FAQ Category: Lumbar Spine

Spinal stenosis (SS) is a common problem today in older adults. Older adult is defined today as anyone over 65 years old. Stenosis is described as the compression of nerve tissue (nerves, spinal cord). It’s caused by a narrowing of the space where the neural tissue is located.

Normally, the spinal cord and spinal nerves only take up about one-third of the space around them. But as we age, this space starts to narrow. Bone spurs, thickening of the ligaments, and disc collapse all contribute to this problem.

Stenosis may be accompanied by another problem: scoliosis. This is a curvature of the spine that develops as the supporting structures of the spine degenerate. The vertebrae start to slide sideways and rotate. This can further complicate the picture.

Although stenosis can be congenital, most of the time it is acquired. This means it develops as a result of the age-related changes mentioned. Whether or not stenosis is becoming more of a problem in today’s older adults compared to previous generations is unknown. Studies to determine causes and risk factors are underway.

Many studies confirm the fact that discectomy (surgical removal of a herniated disc) has a large window of opportunity. Patients can wait several months and still get good results from the operation.

Long-term studies show that in the end (say four to 10 years later), patient outcomes aren’t much different between surgical and nonsurgical care. This means if you don’t have that disc removed, your results years down the road won’t be any worse than if you do have the discectomy.

The real difference occurs in the short-term results. Your chances for pain relief sooner than later is better with surgery compared with conservative (nonoperative) care.

People who have surgery to remove part or all of the disc perceive greater improvement compared to patients treated without surgery. But at the end of the first year, the benefits are no longer so obvious between those who do and those who do not have surgery.

If immediate relief of painful symptoms would improve your quality of life and function, then it may be worth the risk of surgery for you. Be prepared though: not everyone gets pain relief right away. It could take a few weeks to months after the operation before your symptoms gradually go away.

Sciatica is a condition of leg pain caused by pressure on the sciatic nerve. There may be numbness and tingling with it. The leg may feel weak and give out from under the person. Treatment usually starts with conservative (nonsurgical) care.

Pain relievers and anti-inflammatories are often tried first. Positioning and exercises under the direction of a physical therapist may be helpful. Treatment can be applied more specifically if the cause of the sciatica is known.

Anything that can put pressure on the sciatic nerve can cause sciatica. For example, a herniated disc, tumor, or infection are the most likely sources of compression. Bone spurs from arthritic changes and narrowing of the intervertebral spaces from degenerative disc disease can also contribute to sciatica.

Infection can be treated with antibiotics. Tumors may require radiation therapy to shrink the tumor first before surgery is done (if at all). Surgery to remove a herniated disc gets fast relief but the long-term results aren’t any better than conservative care.

So the first step is to find out what’s pinching the sciatic nerve. See a medical doctor for an examination and any imaging studies required. The doctor can lay out all treatment options for you based on your situation. The pros and cons of each approach should be considered along with expected short-term versus long-term results.

Studies have shown over and over now that surgery for some herniated discs can be postponed. Most patients judge the type and timing of treatment based on how severe or tolerable symptoms may be.

For patients who can work and carry out daily activities, conservative care may be all that’s needed. And the reason researchers have come to that conclusion is because they compared long-term results for patients who had surgery versus those who didn’t.

It turns out that at the end of 12 months, the results are no different between the two groups. So the best advice is to avoid surgery. Even if it means a prolonged period of nonoperative care, it’s probably worth it.

On the other hand, if you can’t tolerate the pain, then early surgery is still an option. Likewise, if there is enough nerve damage to cause weakness, disc surgery is a sensible choice.

This is a very good question. Standardizing research results so that everyone collects and reports the same data would be very helpful. Scientists could analyze and use the results to find better ways to treat various health conditions.

The problem is that each condition has its own unique features. Even with a single symptom like back pain, different tools are used. This may depend on where you are in the process, and what are the goals of treatment.

