated for any factors that might change how the results are weighted.

You may want to consider setting up a research design to track the results. The hope is that with a standard baseline MIC value, treatment can be compared from center to center. The goal is to find out what works best for each patient or groups of patients. Using standard measurements and pooling research data of this type can really advance our knowledge in these areas.

Metallosis is the result of the body reacting to a metal implant. The immune system sees this device as foreign. It mounts a defense against the prosthesis (implant) and tries to rid itself of it. Inflammation and scarring around the implant are the result.

Anytime there is metal-on-metal, tiny flecks of metal are shaved off and released into the area. The particles are called debris. Debris of this kind set up a foreign-body reaction.

Bone and soft tissue can be destroyed as the body tries to respond to the metal ions. The final result can be failure of the implant. Bone loss results in loosening of the device.

Fracture, infection, or loosening of the implant often requires a second surgery. The prosthesis (implant) is removed and replaced with bone grafts and/or another device. This second surgery is called a revision.

Conservative care, which is treatment that does not involve anything that is invasive such as injections or surgery, is proven to be effective in most cases. Studies have shown that stopping the activity that could have caused the pain, wearing a custom fit back brace, and then rehabilitation to restore strength and range of motion is most effective. These limitations may need to be carried out for up to three to six months for optimal recovery.