FAQ Category: Lumbar Spine

You could both be right. Studies conclusively show that psychosocial distress is a key factor in chronic low back pain (CLBP). But whether psychosocial distress ia a cause or the result of CLBP is much like the chicken and the egg. No one knows for sure which came first.

It makes sense that anyone with chronic pain of any kind is both stressed and distressed. But studies also show that people who are distressed are more likely to develop back pain. Distress is defined as abnormal or heightened stress responses.

Distress manifests itself in a variety of ways. Anxiety, depression, and fear top the list. Uncertainty, anger and hostility, and increased awareness of the body are also subsets of distress.

No matter which it is, dealing with distress is essential when treating back pain. Patients should be tested for types of distress and management or treatment geared toward the findings. For example, insomnia (difficulty sleeping), agoraphobia (fear of public places), and somatization (body pain as a result of anxiety) are identifiable and treatable.

Unfortunately, when it comes to chronic low back pain (CLBP), there isn’t a one-size-fits-all test. Each survey, questionnaire, or instrument measures some specific aspect of distress and disability. So far, combining or paring down the assessment tools has not proven successful.

The idea behind such extensive testing is to identify underlying factors that are linked with disability. If treatment can be focused on those risk factors, then management of CLBP may be more effective. Improving function and decreasing disability is the overall goal.

Conservative care is usually the first-line of treatment for lumbar radiculopathy (sciatica). Most patients get better with a combination of treatment in the first six to eight weeks. Anti-inflammatory drugs, physical therapy, and exercise are used most often to obtain relief from painful symptoms.

But when non-operative measures fail, then surgery may be the next step. Imaging studies identify the underlying pathology. It could be a herniated disc, bone spur, or cyst that’s putting pressure on the spinal nerve causing the radiculopathy. Removing the cause of the problem seems to work in about 80 per cent of all surgical cases.

But what about the other 20 per cent? These are the patients who fail both conservative and surgical treatment. Studies show that certain psychosocial factors may be to blame. The presence of anxiety, depression, worry, fear, and other psychologic traits actually predict a negative outcome from treatment.

Patients who report joint pain in the extremities along with sciatica are also more likely to have a poor outcome after surgery. The joint pain is not caused by irritation of the spinal nerve. And it is not relieved by decompression surgery to remove pressure on the nerve.

Patients who are involved in personal injury claims or worker’s compensation claims are also at increased risk for poor results. Patients with any of these risk factors may want to proceed with surgery carefully or not at all.

You may want to ask your surgeon for a psychologic or psychiatric evaluation prior to scheduling the operation. There are several tests that can help identify emotional and psychologic distress. The results may predict your relative risk for a poor, fair, good, or excellent outcome.

Sometimes, in a small number of cases, surgery for sciatica just doesn’t help as expected. Pain relief may be minimal to non-existent. Some patients are able to go back to work, while others go on disability.

Doctors are working hard to figure out why some people are helped by surgery and others are not. If they can find a way to predict the results, then surgery can be advised or discouraged accordingly.

Each patient would be evaluated for his or her positive or negative risk factors in making this decision. So far, several predictive factors have been identified. These include axial joint pain (arms or legs) and overall pain levels and location.

Psychosocial issues and claims status are also important. A recent study of this issue showed that there was no probability of a good or excellent outcome when the patient exhibited psychiatric factors. The same was true for patients involved in personal injury claims. Workers’ compensation cases werre only slightly more likely to be helped by surgery.

Based on these results, surgeons are more cautious in recommending revision procedures.

The pars defects are likely due to stress fractures. While they likely will not heal on their own, they are not always a source of pain. When painful, conservative care such as physical therapy, medications, or bracing may be helpful. If surgery is recommended, there are 2 major types of surgeries that are usually done. One is direct repair of the facet joints with wire and bone grafting to support the fractures. The other is fusion of the segments in the lumbar spine that are involved. There are advantages and disadvantages of each type of surgery. Return to previous level of activity may be more likely following surgery than with conservative care.

Yes, it is important. While your surgery may include the placement of hardware or bone grafting, it will not be strong enough to support the repair. It is more likely that the bones will not heal properly, and the hardware may break if you do not follow directions for wearing your corset.

The condition you describe is called failed back surgery syndrome (FBSS). Although many patients are helped by back surgery, there are some who end up with intractable back/and or leg pain. This type of pain is called neuropathic pain.

As you have experienced, neuropathic pain associated with FBSS can be extremely disabling. Pain, loss of function, and decreased quality of life can lead to the loss of a job and permanent disability.

Conventional medical management does help some patients, but the majority express low satisfaction with treatment. Spinal cord stimulation (SCS) is achieved with a device that is implanted in the body. The device delivers a low level electrical current through wires. The wires are placed in the area near the spinal cord. The device is about the size of a pacemaker.