For example, early on there is a need to know levels of pain. The health care worker may ask you to rank your pain from zero (no pain) to 10 (most pain). Treatment is directed at reducing the intensity, frequency, and/or duration of your pain. Once the pain persists past the expected time for healing, then it’s called chronic pain.

The goal of treatment may be to increase your function without changing the pain intensity. In other words, the therapist helps you to do more within the confines of your pain. If that’s the case, then functional tests may be used to measure results of treatment. Each test is different based on the activities you are working on.

There is a move in research circles to try and coordinate efforts to collect and analyze data. The World Health Organization (WHO) is working hard at bringing this information to all health care professionals. If everyone uses the same outcome measures but different measuring sticks (tools), then researchers might be able to use one another’s results to study specific diseases and conditions.

You may be getting the same results but you just don’t know it. According to a recent review of many studies on exercise for low back pain (LBP), only a fraction of people get the positive results reported.

This over-reporting of conclusions is fairly common. The statistics show one thing but the actual clinical results don’t match up. This means that treatment effects are over estimated.

The reasons this happens can vary. Sometimes the number of people in the study is too small to really measure treatment effect. But the data is analyzed and the statistics look very favorable.

In other cases, the researchers use a very narrow change in measures to show a positive result. This statistical tool is called the minimally clinically important difference. If pain and motion are the main measures of results and an improvement of one per cent is used, the results will look better than if 10 per cent improvement is required to show a positive effect of the treatment.

If exercise alone isn’t helping, then adding one other treatment at a time may help sort out what works and what doesn’t for you. Sometimes there is a particular combination of treatment that works best for an individual.

Finding that best match may take some time and lots of trial and error but it can be done. Take good notes or keep a daily log to help you look back on your own results and see what’s working for you.

Good question and one we don’t have an exact answer for yet. What we can tell you is that whenever exercise is used to treat chronic back pain, the results show improvement. Pain is less, function is better, and the patients report less disability.

Other benefits show up too. Patients go to the doctor less often. They miss fewer days of work. They return to work sooner or they go back to work after being off because of their back problems.

There are different types of exercise. There’s resistance training to help increase your muscle bulk and muscle strength. There’s endurance training to help increase your stamina and staying power. You can go longer with less fatigue.

And there’s aerobic exercise, which is actually a way to train one specific muscle and that’s your heart. Of course, improving the function of your heart also improves circulation and overall health and fitness.

Then there are specific exercises designed for the specific problem. This is usually prescribed and administered by a physical therapist. It could include stretching to promote flexibility or core exercises to stabilize the spine. Postural exercises and range of motion are also tools the therapist uses.

Many other forms of exercise have been tested and proven effective such as tai chi, yoga, swimming, biking, and walking. The best advice is to get started with some form of exercise. See what works best for you. Try to vary what you do so that you get several sessions of each kind every week.

If engaging in a general exercise program doesn’t net the improvements you are looking for, then see a physical therapist. Keep track of what you are doing in a journal so you can see what you have been doing and the results over time.

It may take weeks to months to get a consistent program going and then to evaluate the results. Take your time and stick with it. Consistency is one of the most important factors. Consistent, regular (daily if possible) exercise shows up over and over in studies of exercise as the key to success.

Chymopapain was a treatment used to dissolve the herniated disc with an injection of enzymes. This type of treatment is called chemonucleolysis. It was used in the early 1970s but was taken off the market because of safety issues.

It was re-released by the Food and Drug Administration (FDA) in the early 1980s. Since that time, its use has fallen out of favor due to other more updated treatment methods.

This decision may have been premature. A recent historical review of the records showed that chymopapain is less invasive than surgery and may work better. After 40 years of collecting data, it looks like this type of treatment works better than a placebo and the results last 10 years or more.

It has been suggested that chemonucleolysis should be used as the next step after conservative care. It is a minimally invasive procedure. And it may be able to prevent patients from having open surgery.

