FAQ Category: Lumbar Spine

Cognitive-behavioral therapy or CBT is a way to help patients understand their beliefs about pain and how it is affecting their recovery. Studies have shown that our beliefs about pain are linked with pain intensity, psychologic distress, and even physical disability.

Patients who believe that their pain is an indication of ongoing disease are more likely to seek medical treatment and fail to return to work. In fact only 0.2 per cent of the back pain population have a true organic cause of their symptoms. The majority of chronic back pain sufferers have noninflammatory, mechanical low back pain. Theis means there isn’t a serious underlying illness or disease causing the pain.

Pain beliefs are learned over time and can be changed. They have become a target of intervention as a means of modifying outcomes of treatment. CBT is an important tool to help move patients away from focusing on the negative aspects of pain.

Understanding the cause of your low back pain is important. Believing there is something seriously wrong with your spine when the condition is really noninflammatory can delay your recovery process. You may want to discuss this more with your physician. Find out why he or she has recommended CBT. It may help you move forward with a successful treatment program.

Patients’ belief systems have a lot to do with how they respond (or don’t respond) to treatment. If you think your pain is an indication that there’s something wrong or that anything that makes it hurt is actually damaging your spine, then exercise and activity won’t seem helpful to you.

Exercise has been shown over and over to be beneficial for patients with chronic low back pain. But sticking with a program every day is essential. Patients who believe movement and activity will only make things worse have a more difficult time carrying out a regular schedule of exercise.

In some cases, general activity may not address your specific needs. At this point in your rehab, you may need a particular type of exercise program. This could be core training, motor control training, or some other specific program to change your movement patterns. A physical therapist can help identify what this may be for you.

Once you’ve gotten past the first roadblock, it should be smooth sailing for you. Knowing that your back pain is not a fracture, tumor, infection, or inflammatory process is very helpful.

Ongoing pain in the case of a nonorganic, noninflammatory cause of low back pain suggests that pain beliefs are present that are hindering your progress. If consistently carrying out your prescribed exercise program doesn’t help, you may need the skills of a counselor or cognitive behavioral specialist.

Together, you, your counselor, and your physical therapist can help you identify and change the way you think in order to change how you respond to your pain. Breaking the links between beliefs about pain, physiologic damage and physical harm, and exercise can change your pain levels and functional ability.

Minimally invasive surgery to decompress the nerve pressed by a herniated or protruding disc is state-of-the-art now. The procedure is called a microdiscectomy. The surgeon makes a tiny incision in the skin and places an endoscope through the soft tissues to the affected area.

The endoscope is a rigid tube with a tiny TV camera on the end. It allows the surgeon to see the area being operated on without making a wide, open incision. Special surgical tools can be passed down through the tube as well. These tools are used to ream out the foraminal space (where the nerve root passes through the bone).

In many cases, removing only the loose fragments or protruding disc material has replaced complete removal of the disc. But the remaining disc can re-herniate requiring a second operation.

This can happen in any patient of any age from months to years after the first discectomy. Recurrence can occur at any lumbar spinal level but L45 and L5-S1 are the areas affected most often. Studies show the recurrence rate varies between five and 18 per cent. The reported rates may depend on how long patients are followed up after the primary (first) operation.

There are blood vessels along the nerve root that pulse with each heart beat. For a successful nerve root decompression, the surgeon must be able to see the nerve root pulsing freely. That indicates the decompression has been complete.

This is important in decompression procedures for both disc herniation and for spinal stenosis (narrowing of the spinal canal or nerve root opening). Removing disc material pressing on the nerve root is the goal of nerve root decompression. Restoring blood flow to the area at the same time helps with the healing process.

In the case of spinal stenosis, interruption of blood supply is the major problem. In both cases, restoring free arterial blood flow is a good endpoint for decompression.

Many studies show that results of imaging tests often have little to do with patient symptoms and/or function. In the case of surgical fusion, successful clinical results are seen even when the X-ray suggests an unstable, unfused spine. And the opposite is also possible. In other words, a patient can have a normal appearing X-ray but suffer from significant back pain and disability.

Experts agree that knowing how solid a spinal fusion mass really is — is a difficult problem. The only way to know for sure is to surgically open the site and look at the state of the fused spine. The X-ray is only a two-dimensional black and white representation of what’s really present.

