FAQ Category: Lumbar Spine

A recent study showed that TNFa is present in a much greater proportion of people with chronic low back pain versus those without. Presently there is no specific treatment to target TNFa. There are anticytokine therapies available but none specifically aimed at lowering TNFa levels.

A recent study where subjects were followed for six months demonstrated that TNFa levels remained elevated even though some subjects were no longer having symptoms of low back pain.

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.

Balloon kyphoplasty has been used to restore height and function of the vertebral bone after compression fracture. Once the bone collapses, pain and deformity reduce function and quality of life.

The advantages of this minimally invasive approach are: 1) rapid pain reduction, 2) fast recovery and return to daily activities, and 3) few risks or problems after the procedure.

Improvements in the kind of cement used seem to have produced even better results. Calcium phosphate bone cement is being used more often and replacing polymethylmethacrylate (PMMA).

The self-hardening calcium phosphate bone cements are biocompatible. They do not heat up or create toxic effects on the bone. They can even stimulate new bone to grow, a process called osteoconductivity.

Researchers are experimenting with the use of cement along with reinforcement of the segment with screws and/or bone graft material. The hope is to prevent vertebral collapse and loss of correction.

Studies show that collapse is more likely without support along the front of the spine. Disc material migrates or moves from between the two vertebrae through the endplate into the fractured vertebral body. That’s why kyphoplasty has become more popular — it reinforces the bone and reduces the risk of failure, especially in osteoporotic bone.

Today, a combination of kyphoplasty and screw fixation to hold everything in place may prevent problems such as you had. More study is needed to find out what are the long-term results.

Patients who are admitted to the hospital and operated on within 24 hours have a good chance of improvement in neurologic function. Studies show that many patients regain full function. This is more likely to happen if the person had an incomplete neurologic lesion (partial, not complete, paralysis).

Results may depend on the condition of the bone. Many older adults have osteoporosis (brittle bones) that cause the compression fracture in the first place. There may be further complications if the surgeon can’t find strong enough bone to support wires or screws.

If the long ligament down the spine was not ruptured at the time of the fracture, the risk of damage to the spinal cord is less. Other problems that can interfere with recovery include infection, diabetes mellitus, or pulmonary embolism (blood clot to the lungs).

Final results after surgery may take some time. Many patients continue to experience signs of recovery up to six months after the procedure. Your surgeon and neurologist may be able to offer you a more realistic prognosis based on what they saw during the operation.

Don’t be afraid to ask for more information. But be prepared for a wait-and-see response. It isn’t always possible to know what will happen with neurologic damage after compression fractures.

No one knows for sure what causes spondylolysis. The condition is characterized by a fracture of the pedicle — the area of bone between the upper and lower facet (spine) joints.

Two per cent of the African-American population is affected. But up to 60 per cent of Alaskan natives have this condition. It could be linked to genetic or lifestyle factors, but exactly what those are remains unknown.

It appears that separation of the bone occurs with repetitive mechanical load or stress. But many people experiencing similar loads don’t develop spondylolysis. So what’s the difference between someone who has spondylolysis and someone who doesn’t? That remains a mystery for now.

Scientists are actively studying this problem. Recent studies of the tissue that forms around the fracture might offer us some clues. It could be that abnormal tissue in the area can’t handle the load across the low back.

Or perhaps fractures occur that heal with callus (bone tissue) in some people and they never develop back pain. Others have poor fracture healing because the defect fills in with tissue that’s more like tendons or ligaments. It’s strong but not strong enough to withstand the mechanical forces on the spine. They develop painful low back symptoms and have an X-ray showing the fracture.

More study is needed to answer the many questions about this condition, including why such a high proportion of Alaskan natives are affected.

Small fractures of the pedicles in the lumbar spine create a condition called spondylolysis. If the two sides of the fractured bone move, it becomes a spondylolisthesis.

The body tries to heal the fracture and stabilize the bones. Unfortunately, it fills in the defect with dense fibrous tissue. It’s more like a ligament than solid bone. As a result, there is motion at the fracture site when there shouldn’t be. This creates a pseudoarthrosis or false joint.

Repetitive mechanical stress or load on the area can cause a spondylolysis to become a spondylolisthesis. In both conditions, low back pain is common. But neurologic signs and symptoms are more likely if the fracture pulls apart or displaces.

Then the upper portion of the bone slides forward. This puts pressure on the spinal cord or spinal nerve roots, causing severe pain, numbness, weakness, and atrophy of the muscles.

A nondisplaced fracture (even with a pseudoarthrosis) can be treated without surgery. Patients with severe back and/or leg pain (sciatica) are more likely to be candidates for operative care. Otherwise, conservative (nonoperative) care is the standard form of treatment.

