FAQ Category: Lumbar Spine

The conservative rehabilitation’ treatment plan also holds statistical weight and has been effective for many at reducing their back pain over the long and short term. The reversible option of getting surgery later remains viable in most cases.

A recent study looked into this very question and found that it is slightly more cost effective to perform a noninstrumented fusion, or a fusion using a person’s own tissue to stabilize the fusion, than an instrumented fusion This cost effectiveness is taking into account the possibility of need for re-surgery, potential complications following surgery like infection, and medication changes.

A laminectomy is a type of decompression surgery.  During a laminectomy, the lamina bone is removed which is typically encroaching on the nerve.  The lamina is a bone that bridges the spinous process (pokey part of your spine) and the transverse process, or the side of the vertebra.  If you are not excited about surgery and have not yet done so, physical therapy can often help to minimize symptoms if not alleviate them completely.

Any surgery has associated risks.  Many of these can be avoided with proper procedures.  Overall, recent data shows the risk for sentinel events or avoidable mistakes to be .8 per 1000 cases in the U.S., so overall the risk is fairly low.  That being said however, you should have a discussion with your surgeon regarding your concerns and he can give you specifics regarding risks of your particular surgical procedure.

This question is highly dependent upon many factors and needs to be carefully assessed by a medical professional. If you have a severe bulging disc in your low back that is putting debilitating pressure on your nerves, then yes selective discectomy surgery can be effective for reducing radiating low back pain.

The exact process to explain the shortening of your spine is speculated in the spine-related research. Two proposed explanations include a cumulative micro-trauma theory at the disc-vertebra interface that creates an inflation process and merging of the cartilage and bone. The second theory suggests a gradual tensioning of the disc pulling on the vertebra that eventually triggers a process of converting the cartilage to bone.

The current research can validly extrapolate that the average middle-aged man is indeed getting shorter, but by only .13 millimeters per year on an annual average. For example, if you are 5 feet 8 inches at age 45, you could safely expect to loose less than an inch by your 60th birthday.

The study was not specific in the “core” muscles activated but they inclued the pelvic floor musculature, transverse abdominus, lumbar multifidi, and the diaphragm.

If you are someone who has a BMI of 25 and above and have chronic low back pain (12 weeks or longer, consistently) reducing your BMI may not change your pain or disabilty. You should contact a skilled health care provider for proper evaluation and assessment of your symptoms.

In this study they found, that for the average overweight American a modest increase in activity time by 17.6 minutes a day (123 minutes a week) reduces risk of lower back pain by 32 per cent and for morbidly obese people an increase of 2.1 minutes can make substantial difference. An example would be adding more time in moderate activity (walking) into your day.

Exercise has been shown to help both conditions. Speak with your physician or a qualified clinician about your back pain and weight. They can assist you in getting started with a safe, gradual and successful exercise program.

Nonspecific means that you can’t specify the cause the back pain, such as a fracture, tumor, infection or inflammatory disease. Nonspecific back pain is generally known as the common back ache or strain.

This is a good question to ask your physical therapist, acupuncturist, masseuse, chiropractor or selected practitioner. A rigorous evidence-based education should provide your therapist of choice with the skills, tools and the body of research to support why they are selecting each treatment. It would not be unwise to have a brief discussion on the rationale behind their treatment choice.

This largely depends on how wide of a search beam you project into the years of research. For example in a recent meta-analysis by Dr. Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, found very little supportive evidence in his meta-analyses on comparative effectiveness of various manual therapies, that include spinal manipulation in his review of the existing literature. “A comparative effectiveness meta-analysis” was performed to compare the relative effectiveness of various spinal manipulation treatments (from the ancient bonesetter to the modern back cracker), medical management (READ: drugs, injections, etc), physical therapy, and exercise for acute (less than a month) and chronic (more than 3 months) nonsurgical management of low back pain.

The good news is most pain originating from the muscles and joint in the
human body is self-limiting, meaning slowing down, protecting your
injury, and letting the body heal will often suffice. Research supports the notion that sixty to seventy per cent of acute low back pain settles in six weeks without any medical treatment. Chronic low back pain sufferers get better in a year without treatment 40 to 70 percent of the time. Pain whether short-term or long-term is indubitably unpleasant, so why suffer any longer than you have to if effective treatment is available.

In a recent meta-analysis by Dr. Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, he determined in the comparison that getting your spine manipulated in the first six weeks has little influence on the outcome of shortening the duration of your acute pain. Five types of spinal manipulation providers (osteopaths, physical therapists, chiropractors, allopathic medical physicians, and bonesetters) were compared. Spinal manipulation by a physical therapist was found to be most effective, and most variable, in treating both acute and chronic back pain.