On the other hand, since more patients having chemonucleolysis ended up having surgery anyway, it may make more sense to just have a discectomy (disc removal) in the first place. With the new, advanced surgical methods for disc removal, it’s unlikely chymopapain will ever be an option again.

Most likely you would have a microdiscectomy or disc removal. There are many ways to do this operation. You will have to talk to your surgeon about which procedure is best for you.

Most discectomies done today are noninvasive. This means instead of an open incision, the operation is done with tiny incisions. Sometimes there’s just a puncture in the skin where the instrument enters the body.

The disc can be destroyed with laser or just removed using surgical instruments. Sometimes the entire disc is taken out. In other cases, just the protruding or fragments of disc are removed.

Many patients experience quick relief from their symptoms after microdiscectomy. There is very little scar tissue and that helps prevent chronic pain. Results may depend on how long the symptoms have been present. The type of surgery performed may make a difference but not enough studies have been done to prove this.

Total disc replacement (TDR), also known as artificial disc replacement (ADR) is a fairly new procedure in the United States. They are used most often with patients who have painful symptoms from degenerative disc disease. Usually at least six months of conservative care is tried first before doing this surgery.

The advantages of TDR over spinal fusion include preserving motion and disc height. This means the spinal joints remain in better alignment, too. The affect of TDR on motion at other levels in the spine has been under investigation for a while.

In a recent study from Korea, scientists tried to find factors that might predict the final results. One of the things they looked at closely was the issue of range of motion. Just as you experienced, they noticed less motion at the L5-S1 level in their patients, too.

They suggested this might be caused by the way the spine is put together at that junction. Because it’s the place where the lumbar spine meets the sacrum, there are slight differences in the bones and soft tissues. In particular, there are many more ligaments in this region giving the area a natural increased stiffness.

They checked to see if motion before the surgery made any difference. It didn’t. They analyzed age, gender, and body mass index to see if any of these factors made a difference. They didn’t.

Overall, it looked like it was just the location at that particular segment. And it may be the design of the implant has to be changed to get better motion. This is a matter for further investigation in other studies.

There is a current review of surgical treatment for this problem. It was conducted by a group of researchers from the University of Ottawa in Canada. They searched the data banks and found a total of 1,923 studies. There were 66 studied that looked like possibilities.

After setting up what they were looking for (diagnosis, treatment, number of patients in the study, and so on), they were able to include 12 studies in the review. In these 12 studies, there was a total of almost 600 patients who had surgery for this condition.

Some patients had a decompression operation. Bone is removed to take pressure off the spinal nerve. In other studies, the surgeon did a decompression and then fused the spine. All the studies reported improvement in patient symptoms and function with the fusion except one.

The general trend in all these studies was for better results with fusion over decompression. Whether it’s better to have a fusion with instrumentation (metal plates and/or screws) or just bone graft isn’t clear yet.

Patients are more likely to get a solid fusion with instrumentation. But there’s also a higher risk of repeat surgery needed following instrumented fusion. Best evidence supports fusion over decompression alone. But long-term patient results comparing different ways of doing the fusion have not been reported yet.

The new total disc replacements (TDR) offer patients with degenerative disc disease an option other than spinal fusion. The TDR allows the patient to keep motion fairly normal at the diseased level. At least, that’s the case for short-term to medium results. Long-term results are still being studied.

The limitations of TDR are also still being investigated. For example, how do these implants affect motion at other segments nearby? How much stress or strain can they take?

Your surgeon is the best one to advise you. Based on X-ray findings, you may be a candidate for revision surgery. If there are no other complications, the TDR may be removed and replaced with a new one. If there are risk factors, the TDR may have to be removed and the spine fused instead.

Your mother’s condition is called degenerative spondylolisthesis. The word degenerative refers to the age-related changes causing the discs and joints to break down. Spondylolisthesis describes the condition where the vertebra slips forward over the bone below it.

