FAQ Category: Lumbar Spine

Experts haven’t decided yet on a definition of degenerative disc disease that everyone can agree on. A definition that might describe it for doctors may not be what’s needed for lawyers. Researchers who collect information such as number and ages of patients with this problem may need yet another (different) definition.

Authors of a recent paper from the Department of Anatomy at the Univeristy of Bristol (Canada) suggested the following definition as a place to start:
An aberrant, cell-mediated response to structural failure. This means too much load on a disc can cause damage that starts a response at the cellular level. The result is even more disruption and damage to the disc.

In the normal, healthy adult, healing is initiated by the body in response to the damage that occurs. Factors that can disrupt healing include genetic or inherited tendencies, smoking or tobacco use, and physical load.

Physical loading refers to repetitive motions such as bending or twisting. Work- or job-related activities that involve bending or twisting while lifting are big risk factors for disc degeneration and damage.

Many people start to develop disc problems in their 40s and 50s. You are only slightly outside the “normal” range for degenerative changes. Any of the risk factors mentioned could be contributing to an accelerated aging process.

The effects of aging aren’t always easy to pinpoint. Lumbar spinal stenosis (a narrowing of the spinal canal) can put pressure on the spinal nerves causing pain and disability.

If the condition is gradual enough, the patient may accommodate or get so used to the pain. He or she doesn’t realize it’s affecting their everyday lives. Little by little their balance and strength is affected. Activities (even daily activities) can become more difficult.

Disability is a complex problem. It’s not entirely clear what causes disability in one person while another (with the same factors) isn’t disabled at all. More research is needed into the cause and effect of spinal stenosis and other factors leading to disability.

A visit with her doctor may be the next best step. A physical exam may answer some of your questions. It could be something as simple as a urinary tract infection and not related to the spinal stenosis at all. Or it may be the stenosis is becoming more bothersome in which case further treatment may be advised.

Back pain in older adults (65 years old and older) is often caused by a condition called spinal stenosis. This is a narrowing of the spinal canal where the spinal cord and spinal nerves travels from the brain down to the low back area.

Persistent low back pain (LBP) is always a red flag, especially in older adults. Even if it is not a life-threatening problem like cancer, pain can cause weakness and loss of balance.

In older adults, these factors lead to inactivity and potentially disability. Getting up from a chair can become a difficult task. A loss of balance and fall can result in hip (or other bone) fracture.

A medical examination to determine the cause is really advised. Once you and your mother know what the root cause is of her symptoms, then a decision can be made about what action to take.

It isn’t always necessary to “put up with” pain. Sometimes a simple analgesic for pain control is all that’s needed. In other cases, an antiinflammatory drug may be prescribed. A physical therapist can help your mother improve her strength and balance and thus prevent falls and fractures.

Staying healthy and active as long as possible is most every senior citizen’s goal. Perhaps if you approach it from this point of view, your mother will be more willing to see her doctor.

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.

Many people with low back pain (LBP) report similar symptoms. Prolonged postures, especially sitting, increases the pain or discomfort. To find out why, scientists are using EMG studies to record the electrical activity of muscles in different positions. They are comparing the results from normal, healthy adults with no back pain to adults with chronic LBP.

So far they’ve discovered that the trunk and abdominal muscles should normally be in a relaxed phase during slumped or slouched sitting. When sitting upright on a stool with no back support, these same muscles are active and contracting to hold the posture.

People with chronic LBP don’t seem to have a difference in muscle activity from one position to the next. They lack the relaxation phase. This altered pattern of motor control may be what sets them up for strain and pain. It’s also possible that this impaired movement pattern started after the back pain came on.

Researchers will continue to try and sort this all out. EMG studies and real time ultrasound are very useful tools in measuring muscle activity. The goal is to develop a rehab program to normalize muscle activity.

Studies show that younger patients have the best results after artificial disc replacement (ADR). “Younger” refers to age 40 and younger. Patients in this age group had fewer problems and complications during and after surgery.