It may not be necessary to do anything more for you. Even with only one side fused, many patients are evidently stable enough and symptom-free to get back to their previous level of activities in a safe and pain free manner.

Back pain appears to be a common problem for adults of all ages from 20 to 100+. Since function and quality of life are clearly affected by pain, treatment at any age is advised.

The first step is to have a medical exam. Back pain could be a sign of a bladder infection or bowel impaction. Simple medical treatment may bring quick and easy pain relief.

Back pain can also be from something more serious such as a vertebral compression fracture related to osteoporosis. Treatment isn’t quite as simple, but there are still effective ways to approach the problem.

And even in the case of cancer metastasized to the bone, there are conservative ways to treat the problem palliatively — that means to treat the pain and at least make the patient more comfortable.

Since more and more adults are living past the 100-year mark, it’s possible your grandmother could live another 10 years. Quality of life at any age is important. Pain isn’t inevitable. Something can be done to help.

Make an appointment today with her primary care physician. It may take a bit of time to sort through all the factors and find the best treatment. She’ll likely need your assistance along the way. Don’t give up if the first treatment approach doesn’t work. Sometimes a specific type of back pain responds better to one method over another. It takes time to identify all the variables involved.

Many patients prefer a combined approach to the treatment of low back pain. However, with this method, they may not be able to tell what really worked: was it the massage? the acupuncture? the manipulation? or some combination of these? In such cases, the individual likes to hit it with everything at once in hopes of getting some pain relief.

Others would rather try one thing at a time. This way they know what worked best. In the future, if similar problems develop, they won’t have to go chasing after all forms of treatment again. They can start with what worked last time and go from there.

Third-party payers may have something to say about this. They are very interested in only reimbursing for treatments that are known to have a positive benefit. This is called evidence-based treatment.

More and more studies are being geared toward finding evidence that one particular treatment works more effectively than others. Patients are randomly assigned to one treatment group. The results for all patients in each individual treatment group are compared with outcomes for other (different) treatment approaches.

Sometimes there’s no difference from one competing therapy to another. In other cases, patients get better results with the clinician who has the most experience. It may be best if research that is done to compare different treatment approaches was only carried out by clinicians with expertise in that one area. This would be an expert-based AND evidence-based trial.

Your sciatic nerve is the long nerve that runs from your lower back down your buttock (one nerve on each side), down to the back of your thigh and down your leg.

Sciatica, pain in the sciatic nerve is almost always caused by pressure of the vertebrae, or bone in your spine, pressing on a nerve in your back. The pain then radiates down the sciatic nerve.

If you have been having frequent episodes of sciatica, you might want to consider seeing a doctor to ensure that there is nothing serious going on in your back. Your doctor may be able to help you develop a treatment plan to prevent further sciatic pain.

It’s possible but not likely. It sounds as though the therapist applied a specific technique called spinal mobilization. Mobilization is the passive movement of the spinal segment (specifically the spinal joints).

The therapist applies a rhythmical, repetitive movement called oscillation. This is usually done in a posterior-anterior direction. In other words, the therapist places his or her hands on your spine and presses downward toward the front of the body. In one-minute, the therapist can move the joint about 30 times.

This type of gentle mobilization can stretch contracted tissue in and around the joint without harming the other soft tissues nearby. Doing the motion over and over helps milk the joint. This means the synovial fluid protecting the joint is evenly redistributed throughout the joint. The result is decreased resistance to motion. This makes for smoother motion and less pain.

Post-operative surgical pain is common after microdiscectomy. And as you have noticed, there can be a wide range of differences in pain sensitivity. Scientists are still trying to understand the complexities of pain and pain control.

The use of pain-controlled analgesia (PCA) is not new. Studies first showed that small amounts of opioids given intravenously were much more effective for postoperative pain control than standard oral (pill) dosing. And the pain relief is faster with fewer side effects (nausea, vomiting, difficulty breathing).

Individuals do have different pain tolerances. They also have different responses to the same drug. The same patient can respond to a single drug differently on one day compared to another. Women are affected differently based on changing hormone levels.

Even ethnic groups have different drug tolerances. For example, Chinese people metabolize drugs differently than Caucasians. They often need lower doses of the same pain reliever.

