FAQ Category: Lumbar Spine

You may be conducting your own “slump” test — a test often used by physical therapists and physicians to assess the neural (nerve tissue) structures. The slump test involves assuming a “slumped” position: sitting with spine flexed forward (bent over) and head and neck forward flexed (chin to chest).

Once in this position, the examiner directs the patient to lift and straighten the leg with ankle dorsiflexion (toes pulled toward face). Reproducing pain down the leg is a positive slump test. It is an indication that the sciatic nerve is being stretched or compressed (though it does not reveal the cause of the nerve tension).

The nerve can become sensitive to mechanical changes (stretch, compression) as a result of adhesions (scar tissue) keeping the nerve from sliding and gliding through the sheath or lining around the nerve. A protruding disc can put pressure on the spinal nerve. Or some other lesion (e.g., tumor, infection) can do the same thing.

Back pain accompanied by pain down the leg is referred to as radicular pain. Most of the time, radicular pain is caused by a “mechanical” problem — an alignment problem within the bony structures and/or soft tissues. This type of problem can be addressed by physical therapy. The therapist uses techniques such as the McKenzie method (specific movements and exercises), manual (hands on) therapy, stretching, nerve gliding, and stabilizing (core training) exercises.

If your symptoms do not improve on their own and/or they get worse, see your primary care physician or physical therapist for an evaluation. Once the problem is properly diagnosed, treatment can be applied to address the underlying cause(s).

There is a new study from The Netherlands that might be helpful to you. They conducted an extensive survey of the published studies comparing three treatment approaches to symptomatic lumbar degenerative disc disease: conservative care and rehabilitation, spinal fusion, or the newer option of disc replacement

Current clinical practice seems to be moving away from spinal fusion and more toward lumbar disc replacement for symptomatic degenerative disc disease. The implants were first invented and designed to help with the problem of adjacent spinal disease that often occurs at the level above or below a fused segment.

After an extensive search on-line, the authors found seven studies that compared results of disc replacement, fusion, or rehabilitation. Combining all the patients in all seven studies, there was a total of 1301 people included. Only one of those studies really looked at rehabilitation.

Analysis of findings showed that patients improved no matter what type of treatment was applied. Patient satisfaction was greater in the group who had a total disc replacement. As intended, these implants did allow patients more natural motion.

But using a five-point criteria for assessing these studies, they found all had low quality evidence. None of the studies looked at subsequent adjacent segment disease, which is the main reason the implants were developed in the first place. The follow-up was two years or less, so long-term results aren’t really available. And many of the studies are funded by disc manufacturers, so there is a need for unbiased research without conflicts of interest.

The authors suggest directed their comments to surgeons and advised caution in the use of disc replacements. They suggested that until high-quality studies with long-term results are available, it should not be assumed that “newer is better.” In other words, this new direction away from spinal fusion toward disc replacement hasn’t been adequately proven as the best approach for everyone. That doesn’t mean this treatment method isn’t ever to be used. Careful patient selection and surgeon experience and expertise with the procedure are key ingredients to a successful result.

Adults suffering from pain, loss of function, and poor quality of life do have the three basic treatment options you mentioned: 1) conservative care and rehabilitation, 2) spinal fusion, or the newer option of 3) disc replacement. Your question of which is best is a good one and one that even surgeons are grappling with.

In order to find out how to advise their patients, surgeons from The Netherlands conducted an extensive survey of the published studies comparing these three approaches. Current clinical practice seems to be moving away from spinal fusion and more toward lumbar disc replacement for symptomatic degenerative disc disease. The implants were first invented and designed to help with the problem of adjacent spinal disease that often occurs at the level above or below a fused segment.

But do they really protect the spine as intended? That’s one question that needs to be answered. They are expensive and long-term results are limited. After an extensive search on-line, the surgeons from The Netherlands found seven studies that compared results of disc replacement, fusion, or rehabilitation. Combining all the patients in all seven studies, there was a total of 1301 people included. Only one of those studies really looked at rehabilitation.

Analysis of findings showed that patients improved no matter what type of treatment was applied. Patient satisfaction was greater in the group who had a total disc replacement. As intended, these implants did allow patients more natural motion.

None of the studies looked at subsequent adjacent segment disease, which is the main reason the implants were developed in the first place. The follow-up was two years or less, so long-term results weren’t really available.

You are essentially asking about something surgeons refer to as salvage procedures. If conservative care fails to help you, then surgery may be the next step. But there are many types of nonoperative treatment. Finding the right one (or combination of two or more) can take some time.