But age by itself doesn’t pose a contraindication for total disc replacement. Older adults can get pain relief and improved function after ADR too. The patient’s overall health and function are also important factors. Anyone with diabetes, heart disease, or other chronic health problems is at increased risk for complications with any surgery.

The best results with ADR are reported in patients with degenerative disc disease. ADRs have been used for other problems like spinal stenosis but debate continues as to what patient groups can benefit most by having an ADR.

One other predictive factor of a positive outcome is a single ADR. Patients with multiple level replacements have inferior results with a higher complication rate.

So at 65 years “young” you aren’t out of the running. Your best bet is to get a consultation with a surgeon who does disc replacements. You’ll be interviewed and examined and then assessed for an ADR.

You have a complex medical history so your question can’t be answered by a simple ‘yes’ or ‘no’ answer. You’ll need to seek the opinion of a surgeon who does artificial disc replacements (ADRs).

Right now it’s not clear which patients should or shouldn’t have ADRs. Studies so far show the best results with degenerative disc disease (DDD). DDD usually accompanies increased age and/or wear and tear. Most studies exclude patients who have spinal tumors, bone metastases, scoliosis, or even irregular shaped bones.

Still, as surgeons have more and more success with this treatment method, the list of possible conditions treated by ADRs is expanding. Good to excellent results over a longer period of time (up to two years) are being reported.

Outpatient lumbar discectomies are on the rise. Data sources show a steady increase in the number of outpatient lumbar spine surgeries done in the United States. About 75 per cent of those procedures are discectomies.

Hospitals with higher rates of bleeding or infection may not have made the switch from inpatient to outpatient for discectomy just yet. Follow-up is needed to make sure that shorter postoperative monitoring doesn’t drive the costs up instead of down.

Institutions focused on quality of care and patient safety may be slower to make the switch to ambulatory status for some surgeries like discectomy. More study is needed before discectomies are done routinely on an outpatient basis.

Studies show more and more discectomies (removal of the lumbar disc) are being done on an outpatient basis. Patients who have surgery and go home within 24 hours’ time are called ambulatory patients. The operation is called an ambulatory procedure.

Outpatient discectomy is both safe and effective. They reduce costs and increase patient satisfaction. Usually ambulatory patients must have someone who can drive them home and stay with them for the first 24 to 48 hours. Any signs of infection, blood clots, or other problems must be reported to the surgeon right away.

You won’t be discharged if there are any complications during surgery or while you are in the recovery room. Occasionally a patient loses too much blood or doesn’t recover as quickly as planned. Overnight hospitalization may be required. Your surgeon will make that decision should anything unusual happen. Otherwise, you should expect to be home on the same day as the surgery.

Safety is a major concern for any company producing devices such as an artificial disc replacement (ADR). Joint wear and fatigue failure are two of the most common problems.

Each implant type is carefully tested in the laboratory and in animals before being used in humans. Even though there are 15,000 Charité ADRs successfully implanted in humans, the company (DePuy Spine, Johnson & Johnson) continues to test and retest these devices.

Most recently, six Charité ADRs were attached to machines and subjected to 10 million cycles of motion. Three implants were bent and extended over and over. The other three were subjected to repetitive side bending motion.

Testing for particle debris showed very minor wear. Motion early on in the life of the implant produced larger particles. Some light scratches were seen on the load-bearing surface of the device. These changes were hard to see and didn’t cause any problems with motion later.

There is certainly room for more testing of these devices. Some patients have had an ADR for upwards of 10 years or more. Long-term results will be reported as time goes by. For now, the consensus of studies is that they are both safe and effective for the right patient.

Artificial disc replacements (ADRs) are used for degenerative disc disease. They reduce pain and restore the natural height of the disc. They also allow more normal spinal motion, which wouldn’t be possible with spinal fusion.

ADRs have been in use for the past 20 years in Europe and 10 years in the United States. Mid-term studies are reporting good to excellent results. Long-term studies are just becoming available.

Successful ADR revisions have been reported. However, inserting the disc anteriorly (from the abdomen) requires the surgeon to find and move the major blood vessels. Doing this a second time in order to remove the first ADR and insert a replacement has some significant risks.