Surgery is done to stabilize the spine. As the vertebral body moves forward, the spinal nerve gets stretched and sometimes pinched. Back and leg pain, especially when walking is common. They may have numbness and weakness of the legs, too.

There are several different types of operations that can be done for this problem. The first is a decompression of the nerve. This is done by removing the bone around the nerve to take pressure off it. Depending on how it’s done, the procedure is called a laminectomy or laminotomy.

Sometimes decompression is all that’s needed. In other cases, spinal fusion may be done. A solid fusion helps stabilize the spine. There are two basic ways fusion is done: with or without instrumentation. Instrumentation refers to the screws or metal plates used to hold the spine in place until full fusion takes place.

The surgeon will take into consideration your mother’s age, health, and condition of her spine when making the decision about the best procedure to offer.

Physical deconditioning occurs when the body loses strength and endurance. Loss of muscle fibers from disuse results in muscle atrophy or wasting. The force of the muscle contraction declines and strength decreases.

Endurance refers to how long the muscle can contract and hold. Or in a more general sense, how long the body can keep going. Pain with use seems to occur when weakness and loss of endurance are factors.

So for example, older adults may experience aches and pains that go away by increasing their activity level. We say they are deconditioned and that exercise is the key to reconditioning.

Aerobic capacity is also part of the equation. The heart is also a muscle that can become deconditioned without the proper amount of exercise and activity. Exercise that increases the heart rate (number of times it beats in a minute) helps improve aerobic conditioning.

Some experts look at decreased body mass and increased body fat as a sign of deconditioning. Very few studies exist to actually prove or disprove the theory that deconditioning is the result of chronic pain.

It seems to make good, common sense but should be studied more closely. Finding out what kind of conditioning program works best would be helpful.

Studies of patients with low back pain are ongoing. Researchers are trying to find out how to tell who will end up with chronic back pain and possibly prevent it. Others are looking for the best ways to treat back pain to get people back to their regular routine of activity.

Recently, it’s been discovered that some people are so afraid they will re-injure themselves that they stop moving. Or they may change the way they move in order to keep from having any pain.

This is called fear avoidance behavior (FAB). There’s a movement amoung doctors, psychologists, behavioral counselors, and physical therapists to help patients break out of this pattern.

A study from the Netherlands also showed some evidence that there are people who cope with their pain much the way your uncle has. They use endurance strategies and overload their body. This can lead to overuse and further injury but no one has actually studied it yet to know for sure.

Most experts advise getting back to regular work and physical activities as the best way to deal with back pain. Your uncle may be more right than wrong in this issue. Without good evidence to suggest he should slow down, there may be no reason to moderate his behavior.

It sounds like each examiner is conducting a straight leg raise test. It can be done in either position (sitting or lying down) but a recent study showed it is more accurate when lying down.

The test is designed to see if the cause of your pain is lumbar radiculopathy. Radiculopathy describes a condition in which one of the spinal nerves is irritated or compressed. This can result in pain we refer to as radicular pain. Radiculopathy can also cause weakness, numbness, or changes in sensation in the foot and leg.

Lifting the leg with the knee straight stretches the sciatic nerve. If there is a herniated disc pushing against the nerve, it won’t be able to glide smoothly. The pressure from the disc may cut off the blood flow. It definitely increases the tension of the nerve.

The test tells the examiner that there is some structural abnormality causing the problem. Whether that is a disc, bone spur, tumor, or infection requires some additional testing.

Sciatica is another term for low back and leg pain caused by spinal nerve irritation. Five nerve roots (L4, L5, S1, S2, S3) that come off the spinal cord are branches that form the sciatic nerve.

Anytime one or more of these nerve roots is pressed against or irritated, pain can occur. The pain is located in the low back, buttock, and/or leg going down to the foot. There can be other symptoms besides pain such as numbness, tingling, weakness, and trouble using the leg.