Salvage options after spinal fusion are fewer than after disc replacement. If the disc implant doesn’t work for any reason, you can always have it removed and then have the spine fused. In some cases, a failed disc implant can be removed and replaced with a new implant (different design).

Understanding salvage options is important when deciding in favor of one treatment over another. You will want to talk with your surgeon about all your options — both before and after surgery of any kind. There may be some specific reasons related to your case that would make one type of treatment a better option than another.

Aches and pains seem to be part of the aging process for many people. Hip pain is especially common but doesn’t always come from the hip so diagnosis can be tricky. Likewise, knee and lower leg pain must be evaluated carefully because the origin can be the lumbar spine or hip. Pain that begins in one body part or region but is felt somewhere else is called referred pain.

A recent study from Chiba University, Graduate School of Medicine in Japan might offer some insights. Orthopedic surgeons there reviewed 420 patient records looking for clues to sort out lower leg pain. Only four had back or hip pain with lateral leg pain so you know this is not a common problem — and not one with a simple answer.

With patients who have both lumbar spinal stenosis (narrowing of the spinal canal or openings for the spinal nerves) and hip joint osteoarthritis — finding the origin of the pain can be a challenge.

Knowing that referred pain is always a possibility means the patient’s evaluation must include clinical tests that focus on the low back, hip, and knee. When there is pain along the lateral (outside away from the other leg) side of the lower leg, then additional testing may be required.

Advanced imaging studies such as X-rays, myelograms, CT scans, and MRIs may be needed. These are helpful but when someone has both stenosis and hip osteoarthritis, it might be necessary to perform some nerve injections.

The four patients in the Japanese study received a lidocaine (a type of novocaine) injection around the spinal nerve at the L5 level. In all four cases, the pain went away. That might confirm the problem was coming from pressure on the L5 nerve root from the stenosis. Especially because they also received an injection of lidocaine into the hip joint without a change in their pain.

But surgery to remove bone from around the nerve and fuse the lumbar spine did NOT relieve their pain. These four patients did have hip pain but they also had low back and severe leg pain like you. Clinical tests of the hip (e.g., Patrick and Friberg tests) were negative. Tests for sciatica and vascular compromise (loss of blood supply to the lower leg) were also negative.

Six to 12 months later (without knowing for sure if the origin of the lower leg pain was coming from the hip), surgery was done to replace the diseased hip joint. And guess what? All four patients experienced complete and long-lasting pain relief. How do the surgeons explain these results?

Anatomic studies in animals have shown that messages via the L4 to S1 level nerves do go to the posterior area of the hip capsule. In other words, it is possible that hip joint pain is transmitted along the L5 spinal nerve. This may be why the spinal nerve injection at L5 relieved the pain.

But if the pain was really coming from the degenerated hip, then why didn’t the lidocaine injection into the hip joint provide pain relief? The authors do not know but suspect perhaps there are central mechanisms, a term used to describe pain messages that are transferred via the spinal cord to the brain. Once the pain message is sent along this pathway, the body doesn’t seem to know how to turn the message off — even when pressure is
removed from the nerve.

This study emphasizes the fact that lower leg pain can be a challenge to diagnose and treat effectively in older adults who have both lumbar spinal stenosis and hip osteoarthritic degenerative changes. Either or both problems can cause referred pain to the lateral lower leg area. Step-by-step evaluation is recommended with conservative care first before considering surgery. The decision to do surgery (lumbar spine decompression versus hip replacement) remains a challenge without clear guidelines to follow.

Don’t give up. Work with your physicians to try one thing at a time to find out what works for you. Sometimes a combination of treatments are needed, especially if there is both peripheral (spinal nerve) and central (spinal cord) pain mechanisms involved.

Pain that begins in one body part or region but is felt somewhere else is called referred pain. There are some referred pain patterns that are well-known and physicians are aware of these. For example, pain from hip osteoarthritis can be felt in the front of the thig, the back of the thigh, and front of the knee, along the shin (lower leg), and even down into the calf.

But other patterns of referred pain can be more difficult to understand and explain. Your nerve block at L5 in the lumbar spine is a good example. From animal studies we know that messages via the L4 to S1 level nerves do go to the posterior area of the hip capsule. In other words, it is possible that hip joint pain is transmitted along the L5 spinal nerve. This may be why the spinal nerve injection at L5 relieved the pain.

