FAQ Category: Lumbar Spine

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.

The position you described is used to allow the abdomen or belly to hang unsupported. Most lumbar surgery is done in this position. It keeps the pressure off the abdomen, spine, and blood vessels. The result is to reduce or prevent bleeding into the epidural space. The epidural space is between the spinal cord and the vertebra.

This position also distracts the posterior aspect of the vertebrae. This makes it easier for the surgeon to remove the disc when necessary.

There are some potential disadvantages with the prone-kneeling position. First and foremost is the fact that the hips and knees are bent. This flattens out the natural lordosis (swayback) in the low back and can lead to problems later. But preventing bleeding is a higher priority than keeping the spine in a certain position.

Scientists are experimenting with different ways to do this procedure. There’s been some discussion about straightening the hips just before inserting the metal rods that go along side the spine. Further studies are needed to look into this suggestion.

Sometimes patients having lumbar fusion are placed prone (face down) over chest rolls. This is done to get the right position in the spine during the procedure. But it can be used for larger patients who cannot lie flat.

In the very obese adult, lying prone even with the rolls may not give the viscera (organs) enough room. In such cases, a special table can be used. This table places the patient in a prone-kneeling position. A special support is placed along the sides and under the arms. The belly is free to hang down without any pressure.

This position is important because it helps reduce bleeding into the spine. The surgical team will be monitoring your husband throughout the procedure. The anesthesiologist makes sure the patient is getting enough oxygen. Vital signs are taken routinely. Any sign of discomfort will be recognized and dealt with right away.

Surgeons have many ways to monitor what’s going on during surgery. Special imaging such as fluoroscopy gives a view inside the spine. This helps with the insertion and placement of hardware such as plates and screws.

With some types of screws, the surgeon can also use a special probe to assure correct placement. This handheld device gives an electrical stimulation to the screw once it has been put in place. If the screw is where it should be, it takes a certain amount of current to cause a muscle contraction and wave on the monitor.

If it is in the wrong place, less current is needed to cause a muscle contraction. This is called an evoked EMG. The surgeon uses this information to change the
placement of the screw. This type of monitoring helps prevent damage to the nerve root or spinal cord.

Other monitoring units are used to alert the surgeon during the procedure to possible nerve damage. An immediate change is made in the operative technique to avoid damage to the nerve tissue. This type of intraoperative monitoring (IOM) isn’t always used. You may want to ask your surgeon what plans are being made to monitor you and prevent complications of this type.

Some people think that if you had scoliosis in childhood that it will cause low back in your later adult years. In fact, the rate of low back pain (LBP) isn’t any different for adults with scoliosis compared to adults who don’t have this condition.

When LBP occurs in adults with scoliosis, it’s more likely to have a profile (characteristic look) all its own. For example, it comes on slowly with no known cause. Doctors refer to this as an insidious onset.

Severity of LBP may be linked with the severity of the scoliosis. There’s some evidence to suggest screening, prevention, and early treatment of LBP in adults with scoliosis is a good idea.

Severe pain is more likely if the vertebrae rotate and dislocate. Treatment should be done to prevent this from happening. Rehab may be helpful. But surgery may be needed to stabilize the spine. Not much is really known about this topic yet. From studies done so far, it seems that every scoliosis has its own natural history (end-result).

Back pain is a common problem among adults around the world. At some time in their lives, most adults will experience low back pain (LBP). Most of the time, it goes away on its own. Stress and psychosocial factors such as job, money, and relationships does seem to be connected with LBP.

Scoliosis (curvature of the spine) doesn’t really go away. Treatment (such as bracing or surgery) in childhood and adolescence is done to keep it from getting worse. Once growth is complete, the scoliosis often stabilizes (stops getting worse).

Adults who had scoliosis as a child probably still have scoliosis. Severe scoliosis is linked with back pain in adults. But the general incidence, frequency, and intensity of LBP aren’t different between adults with or without scoliosis.

So, your back pain may be a response to stress. Or it could be caused by something else altogether. If it persists (doesn’t go away) and/or gets worse, see a doctor. If there’s something else going on besides stress or scoliosis, early diagnosis and treatment can make a difference in the final results.

There is some evidence to suggest that rotation of the vertebrae leading to dislocation in adults with scoliosis should be prevented or stopped. This condition can lead to severe chronic low back pain.

Disc herniations can be grouped or classified based on location and type of protrusion. Locations include central, posterolateral, foraminal, and lateral. Central means the disc pushes straight back equally on both sides. Patients with central protrusion have as much back pain as they do leg pain.

