FAQ Category: General Spine

Surgery is a big decision. Many things can go right. But many things can also go wrong. Fast relief of sciatica and low back pain is the usual reason for early surgical intervention. But pain relief is not guaranteed. Just as many patients feel better as don’t.

For those who do get relief, function improves and the time to recovery and return to work is much shorter. Certainly, in dollars and cents, this makes sense! And your productivity will be greater. This is a big factor for you if you are the business owner or self-employed. Otherwise, the boon goes to the owner of your company and to society.

Studies show that in the long-run, patients with low back pain and leg pain from disc protrusion will get better. Conservative (nonoperative) care often helps but also costs money. For those who are insured, there’s a cost to the insurer and usually a smaller cost to you, the patient.

So, if you don’t want to wait or can’t cope with the pain, then surgery may be advised. If there are signs of permanent motor damage (e.g., muscle weakness, foot drop), then surgery is often considered an emergency procedure. It must be done as soon as possible.

If you really just don’t want to have surgery, then there are some other alternatives. Acupuncture, chiropractic, nonsteroidal antiinflammatory drugs (NSAIDs), and physical therapy all have some potential for improving your symptoms without surgery.

A thoracolumbar spine orthosis (TLSO) is a back brace that is designed to limit motion in the spine. After a spinal fusion, it takes several months for the bones to knit together and form a solid bone fusion. Having a brace to support the back gives the soft tissues and bones a chance to heal. It also makes you more comfortable during the process.

Orthotists are well acquainted with their craft. They don’t usually need any extra input (unless it’s from the surgeon). However, there is one modification that has been reported to increase the rate of pseudoarthrosis (formation of a false joint at the fusion site). This is the addition of a thigh-extension. The extra piece goes around the thigh and is connected to the bottom of the lumbar jacket. It limits hip motion.

There isn’t any research that has specifically looked at this problem. It could be a coincidence. The number of people in the study was small so it may not be significant. But it does point to the fact that further study is needed to find out what works and what doesn’t (and why).

Spinal stenosis refers to a condition in which the spinal canal narrows pressing on the spinal cord and spinal nerves.

It is a problem that occurs as we get older. It is usually caused by degenerative processes. Arthritic bone spurs form around the joints, discs flatten out putting even more pressure on the joints, and the ligaments start to thicken. All these things impinge on the opening where the spinal cord or spinal nerve roots are located.

Spinal stenosis may affect any part of the spine but the neck and low back seem to be involved most often. Lumbar spinal stenosis is the most common. Patients with lumbar spinal stenosis have low back and/or buttock pain. They often have abnormal sensations, discomfort, or pain in the lower legs. In severe cases, there can be loss of bladder and bowel control.

There are different ways to classify stenosis. The international classification system breaks it down into several subgroups based on the underlying cause. These groups include (1) degenerative, (2) congenital/developmental, (3) spondylolytic spondylolisthesis, (4) iatrogenic, (5) post traumatic stenosis, and (6) combined.

Congenital/developmental is present at birth. Spondylolysis refers to a fracture in the supporting structures of the vertebrae. If the fracture line opens and the bone separates, one vertebra can move forward over the vertebra below it (spondylolisthesis).

Iatrogenic means it occurs as a result of some other treatment. Patients with the combined type may have several types of stenosis going on at the same time. This is apparently what is happening with your father.

Treatment depends, in part, on the cause and type of stenosis present. In some cases, conservative care can be very effective. For anyone who does not get pain relief with nonoperative care, surgery may be needed.

There are mixed opinions on this one. Some experts say the treatment is actually a diagnostic test of its own. If your pain is eliminated, then you know the source of painful signals is the facet spinal joint. If it’s not successful, then you’re no worse off than you were when you started.

Others disagree. They see no reason to continue with facet joint injections since studies have shown it’s not effective in relieving pain or improving function. Just because something doesn’t make you worse doesn’t mean it should be used.

Current back pain guidelines suggest the use of over-the-counter analgesics such as Tylenol or Ibuprofen. Non-drug therapies such as exercise and spinal manipulation are the next treatment approaches to consider.

Surgery has been shown to help relieve pain sooner but the long-term effects are the same. In other words, two years later, patients report the same outcome whether or not they had surgery. That is enough to suggest managing the pain and avoiding invasive operative care until the worst is over.

The treatment for osteochondroma is surgical removal of the tumor. If the tumor is large and removal makes the spine unstable, fusion or placement of hardware may be necessary.

Only one to five percent of non-hereditary osteochondromas become malignant Ten to 25 percent of hereditary tumors can become malignant.