The two most common problems that occur with the SCS are infection and electrode migration. Some patients report a loss of stimulation. The stimulation causes paresthesia (numbness). Without the paresthesia sensation, their pain comes back in full force.

Surgery is often needed to repair the device or fix the problem. It is estimated that one-third of all patients who receive the SCS experience device-related complications. An equal number of patients develop other (non-device) problems. These include side effects from medications, new illness, or new injury.

Facet joints are small joints up and down the spine that allow motion. They can develop arthritis like other joints and be a cause of pain. Facet blocks have been used to help doctors decide whether or not facet joints are a cause of neck or back pain. However, only
half the time a single set of nerve blocks will be accurate in making the positive diagnosis of facet joint pain. If the first nerve block reduces pain by a significant amount such as 80 percent, it should be repeated. If the second one relieves pain also, then the facet joint(s) is considered positive as a source of neck or back pain.

Given the large number of people who have had or have back pain in their lifetime, it is a surprise that only 15 percent of the time back pain could be specifically diagnosed in the past. This meant that the great majority of back pain was termed non-specific. This also meant that treatments were not targeted to specific parts of the spine.

Facet joints, discs, ligaments, nerve roots, and muscles can all be a source of back pain. Some can be eliminated as a source of pain given a patient’s symptoms, physical examination, or imaging such as X-ray or MRI.

More recently, doctors, with the help of injections that numb certain parts of the spine, can make a specific diagnosis in up to 85 percent of patients.

Studies have shown that facet joints, the small joints in the spine may be the source of neck, mid-back (thoracic), and low back pain 25 to 40 percent of the time.

Determining this requires using an injection with a numbing agent such as lidocaine. The lidocaine is used to block the nerve to the targeted facet joint(s). A positive diagnosis can be made if pain is markedly decreased (some doctors require 80 percent improvement) and ability to move or function while the joint(s) is numb is improved.

Most doctors require repeating the injection(s) to ensure a proper diagnosis. Up to half of patients with a positive response initially will have a negative response when the injection(s) is repeated.

It’s estimated that 80 per cent of the adult population will experience LBP sometime in their lifetime. Understanding and treating low back pain (LBP) is one of the most common challenges doctors, physical therapists, and chiropractors face every day.

Health care professionals are actively seeking ways to classify patients according to their clinical presentation. Clinical presentation refers to the patient’s signs and symptoms. What makes them better? What makes them worse? How long does it last? Frequency, intensity, and duration of the painful symptoms are all part of the presentation.

One approach to LBP is called treatment-base classification (TBC). The idea is to find groups of patients with a similar history and presentation. Place them in groups or subcategories. Then look for a treatment program that works for each group.

The current TBC system places LBP patients into one of four groups. If the pain can be changed by specific movements, then flexion or extension exercises might work best. Other patients may do better with mobilization or manipulation. A third group may respond best to spinal stabilization called core training.

The fourth treatment category is traction. Traction is the application of a mechanical force on the soft tissue and bones of the spine. It is reserved for patients who have back and leg pain that doesn’t change with spinal flexion or extension. The traction force helps relieve pressure on the musculoskeletal system.

If you do not get results from treatment, then the therapist will re-evaluate your case and modify the treatment plan. If you do not respond to any of the treatment techniques, then a medical exam is needed.

Core exercise training has become very popular in the United States over the last five years. The core muscles refer to deep muscles of the trunk (spine and abdomen). These include the iliopsoas (hip flexor), lumbar multifidus (LM; spinal muscle), and transverse abdominis (TrA; abdominal muscle).

Electromyography (EMG) studies have shown that these deep muscles are impaired in people with low back pain (LBP). They may be weak and atrophied. Atrophy means the muscle fibers are getting smaller in size. The muscle contraction then gets weaker.

Impairment of the core muscles also means there is delayed activation of the muscles when needed. Slow contraction alters movement and can lead to pain and injury. There is also a lack of voluntary control of the core muscles.

This understanding has led to the motor control theory of spinal stabilization. This theory suggests that core training strengthens the deep trunk muscles. This type of training works to alleviate LBP because these structures control motion between the vertebrae.

With core exercises, patients are able to learn how to activate and train the deep trunk muscles.

Spinal manipulation is often used to treat patients with a variety of spinal disorders. Physical therapists, chiropractors, and osteopathic physicians use this technique most often.

The effects of spinal manipulation are often felt by the patient. There may be an audible pop when the procedure is done. Afterwards pain, stiffness, soreness, and other symptoms may decrease or go away. The goal of treatment is to alter the symptoms, restore joint motion, and improve movement and function.