Posterolateral herniation means the disc has pushed back but at an angle to one side or the other (left or right). Disc herniation straight out to the side is in the lateral group. The foraminal zone is between posterolateral and lateral. Foraminal refers to the opening for the spinal nerve to exit as it leaves the spinal cord or spinal canal area. Leg pain may be more pronounced with these three types of herniation.

All of those classifications are based on location. But discs can be classified according to the type and extent of protrusion. The terms protrusion and herniation are often used interchangeably. But technically, protrusion is a type of herniation.

For example, disc material that pushes past its boundaries equally with a broad base and maintains that width in all planes is a herniation that is a protrusion.

A disc herniation that pushes past its covering and then bulges wider than the base is another type of herniation called extrusion. Sequestration occurs when the disc material breaks off and becomes a free-floating fragment inside the spinal canal.

So in your case, the nucleus (inner portion) of the disc has pushed into the outer part or covering of the disc (annulus). It has moved to the back and toward one side. On an MRI, it would be a bulge like a bubble — rounder or wider at the end of the protrusion than at the base.

When dealing with chronic pain, it is tempting to try any new idea or treatment that comes along. But if you have found something that is working, it might be best to continue with that while slowly adding one other treatment at a time.

Using a combination of ideas won’t necessarily help you understand what works best for you. Studies show that when it comes to chronic back pain, doing something (anything) is better than doing nothing. But doing everything at once isn’t always better than consistently following a single approach.

If you are experiencing increased back pain or boredom with the program, then it may be time to look for another treatment idea. Other medical problems and psychosocial problems can get in the way and set you back. It’s important to keep going even when improvements seem small and progress is slow.

Chronic low back pain (CLBP) can be a challenging and disabling problem. Many patients aren’t able to just get on with life without some outside help. There are many tools available to help with this problem.

The first goal may be to redefine the problem. Instead of focusing on pain, it may be helpful to set some daily life goals. This could be as simple as walking five minutes each day. Or it could be to complete one extra household task each week.

Choosing relevant activities and pacing yourself are important keys to success. Some patients keep a daily journal or log to record performance and to keep track of progress.

Physical activity and exercise are always advised. This can take the form of strength training, aerobics, or fitness exercises. If you avoid movement and activity because it might hurt, then you may need some extra help overcoming these kinds of fear-avoidance behaviors (FABs).

A clinical psychologist and/or physical therapist can help you find ways to overcome FABs and improve healthy behaviors. Motivated individuals who follow a daily program of graded activity and who practice problem solving of difficult areas often have good results.

The decision about treatment for low back pain and/or leg pain caused by disc herniation is not always simple or straightforward. You will want to discuss this with your surgeon. He or she has more information about the type and severity of the herniation.

Studies show that discectomy (disc removal) is more successful improving leg pain compared to back pain. Results do tend to vary from patient to patient, so there are no guarantees of the outcomes.

Nonoperative care is almost always advised first. This may include physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and sometimes steroid injections. Most doctors recommend at least six weeks up to six months of conservative care before trying surgery.

A recent study from Dartmouth Medical School compared the results of discectomy to nonoperative care for all types and locations of disc herniation. They reported similar pain relief no matter what kind or location of herniation was present. Patients were still reporting their pain relief was maintained up to two years later.

Comparing the cost-benefit of various back care programs is very difficult. First of all, patients are very different from one another. They may not have the same kind of back pain. The cause of the back pain may differ, too. Patient motivation and compliance with the program is also important.

These kinds of comparisons can be like the proverbial comparison of apples to oranges. Having said all of that, there are some studies published trying to sort out all the variables and factors in cost, savings, and benefits of treatment for back pain.

A recent study from the Netherlands compared the results of usual care with a physical therapist (PT) versus a specialized intensive treatment program. Patients in the usual care group were examined by the PT. An individual program was prescribed and supervised based on published low back pain guidelines. Patients were treated one to two times each week for six weeks.

A second group was also treated by the PT. This group received intense training including back school education, behavioral training, and exercise therapy. They met 20 times as a group and each one had 10 individual sessions with the therapist.

All the direct and indirect costs were compared between the groups. The intervention group cost more, and the results were the same between the groups. The thing to remember though is that both groups had some kind of physical therapy treatment. The study did not include a control group of patients who had no treatment.

You may want to see a physical therapist for a consultation. Find out what treatment is possible and what to expect. Or find out more about the program your friend went through. Can it be adapted for your specific needs? How long does it take? How much does it cost?