But if the pain was really coming from the degenerated hip, then it makes sense that a lidocaine (numbing) injection into the hip joint would provide pain relief. But that hasn’t been confirmed in human studies. Scientists suspect perhaps there are central mechanisms at play. Central mechanisms is a term used to describe pain messages that are transferred via the spinal cord to the brain. Once the pain message is sent along this pathway, the body doesn’t seem to know how to turn the message off — even when pressure is removed from the nerve.

There is much we still do not understand about pain — local pain, referred pain, radiating pain, central pain mechanisms. These are just a few examples of different types of pain patterns and pain mechanisms. Scientists continue to explore and study pain phenomenon in order to determine the origin and help patients find specific ways to alleviate their pain.

It is true that you will spend more money seeing a physical therapist than if you didn’t go at all — at least in the short-term. But it may not be worth it when you hear the results of a new study from the University of Utah. They found that early referral to physical therapy for mechanical low back pain was linked with: 1) lower overall health care costs, 2) fewer doctor visits, 3) less use of advanced imaging (CT scans, MRIs), 4) reduced risk of surgery and injections, and 5) decreased use of narcotic (opioid) medications.

The study was done by reviewing patient records from a national database of employer-sponsored health plans. Although the study was conducted by physical therapists, they had no influence on who among the 32,070 patients studied was sent to physical therapy (PT). They were just reporting trends observed from analyzing the data.

Of the 32,070 patients who were diagnosed with low back pain as the main complaint, seven per cent were referred to PT. About 1100 patients received early PT (within 14 days of their doctor visit). The remaining 975 patients were categorized as delayed PT. They were sent to PT between 15 and 90 days after the primary care index (first) visit.

What they found was if you live in the Northeast or West (United States), are covered by a preferred provider plan, and you are not taking narcotic medications, then you would be more likely to see a physical therapist early in the episode of your back pain. With early PT, you would be less likely to have surgery or injections and the cost savings would be nearly $3,000.00.

A second feature of the study was to compare cost savings for patients depending on how they were treated. There are Clinical Practice Guidelines (CPGs) based on research evidence that dictate how patients with mechanical low back pain should be treated. Health care providers who follow those guidelines (guided exercise and self-management) were referred to as adherent.

The second category (nonadherent) described patients who received care outside the guidelines such as hot packs, cold therapy, ultrasound. Costs associated with care according to the Guidelines were lower than nonadherent care. Each patient in the adherent group (treated according to the Guidelines) saved (on average) $1,374.00.

In summary, patients receiving early physical therapy for low back pain (within two-weeks of the episode) were less likely to need more invasive treatment with injections or surgery. Costs were less compared with patients referred later, especially if treatment followed the current published Clinical Practice Guidelines.

For almost 30 years surgeons have been fusing the lumbar spine using the popular transforaminal lumbar interbody fusion (TLIF) technique. The surgeon approaches the spine from the side rather than from the front (anterior approach) or the back (posterior approach).

The TLIF method of lumbar fusion has many advantages. The lateral approach gives the surgeon access to the disc and disc space without applying excess pull or traction on the nearby spinal nerve(s). With a lateral approach, it is only necessary to remove one spinal joint (rather than the joints on both sides of the spinal level being fused) in order to get to the disc space.

The procedure can be done now as a minimally invasive (MI) approach. Minimally invasive means a very small incision is made. With minimally invasive surgery, there is usually less blood loss during the procedure and postoperative pain afterwards. Hospital stays are shorter with the mTLIF, which means lower costs.

Other advantages of the minimally invasive approach have been reported. For example, there is less damage to the muscles and less tissue trauma overall. The surgeon uses 3-D navigational (surgical) tools that allow him or her to see the correct pathway and avoid injury to nerve tissue.

The end-result is a faster recovery time, fewer complications, and shorter hospital stays. Most patients are indeed able to go home in less than 24-hours. You will probably work with a physical therapist after surgery. You will be discharged when you can walk at least 100 feet and manage a dozen or so stairs on your own. If you can do these two things, then it’s likely you are safe and independent enough to manage at home. Secondly, you will have to have nursing clearance based on your pain control and tolerance of the pain meds.

Problems after surgery can develop once you are home. The surgical team will make sure you (and a family member) are well aware of what to watch out for (e.g., infection, bleeding, blood clots). Any sign of such complications must be reported to the surgeon’s office. But most of the time, as your surgeon has indicated, all will go well and you will be in and out in less than a day.

First of all, follow all directions given you by your surgeon and surgical team. By now you have probably received your pre-operative instructions. This usually involves getting good nutrition, adequate fluids (clear nonalcoholic liquids), and rest. Certain medications will be tapered or stopped (e.g., aspirin, Plavix, coumadin/warfarin). Tobacco use in any form must be stopped.