Clinical guidelines for the diagnosis and treatment of lumbar spinal stenosis (LSS) have been published by the North American Spine Society (NASS). A large group of health care specialists worked together to make recommendations based on high level of evidence in the literature.

They reviewed all studies up to April 2006 looking for high quality work with dependable results. They found that for up to half of the patients with mild to moderate stenosis, the prognosis is favorable. Pain can be controlled allowing for greater movement and function. Serious neurologic problems are rare in this group.

There wasn’t enough evidence to come to a conclusion about the long-term effects of severe LSS. Treatment options include a wide range of modalities from medications to physical therapy to surgery.

Overall, there isn’t enough evidence from studies to support one treatment approach over another. There are very few studies that show the use of medications provides positive long-term results.

Using measures of pain and function, it appears that the use of a lumbosacral corset can increase walking distance and decrease pain for these patients. However, once the support is removed, the benefit goes away. Physical therapy alone without other treatment has not been studied but a few reports suggest it may be helpful for certain subgroups of patients.

Much more research is needed to sort out who should have what treatment. Steroid injections, manipulation, electrical stimulation, and traction are just a few approaches used alone or together but without enough studies to show if they really work or not. Some things may provide short-term relief but no apparent long-term effects.

For now, it may be best to use a team approach. Your parents’ physicians can help you develop a reasonable plan based on your parents’ wishes. Sometimes it requires a step-by-step program of trial and error to find what will give them the results they are looking for. Be patient with the process as it may take some time.

Surgery isn’t for everyone but it can be helpful for some patients. Studies show that about 20 to 40 per cent of patients with mild-to-moderate lumbar spinal stenosis will eventually have surgery. On the flip side, most of the 60 to 80 per cent who don’t need surgery do get better over time.

The real question is does surgery improve the results? Does decompressive surgery to remove bone pressing on the nerve tissue reduce pain and improve function? It appears that patients with moderate-to-severe symptoms have an 80 per cent chance of improvement with decompressive surgery. They are less likely to be helped by conservative care.

Age doesn’t seem to be an important factor. Younger and older patients were helped equally by surgery. Surgeons are comparing different types of surgical procedures to find the most effective for this group of patients. There may be subgroups of stenosis patients who are helped more by one technique over another.

It’s not clear just if there is one single treatment or group of treatments that should be used with anyone who has painful or disabling stenosis. Talk with your surgeon about what might work best for you.

Many patients are helped by a simple decompression surgery. Others need decompression along with a spinal fusion. Special devices such as the X-stop can be surgically implanted to prevent motion at the diseased level.

A recent study showed that the use of Quantitative Sensory Testing is comparable to nerve conduction studies. The QST is a battery of seven tests that measures 13 different sensory parameters such as vibration, hot, cold, pinprick, blunt pressure, touch, and pain summation.

Your pain is called pseudoradicular pain. Traditionally, it was felt that only pain that radiated below the knee, called radicular pain, could be caused by a pinched nerve in the back. A pinched nerve is a nerve root that is being compressed. However, a recent study has shown that standard neurological testing, particularly of sensation, may not correctly diagnose leg pain. In fact, in some cases, pseudoradicular pain may actually be caused by nerve root compression.

Physicians, nurses, and physical therapists are trained to watch for yellow and red flags in back pain patients. Yellow flags are caution signs that suggest the need to test further or look more carefully at what’s going on. Red flags are more serious warning signs that immediate action is needed.

When it comes to back pain, yellow and red flags are used in two ways. The health care specialist looks for warning signs of physical involvement. There may be a risk of infection, tumors, or fractures. Accurate diagnosis is needed before treatment can be determined.

Or sometimes the warning flags relate to the psychosocial side of things. Emotional or mental stress may be the cause of the back pain. There may be indicators that if these warnings are not paid attention to, the patient will end up with chronic back pain.

Identifying patients who can benefit from behavioral or psychologic help early on is important. This may prevent them from developing long-term unfavorable results.

Low back pain (LBP) is a common problem among all adults. In fact, it’s estimated that at least 80 per cent of adults will experience an episode of LBP sometime in their lifetime.

And according to multiple studies, smokers are even more likely to experience LBP and more than one time, too. It’s not clear yet what the exact relationship is between smoking and LBP. It may be multifactorial, meaning more than a single factor contributes to the problem.

Perhaps there is a cluster of certain risk factors that make the difference. These could include poor nutrition, obesity, and not enough sleep or physical activity. Maybe LBP in smokers is more related to higher levels of stress, distress, and anxiety.

There may be personality traits common to people who smoke and develop LBP. Social, cultural, and economic or educational variables may make a difference. Smokers are more likely to have pain in general (not just back pain) compared to nonsmokers. So maybe there are biologic reasons some smokers develop LBP.

