FAQ Category: Lumbar Spine

Many vertebral compression fractures (VCFs) are never diagnosed. The person doesn’t even know it’s happened until an X-ray shows the healed fracture at a later time. But for those patients with back pain, VCFs are usually treated nonsurgically.

Pain relievers are prescribed along with a wait-and-heal approach. This takes about six to eight weeks. It may take longer in patients who smoke, drink alcohol, or who are in poor health otherwise.

Some patients can benefit from an exercise program or bracing to help them keep an upright posture. If conservative measures don’t help, then surgery may be considered. Usually the surgeon waits until at least eight weeks after the fracture before suggesting a vertebroplasty or kyphoplasty procedure.

In these operations, a long, thin needle is inserted into the bone. Cement is delivered to the vertebral body through the needle. Once the cement hardens, the bone has increased strength. If your father has osteoporosis (likely at age 82), he may be at risk for future VCFs.

Doctors and therapists are aware of the need for a quick and easy method of assessing back pain patients. So far finding an ideal tool for testing has been difficult.

A recent study from Belgium may be what we’re looking for. It’s called the Backache Index (BAI). It takes about one to three minutes to conduct. Patients stay in one position (standing). Pain and motion are scored for five simple motions.

Bending forward is one of the movements. Side bending to each side is measured. Then side bending with extension is tested and that’s it.

The results of the BAI were compared against the results of four other standard back tests. Researchers conducting the tests found the BAI to be both reliable and accurate. More tests are needed to confirm these results but this may be just what’s needed for both patients and examiners.

As you point out, clinical practice guidelines (CPGs) for the treatment of acute LBP have been shown effective. Patients treated according to these guidelines get better faster and at a lower cost compared to patients who receive other treatment.

Despite the evidence that supports using these CPGs, less than half of all healthcare providers use them. Understanding why your staff doesn’t follow a clearly proven treatment plan is the first step. Since many patients with LBP get better without treatment, your staff may not see the need to follow all the steps in the CPG.

It’s important that everyone know what the CPGs say to do. Comparing current practice with the elements of the CPG may be helpful. Find any gaps between these two and develop a plan of action to close the gaps.

You’ll need some way to monitor and measure changes in practice. The Department of Defense developed something similar for use in the military healthcare system. You may find some of these materials useful. They can be downloaded from the Internet and printed from www.oqp.med.va.gov/cpg/LBP/LBP_base.htm.

There are three surgical alternatives to spinal fusion. The first is a total disc replacement. There are four different TDRs available in the United States. The TDR makes it possible to keep your normal spinal motion and height.

The second is a replacement just for the inner core of the disc called the nucleus. The nuclear implants are designed to cushion the spine and absorb water to restore disc height. They also keep their shape even when the spine is overloaded.

Another type of nuclear implant is a balloon-shaped device that is inserted inside the disc. It is injected with a substance that has an elastic memory. This allows it to act as a shock absorber some of the time.

And finally, motion-limiting devices called posterior stabilization devices (PSDs) are a possibility. These are used more often in Europe where research has been done for years using these systems. PSDs may be soft or hard and rigid in design. They can restrict spine flexion or extension depending on the patient’s problem.

Your surgeon would have to advise you which (if any) of these options is best for you. Right now because these are fairly new treatment alternatives to fusion, patients are being selected carefully. The long-term effects remain unknown. Safety is always a primary issue of concern.

The intervertebral disc is made up of two main parts. The inner core is called the nucleus pulposus. It is a fluid-filled gel-like cushion that supports the spine and absorbs the shock with various movements.

The outer covering is called the annulus fibrosus. It holds the nucleus inside and connects each vertebra together. With aging, the disc starts to stiffen and lose its elasticity. Disruption or damage to the disc can result in a herniated disc.

Studies show that degenerative changes within the spine begin in the nucleus. Finding ways to prevent and/or treat this is the goal of many researchers. For now, there are two possibilities: a nuclear implant or disc replacement.

The nuclear implant is a hydrogel pellet surrounded by a polyethylene layer. The pellet can absorb water and swell to mimic the action of the disc. This is how it also restores and maintains the normal disc height.