Take all medications as directed, especially pain meds. Studies show that patients who use more (not less) narcotic medications (as directed) before surgery have faster postoperative recovery and thus shorter hospital stays.

This strategy of preoperative pain control is thought to be protective — it keeps the nervous system from setting up a pain response to the surgery. Surgeons may administer oral narcotics as more of a pre-emptive strike to lower the overall pain experience before and after surgery. The end result is a happier, healthier patient. A small financial investment before surgery (i.e., the cost of the drug) can mean a large (thousands of dollars) post-operative savings.

After surgery, follow all directions given you by your surgeon and hospital staff. This will include your nursing staff and physical therapist. Keep your pain under control as directed. Many patients try to hold out as long as possible before asking for pain medication. This has been proven unwise — staying ahead of the pain is a good way to ensure a safe and fast recovery.

Some of the important factors in achieving the best possible results depend on your surgeon. Shorter operative times (less time under anesthesia, less blood loss, less time with a decreased core body temperature) are all linked with better results and shorter hospital stays.

The longer operative time is important because your body temperature drops as a result of the anesthesia. Decreased body temperature has been linked with heart attacks, death, infection, and problems stabilizing blood.

This factor (longer operative time) is important for the surgeon to keep in mind. And also for the surgeon, another significant predictive factor of a longer hospital stay is the use of crystalloids and colloids and the ratio between them. These fluids are used to help keep your body hydrated and replace fluids lost due to bleeding.

The longer the operative time, the more fluids are “pushed” so-to-speak. This finding suggests that a more “restrictive” use of fluids may be better than a “liberal” amount. And other studies have shown better postoperative results with fewer lung problems when lower amounts of fluids are given during the surgery.

And finally, of course: pray as directed! As you say, ultimately it is in your God’s hands. But that doesn’t mean the patient, surgeon, and hospital staff can’t help out, too!

The decision to refer a patient with mechanical low back pain to physical therapy is not universal across the United States. And it may not be universal among patients seeing the same physician. But if your physician is following current evidence-based Clinical Practice Guidelines (CPGs), then each patient would be evaluated and referred according to that plan.

The CPGs recommends against early referral for treatment. Early symptoms of generalized low back pain that are not caused by infection, tumor, or fracture should be managed with a very short period of rest followed by activity as tolerated. Self-management skills of this type are advised. Physical therapy would be indicated more for the person who does not recover following the CPGs.

However, a recent study from the University of Utah has brought to light that early physical therapy (PT) treatment results in lower overall health care costs. Patients who have mechanical low back pain and see a PT within the first two weeks have less chance they will need advanced imaging (CT scans or MRIs). It is also less likely that they will have more invasive treatment (surgery, injections).

It’s likely there are specific reasons why your physician treated you differently than your sister. But you would have to ask to find out more about his or her thinking in this decision-making process. Other factors can come into play such as age, general health, fear-level (anxiety), and the presence of other health problems (e.g., diabetes, heart disease, cancer).

The value of physical therapy in the treatment of low back pain remains an area of debate and study. This particular study did not examine which patients should be referred to physical therapy or the patient outcomes for those who were referred early versus late. Further studies are needed to help determine who should be referred and how soon after diagnosis.

Between the vertebral bones of the spine is an intervertebral disc. The discs provide a cushion or shock absorber for the spine. Each disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus. The annulus is a series of strong ligament rings around the nucleus.

People often refer to a disc herniation as a “slipped disc”. The disc doesn’t actually slip out of place. Rather, the term herniation means that the material at the center of the disc has squeezed out of its normal space. The nucleus presses against the annulus, causing the disc to bulge or prolapse outward. The bulged disc material is still contained within the annulus.

But in some cases, the nucleus pushes completely through the annulus and squeezes out of the disc. This is called a disc herniation or protrusion. Herniation and protrusion are two words for the same thing.

If a piece of the disc breaks off, it’s called a sequestered fragment. This is a more serious situation and surgery is almost always needed for sequestration. The loose piece can enter the spinal canal and put pressure on the spinal cord or spinal nerve roots causing serious problems.

So you can see from this brief description, there are different degrees of disc problems that make a difference in treatment and prognosis. Athletes are just as susceptible to disc problems as nonathletic adults. But this problem occurs more often due to trauma rather than degenerative processes linked with aging.

Football players may be quicker to receive intensive physical therapy, antiinflammatory medications, and steroid injections in order to get back on-the-job, so-to-speak. Anyone (athlete as well as nonathlete) who does not respond favorably to conservative (nonoperative) care of this type, may need to consider surgery to remove the disc and possibly fuse the two spinal segments on either side of the diseased disc.

