…clear, understandable information about muscles, bones and joints
It is true that some people who have surgery may have a repeat slipped, or herniated disc, later on. However, research has shows that it is a particular type of slipped disc that has the highest risk of recurring and that is the protruding disc. Looking at the statistics, over 90 percent of young men, between the ages of 20 and 40 years did not have a recurrence of a herniated disc.
Have your husband speak about his concerns with this doctor as that is really the best solution.
Normally, the bones of the spine (the vertebrae) stand neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis is a condition that alters the alignment of the spine. One of the vertebral bones slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves can become irritated and painful.
In younger children and teens, spondylolisthesis develops as a result of excessive or repeated strain on the pars interarticularis of the vertebrae. A crack or bone fracture forms in the pars, which is part of the bony ring on the back of the spinal column. At first the fracture remains stable and the bones do not separate. That condition is referred to as spondylolysis. But if the bones separate at the fracture site, and the vertebrae slips forward, it creates the condition called spondylolisthesis.
Older children and teens whose bones are still growing are at greatest risk for this condition. Low back pain in athletes with spondylolysis may be more common in football players, gymnasts, wrestlers, weightlifters, and volleyball players.
But older adults can also develop a degenerative form of spondylolysis that can progress to become spondylolisthesis. Most of the time (in adults and children), the defect is present on both sides. In older adults, degeneration of the disc and facet (spinal) joints can lead to spondylolisthesis.
Facet joints are small joints that connect the back of the spine together. Normally, the facet joints connecting L5 to the sacrum create a solid buttress to prevent L5 from slipping over the top of the sacrum. However, when problems exist in the disc, facet joints, or bony ring of L5, the buttress becomes ineffective. As a result, the L5 vertebra can slip forward over the top of the sacrum.
Spondylolisthesis from degeneration usually affects people over 50 years old. This condition occurs in African Americans more often than in whites. Women are affected as much as three times more often than men. The effect of the female hormone estrogen on ligaments and joints is known to cause laxity or looseness. The higher levels of estrogen in women may account for the greater incidence of spondylolisthesis. Degenerative spondylolisthesis mainly involves slippage of L4 over L5.
With spondylolisthesis, there is a fracture in the bony ring along the back of the vertebra. If the bone separates at the fracture site, it’s called spondylolisthesis. The affected vertebra slips forward over the one below it. The result can be a narrowing of the spinal canal (opening where the spinal cord travels down the spine). As the spinal canal gets smaller, any pressure or pulling on the spinal cord or nerve roots can cause neurologic problems.
When making the diagnosis, CT imaging is a better diagnostic tool (more accurate, more reliable) than X-rays. With these conditions, the fracture can be missed on X-rays depending on the patient’s position (standing up or lying down. The effects of gravity and postural muscles can really make a difference on X-ray results.
Whether or not spondylolisthesis is really the cause of low back pain remains a topic for discussion. Studies have not proven a clear and conclusive link between the two. There are just as many people with spondylolisthesis who do not have back pain, as there are people with back pain who have spondylolisthesis.
It’s natural to make the assumption that low back pain in someone who has a spinal defect seen on X-ray or CT scan must be caused by that condition. But this just isn’t so. Surgeons, scientists, and others are studying this problem looking for ways to prevent spondylolisthesis and reduce back pain from any cause.
Most often, degenerative disc disease (DDD) occurs as part of the aging process. But there are other factors that can accelerate this condition and bring it on sooner. The most common is repetitive physical loading of the spine from overtraining and strenuous exercise.
Activities that involve repeated rotations of the vertebra (twisting motions of the spine) put athletes at increased risk. Sports such as high-load swimming, baseball, gymnastics, and soccer are particularly problematic.
Heredity is also a major factor for DDD. This condition tends to occur in families. More than half of all cases of DDD in the upper lumbar spine (L1-2, L2-3) have a hereditary component. And about one-third of the DDD in lower lumbar levels (L345) can be accounted for through heredity.
Although the evidence is still controversial, there are some experts who think obesity can be linked to DDD. Highly skilled athletes aren’t usually obese, but their body mass index (BMI) (calculated using height and weight) is often greater than nonathletes.
