FAQ Category: Lumbar Spine

Researchers from the Netherlands recently put together a report that summarizes the evidence on deconditioning and chronic low back pain. They took a look at all the studies done on chronic low back pain sufferers with two things in mind: physical activity levels and physical fitness.

Physical activity included daily activities of living like cooking, walking, working, bathing, driving, brushing teeth, and so on. Physical fitness included muscle strength, endurance, postural control, and cardiorespiratory function.

Two interesting results were observed. First, the physical activity level of patients with chronic low back pain wasn’t that different from healthy individuals. And second, the risk of developing long-term back pain was highest among sedentary (inactive) people and those who participate in strenuous activities.

Several studies have shown that the disability associated with chronic low back pain really starts in the mind. Patients who perceived that they were losing function and became fearful of moving experienced more disability than those who worked and played despite their pain.

Patients who see their pain as threatening become afraid that movement will increase the pain, so they stop moving. This phenomenon has been labeled catastrophizing and may be a factor in deconditioning but that hasn’t been proven yet. Two other results of inactivity are weight gain and loss of bone density.

Researcher shows that people who continue working despite their back pain have better physical fitness and conditioning. The conclusion of the studies is that people should be encouraged to stay active at work.

Disc degeneration and herniation are common problems leading to surgery to remove part or all of the protruding disc. But back and leg pain from disc problems can come back after surgery.

Recurrent lumbar disc herniation occurs in anywhere from five to 15 per cent of patients. So patients with back and leg pain that goes away after disc removal (a procedure called discectomy) but comes back six months (or more) later are faced with the decision about what to do.

Once an accurate diagnosis has been made, then the patient and surgeon can get down to the business of treatment. Conservative (nonoperative) care is almost always tried first. There’s no sense in doing another surgery if antiinflammatory medication, physical therapy, or steroid injection would take care of the painful symptoms.

Not everyone responds to conservative care. There are some patients who don’t get pain relief no matter what is done. The effect on their quality of life and ability to work is such that a second surgery to remove the rest of the offending disc can’t be avoided. Anyone with pressure on the nerves causing bowel and bladder changes is a candidate for surgery right away.

For those patients with spinal instability (the vertebrae are shifting back and forth or collapsing), surgery to fuse the segment may be indicated. This type of situation is most likely to develop in patients who have already had more than one disc herniation. The surgeon does what is needed to take pressure off the spinal nerve roots and then uses metal plates, screws, and bone graft material to fuse the segments together.

If you are unsure about the reasons for the surgery or the expected results, it might be a good idea to visit with your surgeon and ask some additional questions. Fusion is permanent and is intended to hold that segment still during spinal motions. As with any surgical procedure, there are some risks involved. You’ll want to head into surgery with a clear idea of the intended effects and possible complications.

Over 200,000 discectomies are performed every year in the United States. Discectomy refers to removal of the disc, which is a cushion and shock absorber between two vertebral (spinal) bones.

Depending on how things look in the spine, the surgeon may remove part or all of the disc. The procedure can be done with minimally invasive techniques so that only a small incision is made with minimal disruption to the surrounding tissues.

The surgeon may use a minimally invasive method such as microdiscectomy. A small incision is made and the damaged portion of the disc is removed. A microscope helps magnify the disc so the surgeon can see the area clearly.

Another surgical technique is the endoscopic discectomy. This is another minimally invasive procedure. The surgeon uses an endoscope, which is a tube through which instruments can be passed to remove the damaged portions of the disc. The surgeon can see on a video screen as the disc is removed.

Sometimes surgeons combine parts of both procedures to perform what’s called a hybridization of techniques. The goal is to avoid bleeding and soft tissue damage while removing the offending disc. The hope is to reduce hospital time, use of narcotic (pain) medications, and get the patient back to work as soon as possible.