Once you evaluate all of these factors, you may be closer to coming up with the right answer for your own situation.

Exercise is always the first line of treatment for anyone with chronic low back pain. But not everyone likes to exercise and getting started can be a real chores. Once started, it can be equally difficult to stay with it over time. People who have a positive attitude toward exercise tend to be more consistent with the program and get the full benefit of the exercise.

If you live close to your uncle, offer to walk with him. Set up a regular schedule. Even once a week for 10 minutes is a step in the right direction. Once he sees how easy it is or finds out how much he enjoys being outdoors, then he might continue on his own.

If walking outside isn’t possible due to weather or other factors, consider walking indoors at a mall or track. A home treadmill works well for some people. They can watch their favorite TV program while getting some exercise.

Some people are reluctant to exercise. They may be afraid they will hurt themselves. This is called fear-avoidance behavior. Sometimes it’s necessary to see a physical therapist and/or a counselor to break out of FAB thought patterns.

In general, exercise gives people a sense of better well-being. But even the most well-intentioned person can fall out of the habit of getting some exercise every day. Having a partner or a supervised exercise program at a fitness center or health club can make the difference.

The discs are located between the vertebrae and act as shock absorbers. They are made up of two parts. The inner nucleus is a gel-like substance. The outer fibrous covering is called the annulus.

As we get older, we lose fluid from the annulus. The discs become dry and brittle. The collagen fibers in the annulus start to break down. The annulus can crack and form fissures. Chemicals leak out from the center. These chemicals irritate the spinal nerve roots and cause discogenic pain. The patient is diagnosed with degenerative disc disease (DDD).

Low back pain that comes and goes is often the first symptom of DDD. Sitting or standing seems to make it worse. Lying down can make it better. Some patients have LBP that goes down the leg. This is called sciatica. It is caused by pressure on the sciatic nerve.

Early on, the disc has some limited ability to heal itself so the symptoms go away. But over time and with repetitive motion and overloading, the disc degeneration continues. When the pain becomes constant, then many people seek medical help.

Treatment may begin with nonsteroidal antiinflammatory drugs (NSAIDs). NSAIDs reduce inflammation but also act as a pain reliever. Chiropractic or physical therapy care may be helpful as well.

Surgery may be needed for patients who have had disabling pain despite conservative measures. Progressive neurologic symptoms such as increasing numbness, weakness, and muscle atrophy point to the need for surgery. The surgeon may perform a discectomy (disc removal).

It’s possible now to have a partial or complete discectomy using minimally invasive techniques. The surgeon inserts a long thin instrument into the spine that allows him or her to see inside the spinal segment. The procedure can be done without a large incision.

A nucleoplasty can also be done this way. In this case, the surgeon only removes loose fragments of the disc in the intervertebral space. The disc is not punctured or entered at all.

Your mother may be a candidate for one of these procedures. But a three to six-month course of conservative care is usually advised first.

You may be thinking of intradiscal electrothermal (IDET) therapy. This is a minimally invasive procedure that has had good success so far. The surgeon inserts a catheter (long thin tube) into the disc space. A heating coil is passed down through the catheter into the disc space. The coil is used to raise the temperature.

Studies are still in the preliminary phases. This treatment has not been compared directly to spinal fusion. The cost of IDET is certainly much less than fusion. The risk of complications or problems after the procedure is minimal compared to fusion.

Results of research so far suggest that patients should be selected for IDET very carefully. The success of the IDET treatment seems to depend on proper patient selection. Each surgeon will have his or her own criteria for candidates. These may include:

Injection of a local anesthetic and steroid is a common treatment for lumbar facet joint osteoarthritis (OA). Studies don’t support the use of this approach for everyone. Research has shown that it simply doesn’t work for some people.

Scientists are trying to discover who can benefit most before just injecting all patients who have painful and disabiling OA of the joints. Finding the right candidates for the treatment may not be the answer. Perhaps there’s an optimal dose per injection or number of injections that are needed for successful results.

New therapies are being studied. One of those is the injection of hyaluronic acid (HA) into the lumbar facet joints. HA has been used with good success in other joints affected by OA.

Most of the trials have been done on large joints such as the hip, shoulder, or knee. The facet joints are much smaller and may require a slightly different approach. One of the first studies using HA in lumbar facet joint arthritis has been published. The results were disappointing as there was no decrease in pain or improvement in function.