In one study from Japan, a group of athletes with DDD were compared with another (control) group of nonathletes. The athletes had both higher BMIs and a higher incidence of degenerative disc disease.
When someone has a sore lower back, the usual first approach to treatment is using medications to relieve the pain and exercise to help strengthen the back. However, when a doctor tells you to exercise, he or she doesn’t mean just any type of exercise – there are certain strengthening and conditioning exercises that can be done safely that don’t further injure your back.
Most of the time, doctors will refer patients with lower back pain to physiotherapy so they can learn the proper techniques and types of exercises to strengthen the back.
Lower back pain is common – it’s one of the most common complaints of pain in the developed world. People hurt their lower back in a number of different ways, from traumas to illness or defects in the spine.
The spine is a very complicated body part and many parts of it can be injured or cause pain. In order for doctors to treat the back pain, they have to understand what caused it and where exactly the pain is. And, because there are so many causes and people react to treatment differently, even the most commonly used back treatments may not work on everyone.
If you have a slipped or bulging disc, what may help you relieve your pain may not help your neighbor who has the same problem. The issue there is how severe is the injury, how did you injure it, how long ago did you injure it, what type of work or activities do you do, how old are you, are there any other health issues, and so on.
Back pain, especially lower back pain, sometimes isn’t as clear as we think it should be. While it makes sense to think that if your lower back hurts, it must be something in your lower back that’s causing the pain, sometimes, it’s another part of the body.
About one-quarter of people with lower back pain find out that their pain is really caused by their hips or by the sacroiliac joint, the place where your lower back meets with the pelvis.
If someone’s back pain is caused by the hips or the joint but the doctor focuses on the lower back pain, he will end up only treating the symptoms, but not the cause. The goal of treatment is to remove or treat the cause, therefore allowing the pain to go away.
Taking part in a study has many benefits but it can also take up a more time than some people are willing to give. When people are first brought into a study, every step should be explained clearly, from physical examinations to filling out questionnaires to participating in the actual treatments. The issue seems to be that perhaps you didn’t understand the explanations or that perhaps you didn’t learn about the reasons behind all the different aspects of the study.
At first, many questions need to be answered about who you are (age, employment status, etc) so that the study subjects can be broken down with the statistics. This is very important because this type of information can tell researchers that a person of a certain age with a college education may have one problem, while a person of the same age but with a high school education doesn’t.
Some questions are repeated throughout the studies and this is to measure any improvement or changes in your status. So, if you’re asked to rate your pain on a scale of zero to 10 before the study begins and then every time you see the doctor, they’re looking for changes in your scale. The same thing occurs with questions about movement, function, if you are getting out of the house, and so on. At the end of these studies, this is all tabulated and results are determined – hopefully to help other researchers and, ultimately, the patients.
Acute low back pain is common in all ages from young to older adults. In fact, it’s estimated that if a poll was taken on any given day, 20 per cent of the American population would say they were having back pain that day.
It’s true that the majority (80 per cent or more) of individuals experiencing a bout of back pain will get better. Usually the symptoms resolve (go away) gradually over a period of 10 days to two weeks. Occasionally, painful symptoms may linger for three or four weeks.
But when they don’t go away, and the person’s function (mental or physical) is impaired, it’s time to see the doctor. A careful medical exam is warranted. This is true even if the patient saw the doctor at the beginning of the problem. With time, things may have changed from what the doctor saw on the first day. Sometimes this is referred to as progression of disease or progression of clinical presentation.
Your husband may have progressed from an acute to a chronic stage of back pain. This occurs in about five to 10 per cent of patients who experience some form of acute low back pain. If it’s pain of a mechanical nature (involving the alignment and movement of bone or soft tissues), then it may be time to see a physical therapist.
The therapist will evaluate posture, musculoskeletal alignment, and movement and formulate a plan of care. This may include manual therapy (a hands on approach to restore tissues to their normal state) and prescriptive exercises.