Research shows that spinal manipulation does have a direct effect on muscle function. Specific studies have shown this to be true for the quadriceps muscle (front of thigh) and the erector spinae (muscle alongside the spine). Deep muscles of the neck and low back also respond favorably to spinal manipulation.

The exact mechanism by which spinal manipulation works is still unknown. Various theories have been proposed by many experts. There may be a direct neurophysiologic effect. However, it’s likely that there is a reflex involved. Movement of the spinal joints may just trigger an automatic response much like a knee jerk response.

Other theories include biomechanical or neuroendocrine changes. It’s also possible there is an immune system reaction and/or circulatory changes that can account for the effect of this treatment.

As imaging technology improves, more studies will be done to help identify the exact physiologic and biologic steps that occur. Studies are underway now using a new, noninvasive approach called rehabilitative ultrasound imaging (RUSI). This tool makes it possible to assess and measure deep muscle function.

Many people report stiffness in the low back area without pain. Sometimes it’s possible to point to the exact spot that is stiff. This is called localized stiffness. In other cases, stiffness seems to be a more diffuse or regional symptom.

There are many possible reasons for this condition. In some cases, decreased motion at one or more segment may be the problem. This is referred to as spinal hypomobility. Postural and muscular changes accompany spinal hypomobility. But which came first (the decreased motion or the other changes) remains unknown.

Treatment is directed toward restoring motion of the affected joint(s). It’s best to have an exam done by a physical therapist, chiropractor, or orthopedic surgeon. The examiner can perform special tests to assess muscle function, joint motion, and spinal mobility.

Exercises may be prescribed. In some cases, spinal mobilization or manipulation may be needed. Mobilization is a technique used to move the joint through its full range of motion. Manipulation takes the joint to its end range and applies a thrust.

You may not feel any direct effects from mobilization. Manipulation is often accompanied by a click or pop that can be felt and/or heard. Decreased pain or stiffness, increased motion, and improved function are the end results of either technique.

It’s true that heat should be avoided in an acute injury or trauma. Cold is still advised for the first 24 to 48 hours to reduce swelling and inflammation. Heat can be used carefully during the subacute phase of an injury.

This means the initial inflammatory period has passed. Heat for 10 to 20 minutes helps promote circulation and may speed up the healing process. But it shouldn’t be used in the presence of swelling, redness, or tissue heat without a physician’s approval.

Heat is a common way to treat chronic pain. Chronic pain refers to symptoms that have been present for three months or more. The new heatwrap therapy treatment provides sustained low-level heat. Most wraps last eight hours. You can wear it for any length of time up to eight hours.

Studies show that continuous low level heatwrap therapy reduces pain, muscle stiffness, and disability. As a result, motion and flexibility are improved. Less pain also means less stress. The effect of low-level heatwrap therapy on stress has even been measured.

Researchers measured electrical activity in the brain using electroencephalograms (EEGs). Higher EEG frequencies are linked to pain and an arousal state present during stress. Lower EEG frequencies indicate reduced stress and a lower state of arousal.

The use of a heatwrap left on at least four hours was to decrease EEG frequency reflecting a lower arousal state. Since there is no inflammation present in chronic pain states, the use of prolonged low-level heat is safe and very effective.

If you’ve had back pain that hasn’t changed or has gotten worse over the last six to eight weeks, then a medical exam is needed to rule out a more serious problem. The presence of any additional symptoms such as nausea, painful bowel movements, or blood in the stool also warrants a visit to the doctor.

But if you are troubled by a simple backache from stress, overuse, or fatigue, then a variety of steps can be taken. Oral analgesics such as ibuprofen can work very well. However, you may not need the antiinflammatory properties offered by ibuprofen. If pain control is all you need, then a simple pain reducer such as tylenol may be all that’s necessary.

Modalities such as heat and cold can also be used judiciously. If there’s no injury and the back pain is linked with stress and muscle tension, then heat may be the best approach. A heating pad is often used but people fall asleep on them and suffer burns easily.

The new low-level heat therapy from heatwraps may be the best option. These units are wrapped around the abdomen just below the waist. They apply continuous heat to the low back area for up to eight hours. You can even combine the use of an oral analgesic with heat therapy.

Some people respond better to a cold pack applied to the painful area. With noninflammatory, mechanical backpain, you can experiment to find out what works best for you (heat or cold). Keeping cold on for more than 20 minutes is not advised and hard to do anyway. Most cold packs warm up and lose their cooling capacity.

Once you see what works for you, then combine the use of oral analgesics, heat or cold, and exercise. Exercise (even just walking) is still the best treatment for back pain of any kind.

Low back pain can be caused by a wide range of problems. Nerves, muscles, ligaments, joints, and discs can all be either a direct or indirect cause of painful symptoms.

Identifying the involved anatomy can help direct treatment more specifically. The chances of recovery without recurrence may improve with treatment directed at the cause of the problems.