At the same time, surgical technique can make a difference. Minimally invasive surgery can be done with less trauma to the nearby muscles. A skillful surgeon handles all tissue carefully with minimal disturbance. The type of incision, length of time in surgery, and type of surgery are all important factors as well.

A recent one month study in Denmark demonstrated that persons with chronic low back pain are generally more satisfied with a waterbed with foam layers to stabilize the water, or a body conforming mattress after. While some people benefited from a firm mattress, most reported negative effects. The dropout rate was also greater among this group, most frequently due to increase in pain.

Many people report advantages or disadvantages of specific mattresses. A recent study using 120 subjects suggests that body conforming mattresses can improve back symptoms, function, and sleep. The dropout rate was lowest among those using the body conforming mattress versus the other two mattresses studied, indicating it is also well tolerated.

One can never know if there will be a cure for anything, however, back pain is one of the trickier health issues to predict. Chronic back pain is one of the most common complaints in western society. The lifestyles often contribute to back damage and back pain.

The spine is not easily fixed and there are many things that can go wrong with it, from traumatic injuries to osteoporosis, or so-called wear-and-tear arthritis. As the population ages and the issue of back pain grows, a lot of resources are being placed into prevention of back injury, as well as in back treatments.

Research is currently underway to answer this question more completely. When total disc replacement (TDR) was first approved by the FDA (2004), the implant manufacturer published a list of patients who should NOT have this operation.

Since that time, the implant devices have improved. The surgical technique used has also improved. Surgeons are getting better results now than in the beginning. This means more patients may be included in those who are considered good candidates for the procedure.

The most common use of TDR is for patients with degenerative disc disease. Anyone with disc herniation or protrusion is usually treated conservatively before even considering surgery. If severe, disabling pain persists, then a microdiscectomy may be done.

In this operation, a small incision is made and a special surgical scope is passed through the opening into the spine. The scope has a tiny TV camera on the end. Pictures broadcast on a TV screen allow the surgeon to see the spinal structures as the operation is done. Part or all of the disc is removed.

TDR may be used for patients who would otherwise be having a spinal fusion. The implant preserves the disc space and disc height while maintaining motion at affected the spinal segment.

Each surgeon makes his or her own criteria for inclusion or exclusion for TDR. You may have to ask your surgeon more specifically why you don’t qualify.

Patients who are candidates for total disc replacement (TDR) aren’t usually determined based on who is the third party payer. Insurance eligibility is a separate decision from qualifying for the procedure.

Sometimes, there are concerns about secondary-gain issues for Worker’s Compensation patients. Each program is run differently depending on the state in which you live. If you are considering this option, then you’ll be subjected to two separate assessments. One is whether or not you are a good candidate for the operation. The surgeon makes this decision.

There are several clinical guidelines (including contraindications and indications) currently used in this assessment. Patients with scoliosis or other spinal deformity, lumbar spinal stenosis, and disc herniation with sciatica are not considered good candidates for TDR.

Likewise, anyone with spondylolysis, spondylolisthesis, facet joint degeneration, or osteoporosis is not a good candidate either. Spinal instability for any reason and spinal infection also exclude patients from having a TDR.

The other major deciding factor is whether or not the Worker’s Comp program in your state covers this service. It may be approved on a case-by-case basis. You will have to contact your Worker’s Comp case manager to find out if you are eligible for a disc replacement.

Bone is very strong but also very porous. There are tiny holes between cells where new bone growth can form when needed. In the case of bone graft material, bone from a bone bank or harvested from some other part of the body is used. Bone taken from your own pelvic crest (hip) is referred to as an autologous graft.

The body usually works better making new bone when the donor graft is your own bone. But bone from a bone bank (when well matched) can work, too. The bone graft doesn’t really grow new bone cells. Once the bone is removed, the cells are not alive. What they provide is a collagen matrix or structure.

The collagen matrix is removed and replaced as the body sends in blood vessels to destroy the old collagen and replace it with living cells and new bone cells. The new bone grows into the interconnecting pores of the old bone. A microlock-type of interface is formed between the two bony surfaces.

Bone substitutes such as ceramic and other products don’t form new bone. They just provide a porous surface with excellent surface bonding properties to promote attachment of new bone. Some of the compounds used are bioactive. This means they are biologically active and ensure the rapid growth of new bone.