There are injectable substances. These fill in the space when the disc is removed but not replaced with an artificial disc replacement. The injection is a liquid polymer that cures in about 15 minutes. It’s firm but has some give to it.

Not all orthopedic surgeons have been trained to provide all of these options. Some are fairly new treatment methods. Further long-term studies are needed before they can be offered to everyone.

Talk to your physician and see what he or she suggests. Your age, diagnosis, general health, and condition of the spine are all factors in the final decision. Conservative care is always advised first before considering surgery of any kind.

A progressive loss of pain control is a yellow flag. It could mean there is a problem with the hardware. You’ll want to make an appointment with your physician to have this evaluated.

It’s also possible you are experiencing something called tolerance. This is not a true hardware problem. It’s probably not a biologic problem either. It’s more likely caused by neural plasticity.

This means the pain processing in the central nervous system builds up a tolerance to the stimulation. Eventually the signals are no longer blocked and more of the pain signals get through.

Experts aren’t sure yet how to best respond to this plasticity. Changing the placement of the electrodes may help. Altering the settings on the programmable unit may be a second option. Your surgeon is the best one to help you explore your options on this one.

How patients view the results of their surgery isn’t always just about the biology and mechanics of the spine. Some people do tend to catastrophize or blow their symptoms out of proportion. Others are more stoic suffering in silence.

When painful symptoms or physical discomfort aren’t improved (or remain the center of a patient’s focus), then quality of life may be a good measure. For example, you may ask your friend if she is sleeping any better after the surgery? Perhaps waking up less often or getting back to sleep faster after waking up?

What about daily activities? Is she able to walk farther with less pain? Can she get in and out of bed, the car, or a chair with greater ease? Has she noticed any difference in her appetite or even elimination patterns (bowel movements)?

Though it’s a little more delicate, some patients also report improved sexual activity as a benefit of back surgery. By asking these questions and drawing her out, you may be able to help your friend look at other areas of improvement besides just pain control.

There are always certain risks that come with having any kind of surgery. This must be weighed against the likelihood that you’ll get better on your own or with conservative care.

Many experts require six months or more of nonsurgical treatment. Such care may include medications, change in activity, and physical therapy. Sometimes steroid injections and bracing are also given a trial period.

A recent study from Finland compared the change in quality of life before and after neck or back surgery. Patients either had spinal stenosis (narrowing of the spinal canal) or disc problems. The researchers were able to calculate the cost on a unit basis using quality of health as a measure.

They showed that patients who had surgery early (within 60 days) did much better compared to patients who delayed operative care (after 60 days). There is some controversy over these findings.

Long-term studies show that conservative care is just as good as operative treatment. The difference is in the short- to mid-term quality of health, which is better with surgery. So your neurosurgeon is right in suggesting surgery done now will give you better immediate results. But in the long run, a wait-and-see approach may have the same final results.

Recurring low back pain (LBP) is a problem for many people. In the first year after an acute episode of LBP, 60 to 80 per cent of adults are likely to have a second (or third) bout of LBP.

Experts aren’t sure why this happens. Physical therapists are busy studying ways to prevent recurrent LBP. One of their key findings has been the role of motor control in recovery of normal motion and prevention of future problems.

For you this means that you may need a little different rehab program to recover normal muscle control. After injury, the trunk muscles aren’t always to get back to a normal flow and pattern of movement. Some muscles may be too late in contracting. Others contract but don’t relax when they should.

Motor control problems of this type put an increased load on the spine. Instability, pain, and loss of function are common problems. Restoring core control of the trunk and abdominal muscles may be a key to recovery for many people.

The neutral zone (NZ) refers to the alignment of the lower spine and pelvis in a normal lumbar curve. Keeping the lumbar spine in the NZ while moving helps protect and stabilize it.

Full flexion of the lumbar spine puts the ligaments, discs, and muscles at a disadvantage. The ligaments are in a fully stretched position when the spine is bent forward all the way. The discs are placed under a loading and shear force that can cause damage, especially with repeated movements.