Painful symptoms can come back when a partial discectomy (rather than complete removal of the disc) is done. Forces applied to the remaining disc exert the same pressure that eventually push it out of the disc space. Pressure on the nearby spinal nerve root from the protruding disc or chemicals released by the damaged disc can irritate the nerve causing back and/or leg pain.

If the pain is not being caused by a recurrent disc herniation, it could be coming from a different disc (possibly the level above or below the disc in question). There are other potential causes for leg pain after a discectomy. An examination and evaluation by the surgeon is needed to make a clear diagnosis.

Simple X-rays don’t show discs but they can help rule out other possible causes of back pain and sciatica such as fractures, spinal instability, or stenosis (narrowing of the spinal canal).

MRIs help show the difference between abscess, scar tissue, hematoma (pocket of blood), and disc herniation. Lab testing of blood also helps the surgeon tell if the new pain might be coming from infection.

Scientists have some evidence that genetics plays a role in disc degeneration and eventual disc herniation. But not everyone who has disc problems has a positive family history like you do. The cumulative injury model suggests that a history of physical activities or other stresses and loads on the disc may explain some of these injuries.

And, of course, it’s possible that some people have both going on at the same time: genetics and repetitive loading on the spine. There’s not much you can do about your inherited traits. Engaging in core training activities for the trunk, back, and abdominal muscles is believed to be preventive. But this hasn’t been completely proven yet.

Likewise, there is a belief that using proper lifting techniques can help decrease the risk of back injuries that lead to disc herniations. But it is a fact that most disc herniations are not really caused by a specific movement or activity.

In fact, it is estimated that only about eight per cent of adults with back pain from disc herniations can point to a specific traumatic event such as lifting. And only one per cent come from falls or car accidents.

That brings us right back to ways that disc degeneration can be avoided. More studies are needed but for now it looks like the following formula may help. Good nutrition, keeping the weight off, avoiding tobacco, and maintaining a good balance of strengthening and stretching exercises may be the best approach.

In the first study of its kind, researchers from five hospital-based spine clinics in Boston recently discovered that most disc herniations don’t come from lifting (heavy or light) objects. In fact, the majority (62 per cent) have no known cause. The patients say the back and leg pain (sciatica) just came on without warning.

Most people started noticing symptoms while doing normal, every day activities. Examples of non-lifting physical activities as inciting events included vacuuming, bending, reaching, leaning, misstepping, and making the bed. These are all very much like your situation of turning over in bed and suddenly experiencing painful symptoms later proved to be from a disc herniation.

In the Boston study, golf, skiing, and tennis were the most commonly reported sports and recreational activities believed to be associated with disc herniation. Physical trauma from falls or car accidents was listed as the inciting event in only 1.3 per cent of the people.

This finding supports the idea that in many adults, discs don’t rupture. Instead, the outer covering called the annulus slowly weakens. Weakening in the protective layer of the disc allows the center portion (the nucleus) to poke through.

So even though someone develops pain after sneezing, coughing, or simply turning over in bed (from what later turns out to be a herniated disc), that final event was like the straw that broke the camel’s back. The disc was ready to go and the coughing, sneezing, laughing, or turning one way or the other was just the final physical stress to herniate an already damaged disc structure.

This idea of a spontaneous disc herniation isn’t entirely accurate either. Most experts agree that disc degeneration leading up to disc herniation takes place over a long period of time. Repeated loads on the spine combined with the effects of aging are probably the real culprits. It’s likely that there are some hereditary factors involved as well.

Synovial cysts, cysts that appear on the synovium or lining of a joint, can appear on the spine, which is a whole bunch of joints, one on top of the other. They are more frequently found in wrists, ankles and feet, but can occur anywhere. They are fluid filled masses, or sacs, that are caused by irritation. Depending on the cause of the cyst, it could be that the fluid is building up to try to protect the joint from bone rubbing on bone.

The cysts may cause pain or disability – it could affect the nerves going down from the back, depending on where in the back the cysts are. Some people feel back pain, leg pain, numbness in the legs and/or feet, or even inability to control bowel and/or bladder.