A recent study of five female contortionists between the ages of 20 and 49 demonstrated several degenerative changes among all the participants. It is hypothesized by the authors of the study that extreme extension is probably the cause of anterosuperior limbus fractures, the most significant of the findings on magnetic resonance imaging. Three of the five contortionists had limbus fractures. Disc bulges, annular tears, and osteophytes were also among the findings. The authors did comment that given the extreme spinal extension of the contortionists, they had less spinal pathology than expected. This was hypothesized to be due to their rigorous training, starting at a young age.

The earliest symptoms are usually pain and change in sensation that correlate with the level of the spinal cord involved. As damage progresses, you may experience ataxia, partial paralysis, headaches, autonomic dysfunction, scoliosis, or swallowing problems.

The use of epidural steroid injections (ESI) has increased despite a lack of evidence to support it. Doctors and patients turn to its use when conservative (nonoperative) care has been tried and failed. They like it because it seems like a safe (and less expensive) alternative to surgery or opioid use.

But studies on the use of ESI report a wide range of success. Success rates vary from 18 per cent up to 90 per cent with ESI use. And it’s not clear yet how many, how often, and in which patients ESI should be used.

Some surgeons use ESI to pinpoint the exact cause of the problem. If they can find the pain generator, then surgery to deal with the problem can be more precise and accurate. In a recent VA study, the use of ESI did not reduce the number of patients receivingopioids (narcotic drugs). And it wasn’t always a substitute for lumbar surgery.

Before having a fourth ESI, your sister may want to explore other options. A multimodal approach to chronic pan is often suggested. This type of treatment combines many different treatments until optimal pain relief or control is obtained.

The problem of debilitating back pain has become an epidemic in the United
New ways to control pain are being developed. These measures include epidural steroid injections, spinal cord stimulation, and morphine pump. Use of epidural steroid injections has been shown to decrease the frequency and intensity of the pain. One to three injections are common.

Persistent pain from a failed back surgery can be a complex and challenging problem. It may take some time to sort all the factors and find the best treatment approach. The first step is to see a physician for a diagnosis. Once the problem has been properly identified, then a specific treatment plan can be determined.

More and more adults in the United States are having back surgery. This comes along with a higher number of patients who don’t get better after the first operation. A second surgery may be suggested. But only one out of three patients who have a second surgery report feeling better.

A review of the literature suggests why primary care specialists don’t have a quick and ready response for their patients with chronic back pain. There isn’t one! There is very little agreement on the best way to treat this problem.

Should the patient try physical therapy? If yes, what works best? If no, what is the next option? Should another surgery be recommended? What kind?

Right now, physicians are advised to use a collaborative multidisciplinary approach to this complex and challenging problem. This means working with other health care professionals such as the physical therapist, pain management specialist, and orthopedic surgeon or neurosurgeon.

It must have been a surprise to have the pressure put on the painful area – it might have been a good idea for the doctor to warn your mother if he didn’t. That being said, what her doctor did isn’t unusual.

When a patient comes in with lower back pain that has no obvious or diagnosed reason, it’s hard for the doctor to give a good treatment plan. If he or she can get a better idea of the pain, then managing it can become more realistic.

In your mother’s case, it could be that the doctor was looking if the pain was local (right at that area) or if she has referred pain, which means that if he presses on one spot, the pain is worse in another.

By knowing this, the doctor has a better idea of what is going on.

Flexion-distraction injuries (FDI) of the spine occurs as a result of high-energy forces applied to the trunk (and spine). Usually there is a flexion force against the chest strong enough to break the back. The distraction force can dislodge the facet (spinal) joints enough to cause them to cross over each other and get locked.

Most often there are other injuries as well. The chest and lungs can be damaged at the same time the spine is injured. In the case of a car accident, the lap belt can cause additional abdominal injuries.

A flexion-distraction injury at the junction of the thoracic and lumbar spine (T12-L2) is called a Chance fracture. The fracture was first described by Dr. G. Q. Chance in 1948. Chance fractures were more common before the advent of lap and shoulder seat belts in the 1980s.

It is felt that gas filled cysts form when a disc containing gas is herniated. The gas then extrudes and can form within a cyst.

While rare, gas-filled cysts in the spine can be rather small, even though they may produce significant symptoms. A CT myelogram is better than MRI at defining the lesion. Discography is the only method that can determine if there is communication between the disc space and the cyst.

There is an ongoing debate among surgeons as to the best way to treat all traumatic spinal fractures. Age of the patient and condition of the bones certainly make a difference. For example, older adults with osteoporosis (brittle bones) and other health concerns may not be good candidates for surgery.

In one-third of all cases, there is definite disagreement as to the best plan of care. Many surgeons feel that surgery is the best option. The spinal segment is stabilized with bone graft or hardware. Healing and recovery are faster. For younger adults, return to work is possible sooner making the operative treatment choice a more cost-effective approach.