Despite spending more than 86 billion dollars a year on treatment for back pain in the United States, Americans continue to struggle with this problem. It has become a national epidemic. Twenty-five years ago, prominent medical doctors called for new ways to diagnose back pain and measure outcomes of treatment. Today, very little has changed. In fact, there is evidence to suggest that Americans with spine problems are worse than ever before.

What have we learned from these last 25 years of scientific inquiry and study? In a recent editorial, Dr. R. G. Hazard from the Department of Orthopaedics at Dartmouth Geisel School of Medicine offers some perspective on this question that may be of interest to you.

First, it should be noted that in 1987, researchers started using scientifically validated measures of low back pain and subsequent disability. And second, the focus shifted from looking for a specific pathologic reason for the back pain to an understanding of the biopsychosocial factors accompanying back pain.

Stress at home and at work, feelings of being out of control of life situations, and self-perceptions were some of the biopsychosocial aspects mentioned at that time. Along with these two new approaches came awareness that treatment at that time was driven by patient complaints, distress, and behavior.

On the medical side of things, it is clear that finding a clear and accurate diagnosis to label each patient is often impossible. Imaging studies with X-rays, CT scans, and/or MRIs are often “negative” (no findings of anything “wrong” in the bones or soft tissues). Even knowing this, physicians continue to use steroid injections, narcotic medications, and surgical procedures to address the problem of back pain.

Not only that, but when clear-cut diagnoses can be made (e.g., lumbar disc herniation), patients with this diagnosis respond differently to treatment. Finding one single approach that works for everyone just hasn’t happened. Some experts even recommend providing patients with amenu of (treatment) options and letting them pick their treatment of choice. This idea is labeled a shared decision-making model. However, results so far have not been any better than with physician-prescribed treatment.

So, where are we today? There is a shift toward emphasizing ability (function) rather than disability (limitations). Instead of focusing treatment on pain relief, rehab programs aim to improve flexibility, endurance, and strength in the presence of ongoing pain. If pain is relieved in the process, well then, so much the better.

Recovering function (daily activities) and the ability to return to work are the main goals of today’s treatment for chronic low back pain. This approach is referred to as the Goal Achievement Model for the treatment of low back pain. Efforts to reduce disability from back pain based on patient goals is a new way of thinking about the problem of back pain.

Concepts such as setting “acceptable targets” and forming “patient-based action plans” are the new words attached to current treatment ideas about chronic low back pain. Health care providers can still use the biopsychosocial model (working with patient values, attitudes, and beliefs) while the patient gets the results he or she is after. This approach has worked quite well with other health problems (mental health and chronic diseases that lead to severe disability). In time, we will see how patients with low back pain fare.

Twenty-five years ago, the focus shifted from looking for a specific pathologic reason for low back pain to an understanding of the biopsychosocial factors accompanying back pain. By then, it was clear that finding a clear and accurate diagnosis to label each patient was often impossible. Imaging studies with X-rays, CT scans, and/or MRIs are often “negative” (no findings of anything “wrong” in the bones or soft tissues).

Stress at home and at work, feelings of being out of control of life situations, and self-perceptions were some of the biopsychosocial aspects mentioned at that time. An awareness that treatment at that time was driven by patient complaints, distress, and behavior started to change things.

There was a shift toward emphasizing ability (function) rather than disability (limitations). Instead of focusing treatment on pain relief, rehab programs today aim to improve flexibility, endurance, and strength in the presence of ongoing pain. If pain is relieved, well then, so much the better. But pain relief is no longer the main treatment objective.

Recovering function (daily activities) and the ability to return to work are the main goals of today’s treatment for chronic low back pain. This approach is referred to as the Goal Achievement Model for the treatment of low back pain. Efforts to reduce disability from back pain based on patient goals is a new way of thinking about the problem of back pain.

Concepts such as setting “acceptable targets” and forming “patient-based action plans” are the new words attached to current treatment ideas about chronic low back pain. Health care providers can still use the biopsychosocial model (working with patient values, attitudes, and beliefs) while the patient gets the results he or she is after. This approach has worked quite well with other health problems (mental health and chronic diseases that lead to severe disability).