More and more adults with chronic low back pain from degenerative (often age-related) conditions of the spine are turning to spinal fusion as the final answer to their pain and disability. But no surgery is ever done without the concern for complications and problems referred to as adverse events.

The standard operating procedure for spinal fusion is to use some of the patient’s own bone (taken from the pelvic bone) to help strengthen the fusion site until the body forms its own fresh bone to fill in. There are three major drawbacks to this type of autograft. One is the fact that it requires a second surgery. The second is the fact that sometimes the patient’s bone quality isn’t that good. And the third is the high number of patients who experience pain caused by the autograft.

That’s why scientists and researchers are helping surgeons find alternative ways to boost bone growth at the fusion site. The bone-growth protein you mentioned is one of those ways. These proteins come from bone and have the ability to initiate the set of steps needed to form new bone.

Adverse effects of bone-growth proteins are very minimal. And they eliminate the need for the second often painful procedure to harvest bone from the patient’s pelvis. Although these proteins do stimulate bone growth, there is no evidence that they cause bone tumors (or any other type of tumors) to develop.

Most spinal fusions are held together with metal plates, screws, and bone graft material. During the healing process, the body fills in and around the fusion site with additional, fresh bone. The initial graft material placed at the fusion site during the procedure is usually an autograft.

Autograft means the bone was taken from the patient. The most common place to harvest bone for the graft is from the patient’s pelvic bone. But there are two major drawbacks to this type of autograft. One is the fact that it requires a second surgery. The second is the fact that sometimes the patient’s bone quality isn’t that good. That seems to be your situation.

Bone graft material can be obtained from a bone bank (donated by someone else). Donor graft material comes with its own set of risks and problems. Scientists are actively seeking alternative ways to provide a strong fusion without bone grafting. One of the methods that has been developed over the last few years is the process of using osteogenic proteins. Osteogenic means bone producing. And that’s exactly what these bone proteins do.

Currently, there are two bone-derived proteins on the market: osteogenic protein-1 (OP-1) and bone morphogeneic protein-2 (BMP-2). Studies are underway comparing these two products to one another and against the current standard (autografts). The jury is not in yet but it’s looking favorable for bone proteins. They appear to be safe and effective with very few drawbacks.

With the large number of people every year who come to the surgeon with chronic low back pain, the corresponding number of back surgeries has also increased dramatically. Spinal fusion is a common stabilizing procedure used for stenosis, degenerative disc diesease, and spondylolisthesis (tiny fracture or defect in the supporting column of spinal bone).

Your question is a reasonable one but it’s very confusing trying to figure out ahead of time which patients will benefit from back surgery. Surgeons are always looking for predictive factors to help them identify who should have surgery and who would be better off without surgery.

One of those predictors is the use of pain drawings. Patients draw lines, X’s, dots, and use letters like N for numbness or S for muscle cramps on a picture of the human body. The various markings show where pain is located and what kind of pain it is.

Some aspects of this drawing are helpful when evaluating risk of good versus poor outcomes after spinal fusion. For example, patients with unorganized pain patterns express greater dissatisfaction with results of fusion surgery. On the other hand, patients with a more recognizable pain pattern are more likely to report better results after surgery — even when they had more levels fused than in the nonorganic group.

Work status (retired or on sick leave) and insurance or litigation claims are two other predictive factors of poor outcome. Patients who have pain lasting more than two years, patients who smoke, and younger patients are also at risk for poor results after fusion surgery.

There isn’t a one-tool-fits-all kind of assessment that can be used before surgery to predict outcomes after surgery. By sitting down with your surgeon and reviewing your individual risk factors, you may be able to see where you fall in the line up from success to failure following lumbar spine fusion.

Studies show that two-thirds of patients with chronic low back pain who are advised to have surgery do seek a second opinion. And most major health insurance companies cover the cost of a second opinion.