More study is needed in this area. HA has been shown to improve the flow of synovial fluid and relieve joint pain in the knee. It is a safe and effective treatment. If the same approach can be refined and perfected for the lumbar spine, it could offer patients an alternative to steroid injections.

You may be referring to hyaluronic acid (HA) injections. This is indeed, a form of slippery injection. The HA is the goo that lubricates the joint. It’s a natural part of the synovial fluid found in a normal joint.

The procedure itself is called viscosupplementation. That’s because HA increases the viscosity of the synovial fluid. Viscosity refers to how slippery the fluid is inside the joint.

Viscosupplementation works well for some patients with knee osteoarthritis (OA). It has been tried with the shoulder, hip, hand, and foot and ankle. More recently, results from a small study (13 patients) using HA in the facet joints of the spine has been reported.

No changes in pain or disability were observed after one injection. Follow-up was only six weeks. The authors pointed out that one injection might not be enough to really gauge the results of viscosupplementation for the lumbar spine.

And the optimal dose isn’t known either. Since the spinal joint is much smaller than the knee, the amount of fluid used in the injection had to be decreased. But perhaps they didn’t use the right amount of HA. More study is needed before this treatment is adopted for spine OA.

Intradiscal Electrothermal Therapy or IDET is a heat treatment for patients with lumbar disc annular disease. Most often, they have not done well with conservative care such as pain relievers, activity modification, or exercise.

The disc is made up of two distinct parts. The central core or nucleus is a soft but supportive cushion. The outer, fibrous covering is strong protection for the nucleus.

Annular disc disease refers to a breakdown of the outer covering of the disc. Age, overuse, and injury can lead to cracks called fissures in the annulus. If the fissure extends into the nucleus, then material from inside the nucleus seeps out.

These substances can cause nerves to grow causing painful discs. Repeated damage and repair to the torn annular tissue sets up a cycle of inflammation and nerve in-growth.

IDET applies heat to these areas destroying the new nerve tissue and stopping the inflammatory response. The result can be pain relief. With pain relief often comes improved function and increased activity levels. The results may not be immediately observed. Sometimes there is a two-week lag in treatment to response.

Seventy-five per cent of patients report improved health and quality of life as a result of IDET. Physical therapy may be recommended to begin four to six weeks after the IDET treatment. The therapist can help you regain motion, strength, and spinal stability.

Traction is still in use but on a more limited scale now. This is for a couple of reasons. First, there isn’t a lot of evidence to really support its use. Studies are limited but what’s out there fails to support traction as an effective treatment for low back pain (LBP).

At the same time, doctors, therapists, and chiropractors have newer techniques and technology to treat LBP. Traction may have fallen by the wayside in light of these other more hands-on treatment approaches.

Traction units are also large and take up considerable space in a clinic while only serving a small number of patients. Some therapists find that using manual traction (with their own hands) works as well (if not better) than strapping someone to a machine for 30 minutes.

There is a newer traction system out now called the VAX-D. It has a no-slip surface that eliminates some of the harnessing used in conventional traction. A pelvic harness is used but the upper body is not tied down. Instead, the patient uses a special handgrip to keep the upper body stabilized.

Early reports on the use of this system are favorable. Pain and disability were decreased in a group of 250 low back pain patients. All subjects in the study had degenerative disc disease or a herniated disc. At least two other forms of conservative care had already been tried (before traction) without success.

More study is needed to support the use of VAX-D before you’ll see it in more clinics.

VAX-D stands for vertebral axial decompression. It is a type of lumbar traction system that is fairly new on the market. The manufacturers boast that the improved technology makes this unit more successful than traditional or conventional traction units.

VAX-D has a low-friction surface that keeps the patient from sliding up and down on the table. The patient is positioned prone (face down) instead of supine (face up) on the table. An automated logic-control mechanism provides a unique type of traction pull. This is not available in other (more standard or conventional) traction units.

Obviously, pregnancy is a limiting factor in having this type of traction. But if you have back and/or leg pain from a disc problem, then you may be a good candidate for VAX-D traction.

Previous surgery to the spine may mean you won’t qualify for this type of treatment. Anyone with osteoporosis of the spine, severe stenosis (narrowing of the spinal canal), or bone cancer can’t have traction either.

You can always call the clinic and ask if there are any guidelines for patients who can (or can’t) have this treatment. Consult with the doctor or therapist to see if you might benefit from this approach.

Limited studies using the VAX-D suggest there are very few problems after using it. Most patients report decreased pain and increased function after a six to eight week course of treatment.