Pain can be a real deterrent to accomplishing anything from the simple task of brushing your teeth to getting a good night’s rest. Clinical and research efforts are underway in an attempt solve the dilemma of chronic low back pain. In today’s modern practice, you can expect to find yourself in a goal-oriented program that takes into consideration physical, emotional, psychologic, social, and spiritual aspects of care.

Lowering costs, meeting patient expectations, and providing successful outcomes and patient satisfaction are all important but complex factors that must be taken into consideration. Pain relief is part of that approach but only a small piece of the pie. Give this approach a fair try and see what you might be able to accomplish in the long-run rather than having a short-term focus on pain relief. It can be a challenging way to treat back pain (for the patient!) but still very effective.

The 2006 clinical practice guidelines for degenerative lumbar spinal stenosis (DLSS) have indeed been reviewed (based on published studies up to and including July 2010) and revised. In a recent article from The Spine Journal, members from the Degenerative Lumbar Spinal Stenosis Work Group of the North American Spine Society (NASS) provided a summary of the new guidelines. This update is now considered the most recent evidence-based clinical practice guideline (CPG) on LSS.

Sixteen questions were posed and answered in the 2006 Clinical Practice Guidelines. The questions covered topics ranging from natural history of LSS to diagnosis and treatment of this condition. All questions were reviewed and responses provided in this 2013 update. The levels of evidence were indicated for each response using grades labeled A (recommended), B (suggested), C (an option), and I (insufficient evidence to recommend for or against).

The working group also provided a consensus statement when there wasn’t enough reliable evidence to provide a guideline. This consensus statement is the opinion of the group based on all currently available evidence and expert opinion. Here is a sampling of the questions and some of the updated responses:

Lumbar spinal stenosis in this age group is usually caused by the natural degeneration of the spine over time. The condition is described as a narrowing of the space available for the spinal cord, nerve roots, and blood vessels in the spine. The lumbar spine (low back area) is the region affected most often by this condition.

Bending forward helps take the pressure off the neural segments (spinal cord, spinal nerve roots) but this compensatory posture has some obvious drawbacks. The use of a corset or brace has been shown to aid patients by decreasing the pain, thus making it possible to stand upright and walk unassisted. However, once the brace is removed, the benefits are gone as well. In other words, wearing a brace is not a long-term answer.

Other types of treatment have been tried and results reported. Acupuncture, electrical stimulation, and traction are just a few examples of treatments investigated. But not everyone responds well and there is insufficient evidence to direct and guide who is most likely to respond to each treatment type.

Surgery is advised for patients with moderate-to-severe symptoms that persist over time. But keep in mind that patients with mild-to-moderate symptoms have a 30 to 50 per cent chance of improvement over time without treatment. Symptomatic relief with short-term bracing is considered acceptable, especially if there is a chance for symptom resolution without surgery.

Accurate diagnosis of disc herniation can definitely be a complex and challenging process. There is no cookie cutter approach that is reliable. This is because the pathomechanics and pathophysiology of nerve root irritation causing leg pain, numbness, and/or weakness (referred to as radiculopathy) is complex.

For example, two patients can have the same type of disc herniation with pressure on the spinal nerve root from the bulging disc and still have very different symptoms. In fact, the pain patterns and symptom presentation for lumbar disc herniation is often quite variable.

There are several separate components of the problem that must be determined: is there a disc herniation and if so, what level? Is the disc compressing or chemically irritating one (or more) spinal levels? And again, if so, what level(s)?

Currently, there are no neurologic clinical tests that have been shown to conclusively diagnose disc herniation based on the presence of radiculopathy (symptoms from compression on a spinal nerve root). Future studies are needed to find and standardize clinical tests that are valid and reliable in accurately diagnosing nerve root irritation (radiculopathy) associated with disc herniation.

For now, the physician must rely on patient history (what you tell him/her happened and what are your symptoms) along with the results of clinical tests, electrodiagnostic tests, and imaging studies. Even when electrodiagnostic tests are done to confirm nerve involvement, severe disc herniation can be present with no signs of weakness or sensory changes. Sometimes even with all that information, it’s still not entirely clear what the problem is.

Patients who have surgery don’t always obtain relief from their symptoms so the decision to recommend surgery is not made easily or lightly. Conservative care is almost always advised. The physician follows the patient to see what kind of response occurs with nonoperative care. Even this information is diagnostic in nature.

It is possible that you might find another physician who would be more assertive and certain about your diagnosis. And there is nothing wrong with seeking out a second (or even third) opinion (especially if you are facing the possibility of spinal surgery). But give yourself some time to let nature take its intended course (healing) while you pursue a course of recommended self-care via the conservative approach.