Gathering as much information as you can about your diagnosis and proposed treatment is always a good idea. It gives you information about what to expect in terms of outcomes, potential complications or problems after surgery, and prognosis (including how long before you are better).

Be aware that in any given geographical area, surgeons often train and practice in similar ways, so that a second (or even third) opinion may not differ as much as if you went from one coast to another seeking that additional opinion.

Don’t be afraid to ask what to expect and judge your likelihood of getting what it is you want. Many patients go into spinal surgery expecting complete relief of painful symptoms, ability to stop taking all narcotic medications, and even return to work full time. Your surgeon will guide you in understanding what the procedure can provide.

Getting a second opinion gives you the ability to ask different surgeons what results are possible given his or her level of experience and expertise.

When faced with surgery to fuse the spine, patients with low back pain should weigh the risks against the benefits in deciding to go ahead with the procedure. But what is the patient’s minimum acceptable change in symptoms and/or function before having the operation?

Is a drop in pain levels enough to make it worth it? Would you have the surgery even if it meant you still weren’t going to get back to work? Anything less than the minimum acceptable outcome means it’s not worth having the procedure done.

There are different ways to measure this. The most common factors used to measure patient satisfaction usually include pain intensity, function, use of narcotic medications, and return-to-work status. There are many other ways to assess success of spine surgery. Some surgeons use scales that measure patient satisfaction or patient goals.

Others rely on X-rays to show the biologic success (healing) as a means of measuring success. Pain, function, medication usage, and return-to-work status may be the most practical when measuring minimum acceptable outcomes after spinal surgery.

In a recent patient survey study from Stanford Medical School, patients wanted at least a four-point improvement in pain when pain was measured on a 10-point scale (zero for no pain, 10 for maximum pain). They wanted to be free of the need for any narcotic medication. And they considered being disabled, unable to work, or only able to work part-time or with work restrictions as unacceptable.

Overall, the minimum expectation was for a high level of improvement in pain and function. The group did not think it was worth having the surgery if they couldn’t get back to work within two years of the operation. In fact, more than 90 per cent of the group said they wouldn’t have the surgery if they weren’t sure they would be working again.

And it turned out that those patients who did meet their own minimum expectations were, indeed, satisfied with the results. The patients who indicated satisfaction even though their goals weren’t met tended to be those who had other problems with chronic pain, psychologic distress, or who were on Worker’s Comp.

Lumbar spondylolisthesis is a condition where one vertebrae (spinal bone) in the lower back (the lumbar area) slips over the one beneath it. It could be caused by degeneration, such as with arthritis, or by a trauma to the back. In children, this is the most common cause, while in older patients, it is most likely caused by degeneration of the spine.

When the vertebrae slips, it can cause chronic back pain and/or damage to the nerve roots because of the compression. This could result in numbness, loss of feeling, difficulty walking and weakness.

As some people age, they may develop a condition called spondylolisthesis, where one vertebrae, or spinal bone, may slip over the one below it. This could be caused by a deterioration or degeneration of the spine, as with arthritis, or by a trauma to the spine. Regardless of the cause, it can cause significant pain and disability to some people.

Treatment for this condition may involve exercises or physiotherapy, to help strengthen and stretch the muscles around the spine and the abdominal muscles. For some people, a brace can help by supporting the back. If neither of these non-surgical methods work, some physicians recommend surgery to help fuse the spine, taking the pressure of the first vertebrae of the second one.

Back pain continues to be a major health problem around the world — one that costs the health care system a great deal of money. Researchers have confirmed over and over the statistic you quoted — 80 per cent of adults in developed countries (like the United States) experience a short, limited episode of back pain.

A recent study from Germany reported two-thirds of the adults surveyed in the general population said they had back pain at least once in the last 90 days. Although this particular study didn’t delve into all the whys of back pain, many other scientists have explored what’s behind this phenomenon.