Joints in the spine are called facet or zygapophyseal joints. Lumbar zygapophyseal joints (LZJ) are a common cause of unilateral (on one side) pain in the low back area.

One way to both confirm and treat the source of problems from the LZJ is the use of facet joint injection. A numbing and an antiinflammatory agent are both injected into the joint. Pain relief is both diagnostic and curative for many patients.

Radiofrequency denervation called neurotomy is another treatment method. The nerve(s) to the joint are destroyed using heat generated by radiofrequency waves. Pain is prevented from occurring for up to 10 months. Once the nerve regenerates (grows back), the pain can return. At least half the people who have a neurotomy do not have a recurrence.

If you prefer something a little less invasive, then physical therapy may be a good choice. The therapist can apply manual techniques to help realign the joint and restore normal biomechanics. Decreased pain along with improved motion and function are possible.

Some people apply the wait-and-see approach. In many cases, doing nothing and letting the passage of time and natural healing take place is all that’s required.

Identifying the exact mechanism of low back pain (LBP) can be quite a challenge. The discs don’t generate pain directly but they can put pressure on the nearby nerves and set up a pain pattern in that way.

The spinal (facet) joints make spinal motion possible. Forward bending, side bending, twisting, and straightening are movements that all take place at the facet joint. Anything that can reduce the joint space or alter the joint biomechanics can produce LBP.

If more than one joint or disc is affected, you could have pain at more than one level. Pain from the joint can be referred to the knee but does not go below the knee. Pain caused by nerve impingement from disc herniation can travel from the low back to the buttock and down the leg all the way to the foot.

Palpation and position are also used to help sort out the source of painful symptoms. Some positions are known to make the symptoms better or worse in each case. Palpation to reproduce the symptoms is possible when a facet joint is the source of the symptoms. Palpating the painful area will not increase the pain when the disc is involved.

Your doctor will be able to help make the correct diagnosis related to your LBP. It’s important to rule out a more serious cause of pain. Once it’s confirmed that there isn’t a medical problem, then treatment can be applied to help improve motion, function, and reduce symptoms.

Fear-avoidance beliefs (FABs) is a fairly new concept. But it’s one that researchers have validated as real and potentially harmful. FAB is the notion that activity and/or movement is going to cause more pain and reinjury in someone with low back pain (LBP). Studies are being done to see if this same idea applies to neck pain as well.

For now, we know that some people interpret their back pain as a signal that they should stop moving in order to avoid more pain. But in fact, motion is lotion. Movement, activity, and exercise actually seem to be the best way to avoid seeing an acute problem become a chronic disability.

Awareness of FABs is the first step in the right direction. Patient education is a key tool in the prevention of chronic pain. Patients can be taught ways to modify their fear-avoidance beliefs. Your doctor has already begun this process. Ask him or her for more information.

Guidelines for the management of LBP have been developed by national health care organizations. This type of information can get you started. Physical therapists are also trained to help patients recognize FABs. They can assess your level of FABs at work and during physical activity. By observing your movements patterns, the therapist helps train you to change the way you think and move.

National guidelines for the management of low back pain (LBP) recommend staying as active as possible. Rest may be advised during the first 24 hours but after that, patients are encouraged to get up and keep moving. These guidelines are based on evidence from many studies of LBP patients.

Fear of movement and recurrence of pain or injury are called fear-avoidance beliefs (FABs). A high level of FAB is a risk factor for acute LBP becoming chronic LBP with resultant disability. The discovery and understanding of FABs is fairly new.

A recent study from France showed that many general practitioners (GPs) hold to FABs themselves. This leads to patient advice to take it easy when activity should really be the order of the day. According to the results of the study, older doctors in rural settings were more likely to have high scores on the FAB questionnaire.

Efforts to educate both patients and physicians are underway in the U.S. as well as other countries. Such steps may help reduce the high cost of care for disability associated with chronic LBP.

Your grandmother may have a condition called lumbar degenerative kyphosis or flat back syndrome. This is one of the most common spinal deformities in Asia.

It appears to occur most often in middle-aged and older Asian women. Lifestyle and working postures likely contribute to this condition. Sleeping on the floor and eating and working in a crouched position are the main risk factors.

Studies show that surgery to fuse the lumbar spine results in a spontaneous correction of the curves in the thoracic (midback) spine. The studies were specifically of Asian patients with flat back syndrome.

Combining an anterior (from the front) and posterior (from the back) fusion procedure gives the best result. The surgeon is able to regain maximum lordosis in the lumbar spine with this approach. Lordosis refers to the natural swayback position of the lower spine.

In order to achieve this affect, the anterior spinal column is lengthened. At the same time, the posterior spinal column must be shortened. The patient benefits by the results: less pain and improved function and posture.