The average amount of time it takes an athlete to have a diskectomy and return to playing sports is about six months. Some take longer (up to a year) and that is with the benefit of a team surgeon, therapist, and athletic trainer all working together to get that player back on his/her feet and on the field or court. So you aren’t so far from the norm for athletes as you think!

More than any other patient groups who suffer from a herniated disc, professional athletes successfully return to work after surgery. In fact, this response has become what is considered “the expected norm.” So for most (not all) players, it’s not a matter of will they play again but rather when will they return to the field or court.

Predicting time needed off for rehab, and/or surgery and rehab, and recovery isn’t easy. But getting a handle on expected times can be very helpful when agents and players are making important personal, financial, and professional decisions. Not only that, but the teams have to take stock of player availability when making decisions.

A study was done by spine surgeons who provide care for teams in the Los Angeles area. Many professional players from all over the U.S. seek their services for problems like this. To aid surgeons counseling players, they ooked back at the medical records of 85 players who had this type of surgery for a herniated disc. This group of patients included football players, basketball players, baseball players, and hockey players.

For all of the players in this study, diagnosis was made with MRIs. The surgery was performed using a microscopic technique after they failed to get relief or improvement with a nonsurgical approach. Each player had the disc removed from a single spinal level. The most common area injured was in the lumbar spine: either L45 or L5S1. L5S1 refers to where the last lumbar vertebra joins the sacrum.

As it turns out, return to sports is a progressive phenomenon. At the end of a year, there are many more back in action compared with the first three months. On average, it took the players in this study about six months to return to their preinjury level of participation.

To be more specific: half of the group returned to play after three months, 72 per cent at six months, 77 per cent at nine months, and 84 per cent at the end of one year (12 months). The authors report that from their study, the average chance of returning to sports after microdiskectomy in the lumbar spine was 89 per cent.

But please understand that predicting the time it will take to return to play is a challenge and not fool-proof even with the information provided by this study. There are individual player factors that can factor into the equation. Not to be too flippant but these figures are “in the ball park” of what you and your players can expect.

Research-based evidence has resulted in the publication of some treatment guidelines referred to as Clinical Practice Guidelines (CPGs). This is a set of directions, if you want to call them that, to guide physicians when advising patients with acute back pain. Usually acute episodes refers to the first four to six weeks following injury or onset of pain.

Many people do go see a chiropractor right away. And there is some evidence that spinal manipulation is effective to reduce pain and disability associated with acute back injuries. Many patients also express a high level of satisfaction with the care and results obtained through chiropractic treatment.

Research also shows that chiropractic care costs less than traditional treatment that may rely on more expensive advanced imaging studies (e.g., MRIs). Chiropractors tend to use X-rays if and when any imaging at all is deemed necessary.

Most experts agree that a short period of rest (one to two days at the most) can be advised after acute injury resulting in low back pain. Staying active is the key to recovery for mechanical low back pain (i.e., not caused by tumor, fracture, or infection).

If you have any doubt about your situation, see a medical doctor for an evaluation and accurate diagnosis. If it turns out that there’s nothing seriously wrong, then conservative care with a health care provider who can perform joint manipulation, mobilization, and soft tissue mobilization (e.g., chiropractor or physical therapist) may be a good idea.

Current Clinical Practice Guidelines (CPGs) for acute back pain is for conservative care (we will explain that in a minute). Only certain patients require X-rays (or other imaging studies) in the first six weeks following the injury. Even so, research does show a high rate of early MRI among Workers’ Compensation patients.

A recent study looking at the use (and possible over use) of MRIs in Workers’ Compensation found that the folks most likely to have early MRIs include: men, workers with high levels of fear of reinjury, and greater injury severity and disability. Workers who had the lowest rate of early MRIs were first seen for their low back pain by a chiropractor. In contrast, workers who went to a medical doctor (general practitioner, neurologist, or orthopedic surgeon) were the most likely to receive an early MRI.

Okay, so who does need early imaging? Anyone with signs and/or symptoms that suggest a bone fracture, infection, or tumors. Anyone with suspicious neurologic symptoms. And young patients (under 20 years old) or older adults (over 50 years old) require special consideration for advanced imaging.

Some medical doctors routinely order MRIs right away — even though current evidence doesn’t support this practice. Chiropractors rely on X-rays taken in their offices rather than on MRIs provided somewhere else. So if you see a chiropractor, you may automatically have X-rays taken. Workers who are afraid to go back to work for fear of reinjury make up a large percentage of patients who have an MRI for an acute episode of injury-related back pain.