Stress seems to come up as an all-important key. Worry, overwork, lack of satisfaction with life, dissatisfaction with work all tally up as factors in the development of nonspecific (mechanical) low back pain. Nonspecific, mechanical low back pain refers to the fact that it’s not caused by a fracture, infection, or tumor. The exact cause may remain unknown but the pain is likely generated by some joint or soft tissue structure.

The psychosocial aspect of low back pain is probably a result of both being American and human but as this German study showed, it’s not just Americans who are affected.

With any physical ailment, there is often a wide range of experiences. Chronic low back pain is no different in this regard. Age, attitude, sex, the presence of other health problems, finances, and family support are just the tip of the iceberg when it comes to understanding why some people like yourself can cope while others don’t seem to even want to cope.

We do know that some patients need help with pain control while others need to improve their functional level. Research shows that adults in the general population (not a group of chronic pain sufferers) experience back pain with a wide range of pain intensity and disability. Here’s a sample of what that can look like:

Spondylolisthesis usually affects the lumbar spine, most often at the L4-5 level. In spondylolisthesis, a defect in the supporting column of bone allows the vertebra to shift forward or slip over the vertebra below it.

Isthmic spondylolisthesis refers to a slip that occurs as a result of a defect of the pars interarticularis. The spondylolytic defect may be present at birth but is usually acquired between the ages of 6 and 16 years. The child or teen may not even know there is a problem until an X-ray is taken for some other reason and the condition is seen.

Once the slip has occurred, it rarely continues to progress. This defect often develops over time as a result of a hyperextension injury. Athletes involved in gymnastics, ballet, and football seem to be affected most often.

As the name suggests, degenerative spondylolisthesis is age-related and can affect more than one vertebra. Women ages 50 and older seem to develop this problem. The same thing happens: the vertebral body and forward slip of the bone over the segment below it. But with degenerative spondylolisthesis, the shift narrows the spinal canal where the spinal cord is located. The result is pressure on the spinal cord, discs, and spinal joints with pain and sometimes even more serious symptoms.

Isthmic spondylolisthesis doesn’t progress to become the degenerative type. The greater concern is whether a low-grade isthmic spondylolisthesis (less than 50 per cent slippage) will progress to become a high-grade slip. It’s the high-grade slips that tend to cause symptoms, spinal instability, and even scoliosis (spinal curvature).

The idea that chronic pain can’t be changed with surgery comes from the belief that over time pain messages get so engrained in the central nervous system (spinal cord and brain) they can’t be turned off. Scientists refer to this as a central pacemaker. The pacemaker gets turned on when persistent and continuous pain messages are sent from the nerves to the spinal cord and then up to the brain. The result is called centralization of pain.

But this belief that a long period of pain leads to a poor prognosis hasn’t really been tested. And the results of a recent study to look at this particular issue didn’t support this theory either. All 200+ patients with chronic pain from degenerative disc disease got better after the discs were removed and the spine fused. Some even waited over 25 years to have the procedure done.

Did they just beat the odds or was this an outcome that can be repeated? Since patients were still reporting positive results (pain relief, improved function) up to five years later, it looks like the results are real and long lasting. The authors of the study do point out that in their patient selection they were careful to select patients with just one pain diagnosis. No one in the study had other causes of chronic pain like fibromyalgia or arthritis.

The particular approach used in the spinal fusions for all of these patients was one called posterior lumbar interbody fusion or PLIF. The procedure was done from the back of the spine. An open incision was made, the disc removed, and the bone on either side of the disc (lamina and facet joint) was cut away. The bone taken out was ground up and used to pack the middle of the disc space before inserting a device called a cage. One cage went on either side of the bone chips. Then a plate and screws were used to hold everything together until bone filled in to complete the fusion.

The authors concluded that at least for patients with disc degeneration, a posterior lumbar interbody fusion (PLIF) works well even when the patient’s symptoms have been present for a very long time. Chronic and severe pain is not a reason to avoid spinal fusion using the PLIF method. This study also brings the theory of centralization of pain into question. Future studies are needed to further investigate these new findings.