Back in the 1960s, studies showed that small doses of pain relievers delivered intravenously after surgery was a much better way to control pain compared with traditional methods. Since that time, the idea of pain-controlled analgesia (PCA) has evolved.

Today, the PCA system can be programmed to deliver a specific amount of pain relieving drug with a lockout interval. This means the device can be set so that the patient can’t just push the button over and over. Each dose of pain is followed by a certain length of time before the next dose can be dispensed.

Weak but effective pain relieving opioid medications can be used this way. The side effects are minimal. And unless the drug is used for long periods of time, the risk of addiction is minimal.

Some centers are also using an opioid-soaked epidural patch to help reduce post-operative pain. A small piece of fat is removed from under the patient’s skin and injected with meperidine (Demerol). This fat patch is placed over the puncture site where the operative needle was inserted into the spinal canal. The meperidine soaks into the area giving added (local) pain relief.

Mechanical low back pain (LBP) usually refers to pain caused by position, posture, and activities. There may be issues with soft tissue tightness or imbalance or bone malalignment contributing to painful symptoms. But the term mechanical infers that it’s not something more serious like infection, tumor, or fracture.

Most of the time, X-rays or other imaging appears normal or within normal limits for the person with mechanical LBP. Treatment is usually conservative with an emphasis on keeping active.

In older adults, low back pain with pain into the buttocks and/or down the legs is often a sign of disc degeneration. Arthritic changes of the facet (spinal) joints can also contribute to painful symptoms.

You may want to ask your uncle a few more questions about his symptoms. For example, watch for pain at night that wakes him up. This may be a signal of something more serious. Pain that stays the same no matter what position or activity he is engaged in may also be a warning flag.

Even true mechanical LBP raises concern for an older adult. He may become unsteady on his feet or even suffer frequent falls. If there are aging changes in the spine causing stenosis (narrowing of the spinal canal), then pressure on the nerves can cause bowel and/or bladder problems.

Even if your uncle is absolutely certain he has mechanical LBP, it may be a good idea to suggest a physical exam. A medical doctor is really the one to rule out more serious pathology.

And there’s treatment for LBP that doesn’t necessarily involve surgery. Maintaining motion, strength, and function are very important as we get older. A physical therapist can provide your uncle with some practical ways to prevent loss of balance, falls, and fractures that can be very disabling.

Spondylolisthesis alters the alignment of the spine. In this condition, one of the spine bones slips forward over the one below it. As the bone moves forward, the nearby tissues and spinal nerves may become irritated and painful.

There are several types of spondylolisthesis. Some people are born with this condition. This is called congenital spondylolisthesis. It can also occur with trauma (including spine surgery). But most often (and especially in adults over age 50), it is linked with the aging process. This type of spondylolisthesis is referred to as degenerative spondylolisthesis.

As we get older, the protective discs in between the vertebrae starts to thin out and break down. The disc space narrows and the vertebrae settle closer together. This puts pressure on the facet (spinal) joints and changes the way the segment moves. The result is bone spur formation and overgrowth of the facet joint capsule.

These changes can help stabilize the joint from slipping and sliding in ways they shouldn’t. But the increased pressure and pull on the soft tissues and spinal nerves can also cause back, buttock, and leg pain.

Women are affected much more often than men by this condition. Scientists think this may be caused by the hormone estrogen. Estrogen can cause laxity (looseness) of the joints and soft tissues. This factor, combined with changes associated with aging, could lead to a higher incidence among women compared to men.

There is some evidence that the position and angle of the sacrum underneath the lumbar vertebra does make a difference in intervertebral shear forces. Evidently, the more horizontal the sacrum is, the less load and stress are placed on that area. This is a position called lumbar lordosis (swayback).

Body weight, muscle strength (and strain), and age do seem to have some bearing on the magnitude of shear forces placed on the sacrum. Peak load occurs at the L4-L5 level. A fusion at this segment is more likely to create stress and load compared with a L5S1 fusion.

Sometimes the surgeon artificially increases the lordosis by placing an implant to change the spinal orientation. The idea is to slow the degenerative processes that occur above the level of the fusion.

Maintaining segmental stability may reduce biomechanical stresses that lead to disc degeneration. A rectangular-shaped angulation cage may be the answer. More studies are needed to confirm this hypothesis.