Sciatica is actually a symptom. It doesn’t tell us what’s wrong with the leg.

Treatment for the problem depends on finding out what’s causing the sciatica. Magnetic resonance imaging (MRI) may be a good idea. Studies show that MRIs are reliable in detecting problems with the nerve tissue.

You should keep in mind, however, that many people have a positive MRI but no symptoms and vice versa. In other words, it’s possible to have a bulging disc seen on MRI and have no symptoms. It’s also possible to have symptoms that suggest a bulging disc but the discs look fine.

Test results are always combined with other tests, your history, and your risk factors. It sounds like you’ve had this pain for quite some time. If you have tried various treatments without help, it may be time for further testing. MRI might be a good next step. Consult with your physician and see what is the next step.

MRI stands for magnetic resonance imaging. It is a way of looking inside the body at tissues that wouldn’t otherwise be visible. MRI uses non-ionizing radio frequency (RF) signals. It is not an X-ray, which uses radiation to acquire its images. MRI works best for seeing non-calcified (non bone) tissue.

MRI scanners produce a series of two-dimensional cross-sections (slices) of tissue. It can also be used to show a 3-D reconstruction of the anatomy. By changing the way the tissue is scanned, tissue contrast can be altered and enhanced in various ways to detect different features.

Signal intensity changes when there are changes in the soft tissues. Sometimes the signal intensity increases. In other cases, the signal intensity decreases. Advances in MRI techniques and software has made it possible to see these signal changes.

Doctors are still studying MRIs to see if it is possible to link the degree of signal intensity with the patient’s symptoms and/or the results of treatment. Most doctors agree that signal changes indicating spinal cord compression is a sign that surgery is needed.

In the case of spinal cord compressions, the more intense the signal change, the slower the patient’s recovery and the worse the results. Less intense signal changes predicts a faster, easier recovery.

Interbody fusion cages were first approved for use by the FDA in 1997. Since that time, they have become very popular for spinal fusion surgery. Other materials have been tried. Carbon fiber, porous tantalum, and even bone dowels have been used in place of the titanium cages.

Carbon fiber is a nonmetallic substance made from carbon (graphite). It has many, many uses from racing yahts to musical instruments. Skateboards used for downhill speed boarding made from carbon fiber are flexible but hard. This material is used for road bikes and mountain bikes for the same reason. It has been used to make fusion cages because of its high rigidity and low weight.

Tantalum is a hard, transition metal that is resistant to corrosion. It resists attack by body fluids. It is not perceived by the body as irritating, so it’s widely used in making surgical instruments and implants.

More recently, bone dowels have been tried in place of titanium cages. Bone taken from cadavers was machined to form threads for use in spinal fusion. A large hole was drilled in each dowel to allow bone to grow in and around the dowel. The dowels were used much like the titanium cages. There were problems though with bone fracture and cracking. The bone dowels did much better when reinforced with metal plates or screws.

Researchers try different materials but keep coming back to the titanium. It is light but strong and bears greater loads through the spine than other materials.

The fact that you’ve already had some general low back pain for two months suggests the problem is ongoing. We would consider that a yellow (warning) flag. The onset of these new symptoms in the last two weeks is really the red flag to suggest some kind of evaluation is needed.

For most nonspecific low back pain, two months is enough time to recover and return to your full schedule of activities. Research supports staying active and working through back pain. For back problems that don’t go away with this approach, early diagnosis and treatment is advised.

Back pain that travels down the leg is called sciatica. This is a sign that something is impinging or pressing on one of the five spinal nerves that form the sciatic nerve. It could be a bulging or herniated disc, bone spur, or tumor. An MRI is needed to sort out the actual cause.

Whenever possible, doctors try to help patients avoid developing chronic pain. That’s usually defined as pain that lasts more than three months. You are approaching that time frame now. Getting a medical exam now would be a good idea to help prevent becoming a chronic pain patient and to move along in your rehab process.