Every surgery has its own set of potential complications. Most of the time these don’t occur. But there are those few individuals who for one reason or another do happen to develop an infection, poor wound healing, blood clots, or other adverse effects after the operation.

One possible complication of lumbar fusion does happen to be this phenomenon you mentioned called adjacent segment disease (ASD). It makes sense that if a spinal segment is fused and no motion is allowed at that level, there’s a change in the way stresses and forces applied to the spine are transmitted. Loss of motion at one level means greater movement and pressure at the segment above and/or the segment below the fused level. The result can be degeneration of the disc in between resulting in ASD.

Adjacent segment disease (ASD) is a problem potentially created by the treatment for the first problem (lumbar fusion). That’s not good — it means you may need another surgery. Surgeons are investigating this problem more closely. They are asking, Are there some patients who are more likely to develop ASD? Who might that be and could it be prevented?

Some studies show that age seems to make a difference (worse results in older adults), while others point to the type of fusion procedure done as the main problem. Still other researchers have found that adjacent segment disease might be more common in adults who already have general age-related disc degeneration (affecting more than just the level that was fused). Other risk factors under investigation include patient-related factors such as menopause, osteoporosis, and sex (males versus females).

Surgeons must discuss potential complications with every patient no matter what type of surgery is being done. Until more is known about adjacent segment disease, it isn’t possible to predict who might and who might not develop this later. We do know that some conditions requiring fusion seem to develop adjacent segment disease more than others.

With a few days left before your scheduled procedure, you can still contact your surgeon with any last minute questions and concerns. Don’t hesitate to mention this particular concern and what the chances are that you might develop disc degeneration at the level above or below the fused site.

Ultrasound could be used as a screening tool before giving the injection. This 3-D, real-time video provided by ultrasonography of the sacrum shows the surgeon exactly where to insert the needle for the most accurate injection.

Ultrasound images give the surgeon precise measurements to use when deciding whether there’s enough space for the needle. The surgeon can use the images to guide the needle into the epidural space. If the diameter of the opening is too small, a smaller gauge needle can be inserted instead. Absence of the opening or a too small diameter would be just cause to cancel the procedure.

Body weight and body fat does not seem to be a problem with this type of pre-test screening and/or injection treatment. With the assistance of a surgical tech, the patient’s buttocks can be pulled apart and away from the sacrum, thus providing a flat surface to apply the ultrasound transducer (head or wand). If necessary, a specially shaped transducer can be used to curve over the soft tissue down to the bone. Physicians using this method on obese patients report that the layer of fat over the sacrum where the needle must be inserted is not very thick even in obese individuals.

When low back pain is caused by a pinched or compressed nerve in the sacral area, a steroid injection into the spinal canal can provide welcome relief. But it’s a tough area to gain access and the chances are high that the surgeon can miss the right spot. That’s been proven over and over in trials conducted by experienced and confident physicians.

When injecting the sacral area, the injection must slip into the sacral hiatus, a tiny opening in the middle of the sacrum. The sacrum is a pie-shaped or wedge-shaped bone that sits at the end of the lumbar spine just above your coccyx (tailbone).

The sacral hiatus is further identified by two bony bumps called the sacral cornua that run along each side of the hiatus. Getting the injected fluid through the hiatal hole and into the spinal canal may improve the accuracy of this treatment approach. Missing the mark doesn’t always hurt the patient — it usually just means the injected fluid goes into the soft tissue surrounding the sacrum. When injected into that spot, it’s not very helpful either.

Researchers are experimenting with ultrasound as a way to screen patients before attempting epidural steroid injections into the sacral area. A special new type of 3-D, real-time ultrasonography is now available making it possible to conduct this type of pretreatment test. Accuracy of injection was improved significantly in a trial conducted on 47 patients with low back pain in need of an epidural injection. The success rate wasn’t 100 per cent, but it was much higher than in previous studies conducted without ultrasound screening.