If it’s not mechanical, then the physician will look for a potentially more serious problem such as fracture, infection, or tumor. The extent of the investigation will depend on the physician’s interview with the patient. The doctor takes into consideration the patient’s personal and family history, clinical presentation, and any red flag associated signs and symptoms. At that point, additional clinical tests, lab values, and imaging studies may be ordered.
Low back pain can be a very complex and challenging problem. Most of the time, a clear and accurate diagnosis is impossible. As you have discovered, medical tests just can’t pinpoint the exact cause. And that can be equally frustrating for the patient and for the physician.
Sure there are degenerative changes present on X-rays or other imaging studies. Most often there are moderate (to even severe) signs of osteoarthritis, stenosis (narrowing of the spinal canal), and degenerative disc disease.
But many people develop these problems without any symptoms whatsoever. Current beliefs are that just because there are radiographic signs of degeneration doesn’t mean that’s the source of the pain or other symptoms. That being said, it doesn’t mean you can’t get some help.
Chronic back pain suffers often find relief through a combined program of education, postural changes, and exercise. Understanding your condition, especially how activities with too much bending or twisting can add to the stress on the spine is essential.
A regular, daily routine of exercise is important to improve (and maintain) conditioning, flexibility, strength, and endurance. For some patients, lifestyle changes such as weight loss and quitting smoking (or other tobacco use) are necessary.
Rest is acceptable for acute episodes of flare-ups. But with chronic low back pain, physical activity (stay active, keep moving) is a central key to improvement. Some studies have shown a benefit of acupuncture, massage, and cognitive-behavioral therapy. Combining two or more of these additional treatment approaches seems to help the most.
The International Classification of Functioning, Disability, and Health or ICF was first approved by the World Health Organization’s (WHO) Health Assembly in 2001. It was the result of the collaborative efforts of many experts around the world. The purpose of the ICF is to provide a model of human functioning.
As a classification scheme, it has many categories and can be used as a tool to describe the severity and course of a physical condition or disease that affects a person’s function and ability. It’s a model that can be adopted and used by health care workers around the world. Having a common tool of this type will make it possible to conduct and report on research in the same way worldwide.
In this new classification scheme, the focus has shifted from assessing, measuring, and talking about impairments, disabilities, and handicaps to now focus on body functions and structures and activities and participation. Two other components within the ICF classifications include environmental and personal factors.
Each of these five components also have subsets or qualifiers to help define the level of functioning and health for the patient problem being described or evaluated. A scale from zero (no problem) to four (complete problem) is used to then quantify (give a number or percentage for) the subset.
Shifting to this new classification scheme will give everyone a common language to discuss health and ability (not disability) for patients with chronic and complex problems. Setting goals, planning treatment, and evaluating results will be framed in a positive light now. Communication within the health care team and with the patient will be improved by the use of language everyone can understand.
The International Classification of Functioning, Disability, and Health or ICF as it is called has been endorsed by your organization (the American Physical Therapy Association). It is a framework for organizing physical therapist evaluations, treatment, and follow-up of all patients with chronic or complex problems.
Within that framework, there ia a subset of categories called the ICF Core Sets for Low Back Pain (LBP). The Core Sets for low back pain actually contain 78 ICF categories. They range from mobility and self care to sleep, energy and drive, and mental function. Other examples of categories include muscle tone and power, ability to maintain or change position, dressing, toileting, and mobility skills such as crawling, walking, or running. Once these categories have been assessed for a patient, there is a very comprehensive picture of the problems that person is having with function, health, and life situations.
Even though there are multiple ICF categories, the beauty of the model is that it allows for one instrument that can be used around the world. Results of research and clinical study can be combined and compared for better statistical significance. In this way, research results can be unified. The ICF provides a standard now for describing function in patients with chronic low back pain. That may not sound like much, but it’s the first time any such standard has become available.
The ICF Core Sets provide the basis for what should be assessed as a measure of outcome. It tells us how to measure what we measure. And we don’t have to throw out popular instruments already in use for assessing low back pain. Tools such as the commonly used North American Spine Society Lumbar Spine Outcome Assessment Instrument, Oswestry Disability Index (ODI), and the Roland-Morris Disability Questionnaire can be linked to the ICF.