And when the spine is fully flexed, the muscles in the low back that extend the spine are at a mechanical disadvantage. In this position, the lumbar extensor muscles can’t help reduce shear forces on the spine. This puts the spine at increased risk of injury.

NZ exercises move the body through various positions while keeping the lumbar spine in neutral. When in a proper neutral position, the pelvis can tilt in equal amounts of flexion (bottom tucked under) or extension (swayback position).

Physical therapists are trained in teaching this type of exercise. Sometimes it is referred to as a neuromuscular training or motor control program.

Lumbago is a term still used to refer to low back pain. Lumbago can also include low back pain that goes into the buttocks, thigh, and then down the leg. It may be on one or both sides, depending on the cause. Patients who report just leg pain are usually diagnosed with sciatica rather than lumbago.

Lumbago may be caused by many different problems. If a specific cause of the pain can be determined, then the diagnosis is usually named by the more precise etiology. For example, disc herniation or degenerative disc disease can cause lumbago but would probably be named by the disc problem.

When back pain is difficult to assess, lumbago is an acceptable term to describe the problem. Muscle strain or other soft tissue problem is often the cause of nonspecific back pain referred to as lumbago.

Vocational rehabilitation sometimes referred to as “voc rehab” is an employment program for people with disabilities. A vocational rehab counselor will help you make career plans, learn job skills, and get a job.

Services are designed to meet the needs of each person. The rehab counselor will try to match the services to your goals for employment. First the counselor will find out about your skills, abilities, and what you want to do. Together you’ll come up with an employment plan.

Your skills, abilities and interests will be matched to the needs of local employers so you can get the job that best suits you. If you need special devices or a specific type of workplace, the vocational rehab counselor will help with that. People in wheelchairs or with limited physical abilities may need some changes in their work station to do the job.

As part of the job placement process, the voc rehab counselor can instruct you in job seeking skills. In other words, you’ll learn how to sell yourself in applications, resumes, and interviews.

There is some evidence that emotional distress predicts poor recovery from acute low back pain. Distress may take the form of anxiety, depression, or somatization. Somatization is a conversion of emotional distress into physical symptoms such as headache, muscle or joint pain, or problems sleeping.

In the last few years, researchers have come up with a questionnaire to help identify patients who don’t recover because of fear-avoidance beliefs (FAB). With FABs, the patient avoids movement because he or she is afraid that movement and activity will set off painful symptoms and possibly reinjure the spine.

The truth is that less movement is more likely to put the patient at risk for poor results. And distress over the situation can put the patient at further risk for disability over time.

If your doctor gives you the green light, start getting back into the swing of things. Focus on returning to your former level of activity and then take it the next step. Consider what you can do to stay active, healthy, and prevent long-term disability.

The first step is to make sure you don’t have a serious medical condition. Have a physician examine you and rule out fractures, infection, or tumors. If you have a muscle strain or nonspecific low back pain (LBP), then you can proceed with a plan for recovery.

Be aware that psychologic factors play an important role in recovery from back pain. Studies show that emotional distress such as anxiety and depression are powerful predictors of chronic pain and disability.

Emotional distress and fear-avoidance beliefs (FAB) both contribute to nonrecovery months after LBP begins. FAB is the avoidance of movement out of fear that it will trigger painful symptoms and/or cause reinjury. If you find yourself saying, “Oops I can’t do that, my back won’t let me” you may be magnifying your symptoms. Any of these behaviors can put you at risk for chronic pain and disability.

You’ll know you are getting better if you can do a little more each day. Keep track of movements and activities that are restricted right now. Little by little, try to resume each of those positions and motions. You can measure progress by seeing if you can do things this week that you couldn’t do last week or the week before.

You may be referring to real-time ultrasound (RT-US). Sound waves are bounced off tissues deep in the body. An image of the muscle can be seen this way on a TV screen. This shows the size and shape of the muscle at rest and as it moves.

Researchers are using RT-US to find out what is normal muscle activity. They are comparing these results with patients who have low back pain (LBP). For example, RT-US has been used to monitor the size of the multifidus muscle when changing position from prone (face down) to an upright position. The tests are also being done as the patient moves from standing upright to a forwared bent posture.