Some studies have shown that industrial workers who smoked and who were exposed to heavy smoking had increased rates of hospitalizations for disc disease. Most of the biologic studies of tissues have been done on animals. It isn’t possible to do these kinds of studies on humans, so we don’t have complete understanding of the biologic factors.

Studies are ongoing to identify specific risk factors. The hope is to prevent smoking first, then reduce risk among tobacco users.

Degenerative changes at the level next to a spinal fusion are not uncommon. At least 10 per cent of the patients with a one-level fusion experience changes in the adjacent segments. The number of patients affected increases as the number of segments involved increase.

Changes can occur in either location: above or below the fusion. In fact, sometimes degeneration takes place in both places. And it’s been reported that disease can occur beyond the immediately adjacent vertebra. These changes aren’t usually as severe as those at the adjacent level.

It’s not entirely clear whether the changes that occur are really the result of the fusion or just part of the normal aging process. Disc degeneration is a natural part of the decline in spinal health that occurs in all older adults.

Disc thinning and decreased disc height along with bone spur formation around the joints are common changes observed even without a spinal fusion. It’s possible that these changes occur at a much faster rate after spinal fusion. There’s some evidence that the segment above is more likely to bear the brunt of changes in load and motion. But the effects are evident in both directions.

Back pain that travels down the leg can be caused by nerve root compression or from changes in the joint and nearby soft tissue structures. In the case of nerve root pressure, the pain is considered as coming from a neuropathic source. With true neuropathic leg pain, the symptoms go down the leg past the knee.

Pain referred from the spinal joint is called nociceptive. Nociceptive pain occurs when receptors in and around the joint are stimulated. This sends a message of unpleasant stimuli up the spinal cord to the brain. The brain signals back pain that can go down the leg but doesn’t go below the knee.

Neuropathic and nociceptive pain responds to drug treatment differently. Nociceptive pain is sensitive to nonsteroidal antiinflammatory drugs (NSAIDs). Neuropathic pain is more likely to respond to antidepressants and anticonvulsants (seizure medication).

The chemical pathway for the pain is different between nociceptive and neuropathic pain. The mechanism of these drugs is based on these chemical pathways and affects them differently. Finding the source of back and leg pain is important so the right treatment approach can be applied. Sometimes it’s a matter of trial and error before the right drug is prescribed for the specific problem.

Radicular refers to nerve pain. Another term for nerve pain is neuropathic. Pressure on the spinal nerve root as it leaves the spinal cord or as it travels down the spine results in pain down the leg.

Depending on the location of the compressive forces, the pain goes below the knee to the calf, ankle, and/or foot. The cause of the pressure is usually a protruding disc but it can be a bone spur, tumor, or other space-occupying lesion.

The term pseudo usually means like or mimics the real thing. In the case of pseudoradicular pain, it means the pain goes down the leg but isn’t caused by nerve compression or nerve irritation.

How does the doctor know the difference? First, pseudoradicular pain doesn’t usually go down past the knee. Second, specific tests for nerve, joint, and muscles can be done to find out where the problem originates (starts).

The results of these tests aren’t always clear-cut. So the doctor uses your history, clinical presentation (signs and symptoms), and responses to the tests to make the final diagnosis. For example, Quantitive Sensory Testing (QST) measures pain thresholds for sensory stimuli. Cold, warm, touch, pressure, vibration, and pinprick can be tested to look for nerve impairment.

Most often, true radicular pain will show signs of changes in the threshold for pain sensitivity. The test isn’t 100 per cent diagnostic though. About 20 per cent of the time, patients with pseudoradicular pain test positive for sensory loss using this test.

This may mean these two conditions (radicular and pseudoradicular) will be treated (in part) the same way. Usually, the neuropathic pain responds to one form of treatment, while the pseudoneuropathic may improve with a different approach. But if there’s overlap, then the patient with pseudoneuropathic pain may require a change in the standard treatment approach.

A treatment for some different causes of back pain is the epidural injection. This injection allows your doctor to put the medication right into the back where the pain is, around the spinal nerves.

To have the injection, you will lie on your stomach. If your doctor is using a guided technique, he or she will need x-rays to guide the needle to the right spot, otherwise, the injection can be done in a doctor’s office or clinic.

Once the needle is in the right place, the medication is slowly injected into the back. Some people do well with one injection, some others need a series of injections. You will need to discuss this with your doctor.

As with all medical procedures, an epidural injection has some possible side effects. While this is something you should discuss with your doctor, here are a few:

1 – Infection from the injection

2 – Bleeding from the injection

3 – Piercing of the membrane that surrounds the spine and the spinal nerves