For others, nonoperative treatment is the first line of care. Bed rest and/or a stabilizing brace offer the same outcomes as surgery with a less invasive approach. In fact, a recent study from The Netherlands confirms this belief. Comparing two groups of patients (operative versus nonoperative care) yielded similar results in terms of pain relief, function, and patient satisfaction.

For patients who choose the conservative (nonoperative) approach, if the bone fails to heal or if the spine remains unstable, then surgery can be considered at a later date. Each patient must be evaluated individually. There’s no single perfect answer for everyone.

With your mother’s permission, don’t hesitate to contact the physician and find out more about her particular situation. Understanding the reasons for this treatment decision may help alleviate your concerns.

Vertebral compression fractures (VCFs) are very common in older adults. Anyone with osteoporosis is at risk for this type of problem. These kinds of fractures can be very painful and debilitating.

Older adults who have VCFs along with multiple other problems may not be good candidates for surgery. This is especially true if the bones are brittle from osteoporosis. The weakened bones can’t support a bone fusion procedure or plate and screws to stabilize the segment.

Usually VCFs are self-limiting. This means they stabilize on their own and stop causing pain after a while. Conservative (nonoperative) care consists of calcium and vitamin supplements, pain relievers, bracing, and/or activity modification.

Two new minimally invasive procedures are now available as well. These include vertebroplasty and kyphoplasty. In both procedures, liquid cement is injected into the vertebral bone. The cement hardens and helps the bone retain its shape and structural support.

Even patients with osteoporosis can benefit from one of these simple operations. It may be worth asking her doctor about the possibility of trying this type of intervention for pain control. It has the added benefit of preserving spinal height and preventing spinal deformity.

Balloon kyphoplasty is a fairly new procedure used to treat vertebral compression fractures (VCFs). The surgeon uses a long, thin needle to insert a deflated balloon into the broken vertebral bone. The balloon is then inflated, which helps lift up the fractured, collapsed bone. A cavity or space is created inside the bone.

The balloon is deflated and removed. A liquid cement is then injected into the bone through the same long, thin needle. The cement fills in the space and hardens. The height and support of the vertebral bone are restored.

Studies show that there is an increased risk of heart attack, blood clot, change in blood pressure, and pneumonia after a balloon kyphoplasty. The reason for this is likely because these patients are already much older and have many health concerns.

Your risk of a heart attack after kyphoplasty is fairly low if you are in good health. Should you ever need this procedure again, the surgeon will evaluate whether or not you are a good candidate. Hopefully, anyone with serious health concerns will be excluded from a treatment intervention that could have such serious complications.

Sometimes even with careful screening, problems still occur. Predicting complications isn’t always possible. Patients are always warned of the possible problems and told what to expect in worse case scenarios. It’s up to the patient to decide if the possible benefits outweigh the potential problems.

Neck and back injuries leading to spinal cord damage is actually more common than you might think. Falling from a hunting tree stand is not uncommon. In fact, tree stand falls has been identified as one of the leading hunting-related injuries in the U.S. One spinal cord center in Philadelphia alone reported 22 cases over a 10-year period of time.

The factors linked with this kind of injury are many and varied. Although alcohol is a key risk factor, only two of the 22 cases in this particular study were alcohol-related. Cold temperatures and poorly dressed hunters can lead to hypothermia as a possible complicating factor.

Accidents often occur in the evening hours when the light is gone making it easy to misjudge the confines of the tree stand. A safety harness isn’t always used when it should be. And finally, proper installation and annual inspections of the tree stand are often neglected. Many elevated tree stands are homemade with improper stabilization.

Most of these injuries are preventable. Hunter safety education should include an emphasis on eliminating the various risk factors presented here. The time between injury and treatment is very important in the final outcome. Hunters should always use the buddy system and check on each other periodically. This will help avoid unnecessary delays in recognizing an emergency situation.

Most patients want a physician who has good credentials, experience, and a positive bedside manner. Choosing a physician may depend on the type of insurance or the third party payer plan you have.

If you have filed a Worker’s Compensation (WC) claim, you may be directed by Worker’s Comp to a list of physicians approved or associated with WC. This could be a primary care physician who is a family practice physician. Or it may be an orthopedic surgeon or occupational medicine specialist.

You’ll want someone who can listen to you, take your symptoms seriously, and explain both the injury and the treatment plan to you. A good examination and an accurate diagnosis are needed to form the best management or intervention approach. If you need more specialized services, the primary care physician can refer you to the right person.

In a recent survey of patients with work-related back pain, most patients valued effectiveness of care more than bedside manner. Patients who were satisfied with their care were more likely to get back to work and return to work sooner.

Patients seemed to respond better with health care that was delivered by a chiropractor, physical therapist, or surgeon. This type of treatment was more active than the passive care offered by nonsurgical medical staff.