If you do not have any of the red flags mentioned and don’t fall into the two age categories in question, then you may be a good candidate for the conservative care we mentioned earlier. This can include a short period of rest (one or two days) but usually the emphasis is on staying active. Activities can be modified to help you maintain good posture and alignment and avoid painful symptoms. Mild pain relievers such as Tylenol or ibuprofen (ibuprofen is also an antiinflammatory) may be prescribed.

If you do not experience improvement in your symptoms in the first two weeks after the initial episode, then a few visits with a physical therapist may be a good idea. Additional imaging studies with X-rays or MRIs are not advised unless conservative care has failed to provide relief from painful symptoms or you develop any of the red flags mentioned.

It sounds like you might be getting the X-STOP®, a metal implant made of titanium. The procedure to put this device in place is minimally invasive. Minimally invasive in this case means the implant is inserted through a small incision in the skin of the low back.

This type of treatment is recommended for mild lumbar spinal stenosis (LSS). It is designed to fit between the spinous processes of the vertebrae in the lower back. It stays in place permanently without attaching to the bone or ligaments in the back.

Spinal stenosis describes a clinical syndrome of buttock or leg pain. These symptoms may occur with or without back pain. It is a condition in which the nerves in the spinal canal are closed in, or compressed. The spinous process is the piece of bone that sticks out behind the vertebra. It is the bump you feel down the back of your spine.

The spinal canal is the hollow tube formed by the bones of the spinal column. Anything that causes this bony tube to shrink can squeeze the nerves inside. As a result of many years of wear and tear on the parts of the spine, the tissues nearest the spinal canal sometimes press against the nerves. This helps explain why lumbar spinal stenosis (LSS) is a common cause of back problems in adults over 55 years old.

What should you expect after surgery? This may depend somewhat on your surgeon and his or her preferences. We can give you a general idea but it would be best to ask your surgeon for his or her recommendations.

You will likely be up and walking with a physical therapist in the first 24 hours. Studies show that patients who are mobilized (move, usually by walking) have fewer problems, especially with blood clots. Some surgeons still have their patients wear a back brace but many others do not.

Motion past neutral spine alignment into an extended position is not recommended or allowed. You will be able to bend sideways and rotate or twist but not past an easy amount of range of motion. Lifting is limited to nothing more than eight to 10 pounds (approximately the weight of one-gallon of milk). These restrictions are in place for 10 to 14 days. You will be allowed to gradually increase motion and lifting limits.

A physical therapist can help you begin learning how to move safely with the least strain on your healing back. As the rehabilitation program evolves, you will be asked to do more challenging exercises. The goal is to safely advance strength and function.

As the therapy sessions come to an end, therapists help patients get back to the activities they enjoy. Ideally, patients are able to resume normal activities. Patients may need guidance on which activities are safe or how to change the way they go about certain activities.

When treatment is well under way, regular visits to the therapist’s office will end. The therapist will continue to be a resource. But patients are in charge of doing their exercises as part of an ongoing home program.

Patients who receive a device called the X-STOP® for the treatment of lumbar spinal stenosis usually have mild to moderate symptoms of back and/or buttock and leg pain. The X-STOP® is a metal implant made of titanium. It is designed to fit between the spinous processes of the vertebrae in the lower back. It stays in place permanently without attaching to the bone or ligaments in your back.

There are several advantages of the X-STOP®. It can be inserted using local anesthesia on an outpatient basis. A small incision is made so the procedure is minimally invasive and no bone or soft tissue is removed.

The implant is not close to nerves or the spinal cord. With the implant in place, you won’t have to bend forward to relieve your symptoms (like you did before surgery). The X-STOP® keeps the space between your spinous processes open. With the implant in place, you stand upright without pinching the nerves in your back.

If you experienced pain relief at first and are now having increased pain, it’s probably a good idea to see your orthopedic surgeon right away. Although there may be nothing wrong, some complications such as the implant shifting, sinking down into the bone, or breaking are possible.

There are also reports from some patients of increased pain associated with fracture of the spinous process after X-STOP® implantation. The spinous process is the piece of bone that sticks out behind the vertebra. It is the bump you feel down the back of your spine. A recent study from Tufts University School of Medicine reported a 52 per cent rate of spinous process fractures in patients with lumbar stenosis AND another condition called spondylolisthesis.