Clinicians treating patients with chronic low back pain can use the ICF Core Sets right from the start. At the first appointment, the patient’s history, symptoms, and clinical presentation can all be documented in the medical record using the ICF Core Sets. Documentation can be done quickly and easily with a checklist on paper or electronically.
The data can be used to set goals, manage rehab, and assess the effectiveness of treatment. These elements are referred to as the Rehab-Cycle. The Core Set has a place to record how the patient feels about his or her situation. There’s a separate section for the health professional to document all clinical findings. In this way, a systematic approach makes it possible to identify and record all potential problems to be considered.
Cauda equina syndrome, pressure on the nerve roots at the base of the spine is, indeed, a surgical emergency. It’s vital that a surgeon remove whatever is causing pressure on the nerve roots to prevent further damage and to try to reduce any damage that may have already been done.
You don’t say if your wife’s pain – although still there – is better than it was before. Certainly, the symptoms of leading urine or not being able to control urine can be quite disturbing.
Your wife should speak with her surgeon and her doctor to find out what she should expect at this point and what could be contributing to the problems. Sometimes, the problems, such as urine leakage, are coincidental, so the doctors need to know that she is still having pain and urine problems.
If you are over 40 years old and you’ve had X-rays of your spine, you might be convinced that any back pain you have is coming from those joints. That’s because as we age, signs of degeneration are abundant. Bone spurs grow around the joints, the joint cartilage thickens and reduces movement, and overgrowth of the joint margins blocks motion.
But the truth is, there are just as many people with degenerative changes seen on X-ray who don’t have any back pain. How is that possible? Scientists don’t really know. But they’ve been studying the relationship between low back pain and facet (spinal) joint degeneration for years.
There’s some evidence that lumbar facets could cause low back pain. The anatomical structures in that area have a lot of nerves that could get irritated and send painful messages up the spinal cord to the brain. Arthritic changes are most common in the lumbar spine, especially at the L4-L5 level.
But most studies don’t show a statistically significant relationship between facet osteoarthritis and low back pain. And it’s not because those changes aren’t present. They are — a recent study of a large number of people (over 3,500) found an increasing incidence of facet joint changes as people got older.
About one-quarter of the group who were 40 years old or younger had facet joint changes. This compared with two-thirds of the group 70 years old and older. But there were no degenerative or arthritic changes that predicted low back pain. And that is a major finding to support the idea that degenerative changes and arthritis of the facet joints are not responsible for low back pain.
Physicians looking at X-rays don’t assume that even the worst of degenerative changes seen on imaging studies have any clinical meaning. That patient’s back pain may not be coming from the facet joint(s) despite appearances otherwise.
Experts in this area suggest that computed tomography (CT) scans may offer the best way to see changes in the facet (spinal) joints of the low back area. But the knowledge gained from the more advanced imaging study may not change your treatment.
That’s because there’s still no proof that degenerative, arthritic changes in the facet joints has anything to do with back pain. There are simply too many people with severe changes seen on imaging studies who don’t have any back pain at all.
It makes sense that if osteoarthritis of the facet joints was the cause of low back pain, then anyone with moderate-to-severe degenerative changes would have the same painful symptoms. But they don’t and that’s what has many doctors scratching their heads.
Even more confusing is the fact that some patients get relief from facet joint blocks. The surgeon injects a numbing agent and steroid into the facet joint area, providing pain relief for the patient. This treatment suggests some involvement at the facet joint. But whether that’s really a placebo (the patient expects the treatment to work, so it does) or some other factor remains to be proven.
There’s a commonly held belief that once you’ve had an episode of low back pain (LBP), you are liable to have another. Studies estimate that the recurrence rate for LBP can be as high as 84 per cent. But the authors of a new study challenge that thinking. They point out how research in this area has been flawed.
There are three common errors in research that have led to an over estimate of LBP recurrence. First, patients included in the studies may not have recovered from the first episode of back pain before they had a second episode. Technically, they have not had a recurrence but rather, persistence of symptoms from the first episode.
Second, some patients recover from their first episode of back pain but not right away. Their recovery may take months instead of days or weeks. Recovery so late means they were at risk of recurrence for a very short amount of time. Using that approach results in misleading numbers of patients reported to have a recurrence of low back pain.