The multifidus is a deep muscle of the back that helps stabilize the spine. A recent study from Hong Kong showed a reverse pattern of muscle contraction of the multifidus for patients with chronic LBP.

Such a test could be helpful in identifying the cause of nonspecific LBP. A treatment program of exercise may help bring muscle control back to normal. Right now, RT-US is not used routinely. It may be some time before this diagnostic tool is used on a daily basis by most doctors or physical therapists.

Many factors may contribute to a forward stooped posture. Some people are able to remain upright throughout their life, so there may be individual or genetic factors here, too.

Gravity has a strong effect on posture. The natural effect of this force is to pull us forward. Inactivity with increased time sitting may be part of the problem. The flexor muscles of the hip can even become shortened from being in a chronically contracted state.

Postural changes can begin to alter the way the muscles contract. Studies show that the multifidus (a deep muscle of the spine) increases in size as it contracts. This has been shown when moving from one position to another such as from prone to upright.

This same muscle decreases in size as the body stoops forward. Changes in strength, size and control of the muscle may contribute to a forward stooped posture. More studies are needed to answer your question fully. Exactly what happens as we age isn’t entirely clear yet.

For now, it seems an active lifestyle with regular activity and standing up straight are your best tools to prevent postural changes. Exercises to stretch the front (flexor muscles) of the body and strengthening exercises for the back (extensor muscles) are especially important.

Many structural changes are seen on MRIs of the lumbar spine. In fact, they are so common in people who have no symptoms that when changes are seen they aren’t automatically blamed for painful symptoms.

No one is sure exactly how to explain these differences. It appears to be more than just a simple matter of pain threshold. It’s likely that many variables are at play here. General health, job satisfaction, and age may make a difference in the presence and intensity of back pain — regardless of the X-ray or MRI findings.

The results of any testing you have done are always available for you. The patient must request a copy of the results and sign the necessary release form. Many physicians just report on positive results.

Some doctors believe knowing the results of abnormal testing may negatively influence the outcome of patient treatment. For example, if an MRI showed major degenerative disc disease, the patient may be less likely to have a positive outcome with conservative care.

Many studies show people with abnormalities and structural changes seen on imaging studies such as MRI or X-rays are completely without symptoms. For this reason, it is still highly debated just how much doctors should rely on MRI findings.

And each patient is different. Some don’t want to know the details of test results. Others prefer full disclosure. Each patient must let his or her physician know what level of information is desired.

Spinal cord stimulation or SCS has been around since the mid-1960s. As technology advances and improves, the number of units implanted has also risen. Today over 25,000 SCS systems have been in use around the world.

The basic design of the SCS unit is an implantable, programmable pulse generator (IPPG) that is tucked inside the abdomen or buttocks. Tiny, thin electrodes connected to the IPPG are inserted into the spinal canal where they can come in contact with the spinal cord. The electric impulses serve to interrupt or stop any pain signals that might be sent from the spinal cord to the brain.

The companies who have designed the SCS systems have tested these devices in animals and on humans. They are safe but not always effective. The rate of adverse events is one-third to one-half of all patients. Most of these problems aren’t serious or life-threatening.

When back pain persists beyond the expected time for healing but no cause can be found, then it is called nonspecific. Imaging studies have likely shown that there is no tumor, fracture, or infection.

Soft tissue structures such as ligaments, muscles, and connective tissue are involved but it’s unclear which ones are at fault and what went wrong.

Physical therapists are starting to classify low back pain patients according to the movement impairment present. If bending forward (flexion) causes the symptoms or makes the pain worse, then a flexion pattern (FP) is named as the motor control impairment. If extending backwards hurts and forward flexion helps, then an active extension pattern (AEP) is named.

Researchers are starting to make headway in finding successful treatment methods using this subgrouping. EMG studies of muscle activity have also shown differences in motor control between the FP and AEP groups.

Future studies using subclassifications like this are expected to end the use of “nonspecific” as a diagnosis of low back pain. The true underlying soft tissue problem will be more clearly identified.