Spondylolisthesis describes a condition in which one lumbar vertebra has slipped forward over the vertebra below. This slippage causes a narrowing of the spinal canal and traction (pulling) on the nerve tissue. Although their study was small (only 39 patients), the high rate (52 per cent) of spinous process fractures after X-STOP® implantation was significant.

The surgeons aren’t exactly sure why spondylolisthesis would increase the risk of fracture. They suspect that the change in alignment with the vertebra shifted forward may have something to do with it. The contact points (where the implant rests against the spinous process) may be further back in patients with spondylolisthesis. This placement is against a weaker part of the spinous process contributing to fracture.

If the surgeon suspects a fracture, you will need a CT scan as this type of fracture does not show up on X-rays. But don’t jump to any immediate conclusions that your pain is caused by any of these suggestions. They are merely ideas of things that can cause increased pain after this procedure. A full evaluation is necessary to make an accurate diagnosis.

Spinal stenosis describes a clinical syndrome of buttock or leg pain. These symptoms may occur with or without back pain. It is a condition in which the nerves in the spinal canal are closed in, or compressed.

The spinal canal is the hollow tube formed by the bones of the spinal column. Anything that causes this bony tube to shrink can squeeze the nerves inside. As a result of many years of wear and tear on the parts of the spine, bone spurs form, discs thin out, and spinal ligaments start to thicken. The result of any of these changes (and especially when combined together) is to cause pressure against the spinal nerves exiting the spinal canal.

This helps explain why lumbar spinal stenosis (stenosis of the low back) is a common cause of back problems in adults over 55 years old. But your question is what will happen now? You are asking about what physicians refer to as the natural history of a problem — what happens over time.

The natural history isn’t the same for everyone. There can be a variety of end-results. The symptoms can often be managed but the actual underlying changes in the spine don’t go away. In some cases, things can get worse as pressure on the nerve tissue causes disabling pain and decreased quality of life. But that’s the potential down-side. Let’s look at the positive side of things.

We know from studies that treatment can be very effective in reducing symptoms and improving function. The first step to managing this condition is usually conservative (nonoperative) care. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) are used to control pain and swelling.

NSAIDs combined with physical therapy may be all that some patients need. The physical therapist addresses posture, strength (especially core strength), and modification of activities. The therapist can teach patients positions and exercises to ease the symptoms. The therapist may use lumbar traction to gently stretch and lengthen the low back, taking pressure off the spinal nerves.

Some patients are given an epidural steroid injection (ESI). The spinal cord is covered by a material called dura. The space between the dura and the spinal column is called the epidural space. It is thought that injecting steroid medication into this space fights inflammation around the nerves, the discs, and the facet joints. This can reduce swelling and give the nerves more room inside the spinal canal.

When conservative care doesn’t work, then surgery may be advised. In fact, the results of the recent studies supports the use of surgery in such cases. When there is pain that doesn’t go away with nonoperative care, decreased quality of life, or loss of function, surgery may be the only answer.

Studies and research investigation into the natural history of lumbar spinal stenosis are ongoing. Scientists hope to find ways to prevent this condition, limit the effects of stenosis, and treat it as effectively as possible when it does occur. Right now there are no known “cures” but management as described can be very effective.

You may want to read our Patient Guide to Lumbar Spinal Stenosis available at /content/lumbar-spinal-stenosis. This guide will give you some background information about the condition, the various types of treatment, and what to expect. Having this type of patient information may help guide you.

Another source of potentially helpful data comes from the Spine Patient Outcomes Research Trial (called SPORT). SPORT has provided much of the evidence needed to provide effective treatment for lumbar spinal stenosis. And by effective, we mean both in terms of reducing pain and improving function as well as providing a cost effective treatment.

NSAIDs combined with physical therapy may be all that some patients need. The physical therapist addresses posture, strength (especially core strength), and modification of activities. The therapist can teach patients positions and exercises to ease the symptoms. The therapist may use lumbar traction to gently stretch and lengthen the low back, taking pressure off the spinal nerves.

Some patients are given an epidural steroid injection (ESI). The spinal cord is covered by a material called dura. The space between the dura and the spinal column is called the epidural space. It is thought that injecting steroid medication into this space fights inflammation around the nerves, the discs, and the facet joints. This can reduce swelling and give the nerves more room inside the spinal canal.

When conservative care doesn’t work, then surgery may be advised. In fact, the results of the SPORT studies supports the use of surgery in such cases. When there is pain that doesn’t go away with nonoperative care, decreased quality of life, or loss of function, surgery may be the only answer. There are several different ways to approach the problem surgically. The most common technique is called decompression.