Third, the definition of an episode of back pain isn’t always the same from one study to the next. This may be changing with some of the more recent studies as authors have become aware of the problem and are making efforts to use a more standardized definition.
The current definition proposed for future studies is as follows. An episode of low back pain is a period of pain in the lower back lasting for more than 24 hours. It is preceded by and followed by a period of at lease one month without low back pain.
Using that definition, you can gauge your own recovery. A fear of pain lingering on is a risk factor for exactly that! The more people fear an event happening (such as repeat low back pain), the more likely it is that they will indeed develop ongoing or chronic pain. Some of this occurs because the individual stops moving or becomes much more inactive out of fear that they might hurt themselves again.
A previous episode of back pain does put you at risk of a second episode, but this happens far less often than anyone believes. Instead of the nearly 90 per cent rate of recurrence reported, it’s likely to be more like 25 per cent. That translates to one in four people.
Don’t be a statistic. The best thing you can do for yourself is to keep moving. Stay active. Don’t avoid movements or activities because it might hurt or you might hurt yourself. This type of thinking is called fear avoidance behavior. Thinking this way can also increase your chances for further problems that you obviously don’t want.
It may be helpful to describe what you (or your mother) are doing in terms of serving/eating nutritious snacks and meals. Then ask her to explain why nutrition is so important. We suspect she is making her recommendations based on current best practice from research findings.
Specifically, poor nutritional status in patients is associated with a trend toward wound infections. Doctors use a blood marker called serum albumin as a measure of nutritional status. Low levels of serum albumin is found in patients with infection.
Since wound infections can delay recovery and sometimes even result in further surgery, nurses do everything they can to help patients prevent this potentially serious complication. Your questions may help her see the need to explain this more clearly to all her patients. You may even want to ask what your mother’s serum albumin levels are and how that compares to the normal standard. This may help you understand the focus on adequate nutrition.
Sacral tumors are fairly rare. They don’t shrink or respond to radiation, so they often have to be removed surgically. The procedure is called a radical resection procedure. The tumor and surrounding tissues are removed until the pathology report shows there are clear margins. Clear margins means there is a rim of normal tissue completely surrounding the tumor. The most common tumors in the sacral region are chondrosarcomas and chordomas.
A popping sound (with or without painful symptoms or loss of motion) should be reported to your surgeon. You can call the surgeon’s office and let the staff know what happened and what are your concerns. With screws, plates, and/or rods, that sound could be a sign of a pullout of a screw, a loose rod, or even a fracture.
Early investigation is advised. If it turns out to be nothing, then you have early peace of mind. If a complication has occurred, then early diagnosis and intervention can result in a better outcome than if you waited and things got worse. In some cases, revision surgery is needed.
Chronic back pain is very common in our society, so it’s understandable that when someone has an acute injury (one that just happened), he or she may worry that it will become long term or chronic. The reality is, most people who have an acute back pain don’t end up with chronic back pain. Those who end up with chronic pain are in the minority.
Doctors have found that there are a few things that can help them figure out who will be most likely to have chronic back pain. They are those who don’t return to work quickly, those whose work environment isn’t adapted, as well as those who have pain that goes beyond the back (radiates down the legs) and where there is more than one area that hurts.
Management of chronic pain is recognized as a challenging and often complex problem that requires careful management to be effective. Starting with an osteopath is a good idea to help get things lined up and restore a more normal musculoskeletal frame.
Branching out to other disciplines is often helpful. There are many health care professionals who work together smoothing the way to recovery for pain patients. Medical doctors (including osteopaths), chiropractors, physical and occupational therapists, and pharmacists are often among the core team members.
Alternative practitioners can also provide effective care. This can include massage therapists, acupuncturists, craniosacral practitioners, naturopathic physicians, Reiki therapists, and so on. If your osteopathic physician has helped you, trust her professional judgment and try this next step. It may be that your system is ready now to handle other types of care. It may help if you ask your osteopath to explain her rationale (thinking) in referring you for other services. She may have a plan of care that would make perfect sense to you.