The surgeon performs either a laminotomy (shaving some of the bone away from the nerve tissue or removing a small amount of bone on one side of the lamina) or laminectomy (removing the bone from around the nerve tissue). The lamina is the covering layer of the bony ring of the spinal column. It forms a roof-like structure over the back of the spinal canal. Decompressive surgery takes the pressure off the spinal nerves.

Although surgery of this type is expensive (estimated in the SPORT study to be $77,600 per quality of life year), the gains made in pain control and improved health were worth it to the patients. Two years later, patients who had the surgery were still reporting positive results from the procedure. When the cost is spread out over the long-term, the economic benefit becomes clear.

In the absence of red flags signaling a more serious problem, you have several options open to you. Your physician is offering you advice we call “best practice” medicine. He or she has obviously kept up with the latest studies and published clinical practice guidelines (CPGs).

These guidelines are based on current evidence that strongly supports staying active during acute episodes of mechanical back pain. Mechanical back pain means it’s not caused by an infection, a tumor, or a spinal fracture. More likely there is some soft tissue, disc, nerve, or joint as the primary cause of the pain.

Whereas walking and biking are done more in a straight plane, golf does involve a lot of twisting and rotation, which can be contributing to your problem. Letting the tissues heal before adding stress to them is a good idea.

You can seek the counsel of a physical therapist who has some expertise in the area of golf. Some therapists attend courses at the Titleist Performance Institute (TPI) and are TPI certified. This person can help evaluate your swing and other golf mechanics that could be contributing to your low back pain. The therapist can help you progress through the appropriate exercises you might need in a way that will protect your back from future injuries.

The current best practice (based on evidence from many studies) is to recommend activity modification while still remaining active in the early stages of back pain. Eighty per cent (80%) of patients with acute low back pain from a mechanical cause (i.e., not an infection, tumor or fracture) get better in two weeks’ time without intervention. Ten per cent take a little longer and only the reamining 10 per cent go on to develop chronic pain.

Studies are ongoing to figure out (predict) which patients fall into the three categories (those who recover in two weeks, those who need a little more time, and those who should receive active treatment earlier than later).

A recent study by a group of therapists has shown us that physician referral patterns are a factor in patients outcomes. Occupational medicine physicians are more likely to refer earlier and those patients do show better results with earlier treatment. The goal is to get workers back on the job and reduce lost work time.

Some of the reasons for early referral may have to do with consumer choice (the patient requests referral to a therapist). The timing of some referrals may be based on reimbursement. Patients in preferred provider organizations (PPOs) and health maintenance organizations (HMOs) tend to receive earlier referrals, too.

Although it’s true that patients who see a physician first may not make it to the therapist at all (or in a very delayed fashion), the law in most states does allow you to go to the therapist without seeing your physician. So, depending on where you live (most states do have Direct Access), you can refer yourself.

Physical therapists are trained to screen for medical causes of back pain and will refer you to a physician if your history and symptoms are not consistent with a mechanical cause of low back pain. Therapists are also aware of (and follow) the current clinical practice guidelines that recommend minimal treatment but active guidance.

Metabolic syndrome is a combination of medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes. Different groups (e.g., American Heart Association, International Diabetes Federation, National Cholesterol Education Program) have varied criteria to define metabolic syndrome. Most at least include these three: 1) raised blood pressure, 2) central obesity (increased waist circumference), and 3) abnormal cholesterol levels.

Studies show there may be a link between metabolic syndrome and low back pain. Any condition (e.g., being overweight or obese) that can reduce or restrict physical activity has the potential to contribute to metabolic syndrome, diabetes, and low back pain. In this study from Japan, researchers investigate the relationship and prevalence between metabolic syndrome and low back pain.

There isn’t clear evidence yet to say for sure that low back pain is a factor that leads to the development of metabolic syndrome. Nor has the opposite been proved: that metabolic syndrome leads to low back pain.

But we do know now that any one who has low back pain should be evaluated for the presence of metabolic syndrome. This is especially true for women who have metabolic syndrome as they seem to have a greater chance for developing low back pain. Treatment to address the metabolic problems may contribute to protecting and restoring normal musculoskeletal function.

Lifestyle changes are key to treating metabolic syndrome (and back pain for that matter). Increasing physical activity, eating healthy, and weight loss are key components of any treatment plan to address being overweight, experiencing low back pain, and developing metabolic syndrome.

You don’t have to do all this alone. Ask your physician for help (e.g., referral to a nutritionist, physical therapist, behavioral counselor). It may take some time but changes in lifestyle and choices can yield some long lasting improvements in health and prevent future problems from developing.