As technology continues to advance better imaging is now available for locating blood vessels and nerve tissue. Improved surgical methods may also help reduce the risks involved with ADR replacement revision.

If revision isn’t possible for any reason, then spinal fusion is a final option. The spine can be stabilized with this treatment approach. However the patient does lose some spinal mobility.

There are a variety of ways to do a spinal fusion. Your surgeon will take into consideration the fact that you’ve had a laminectomy. Bone graft can be used to fill in around the unstable portion of the spine. Since the lamina or posterior part of the vertebral ring has been removed, bone can be taken from your pelvic bone (iliac crest) instead.

A titanium cage can be placed between the two vertebral bodies. The cage is filled with bone graft usually obtained from the patient’s pelvic bone. Plates and screws may also be used to help stabilize the spinal segment until fusion occurs.

If there is some reason why you can’t donate bone to yourself, then a donor graft from a bone bank may be an acceptable option. There is one other product to ask about. Artificial bone substitute can be mixed in with bone to form a solid fusion site. A recent study showed that a 50:50 mix of bone-to-bone substitute worked as well as 100 per cent bone for spinal fusions.

Nonunion, failure to fuse, or pseudoarthrosis are possible causes of failure in spinal fusion. Pseudoarthrosis refers to the fact that there is still some motion at the fused site causing it to act “like a joint.”

There are many different reasons this can happen. It’s not always clear why it happens to any one person. Low bone mass in post-menopausal women may be a factor. Tobacco use in any patient can delay or prevent healing. Sometimes it just takes longer to heal compared to the average patient and fusion occurs much later.

Occasionally, the screw “backs out” or loosens too soon. Without this instrumentation to hold the spine stable during healing, motion can occur at the fused segment.

You may not have to do anything. Your surgeon is the best one to advise you on this. Some patients who don’t have any symptoms adopt a “wait-and-see” approach. Dynamic (moving spine) X-rays can be taken to help with this decision. If there is an apparent loss of fusion on regular X-rays but no motion on dynamic films, then no additional treatment is required.

In these cases, your body may have formed a fibrous union. A thick band of scar or connective tissue may have formed instead of bone. Unless you develop more pain or new pain, no additional surgery is needed. You may see a physical therapist for a short rehab program to help prevent future problems.

Your surgeon will have to make this determination. Return to work after total disc replacement (TDR) is entirely possible. Many people return to their former jobs full-time. Some return to work part-time or with a reduced workload.

The decision to return to work will depend on several factors. Your general health and the type of work you do are the two most influential variables. Persistent low back and leg pain are usually the main reasons why a patient is unable to return to their former jobs.

In such cases, some people are able to get enough relief from their pain to return to work just by using simple analgesics. Heavy laborers may need to find a different job. The surgeon will take X-rays to confirm the location of the TDR in its rightful place and advise you properly.

With a successful TDR, patients obtain pain relief and improved function. These two results help determine the chances of getting back to work.

You didn’t mention how long ago the total disc replacement (TDR) was inserted. Some patients have residual back and leg pain that eventually goes away over a period of six weeks to six months.

Pain relievers is a good first step in trying to control the pain. Analgesics and nonsteroidal antiinflammatories are tried at first. Epidural steroid injection (ESI) may be another treatment method.

An ESI injection can control pain for long periods of time by reducing inflammation and swelling. The hope is to control your symptoms so you can become more active. A local anesthetic such as lidocaine and a cortisone steroid is injected inside the epidural space. This space is the area between the bony ring of the spine and the covering of the spine called the dura. The dura is the sac that encloses the spinal fluid and nerves of the spine.

This fluid is free to flow up and down the spine and inside the epidural space to coat the nerves that run inside the spinal canal. These injections are temporary and may last from a couple of weeks to a couple of months. They may be used to reduce your symptoms so that you can more easily begin a physical therapy program with less pain. They may also be used to reduce symptoms and let the body repair the underlying condition.

Ask your doctor about your options. Treatment methods may vary depending on your general health, your age, and when you had the TDR.

Physical therapists use mobilization (nonthrust joint movement) and manipulation (thrust movement) to treat joint problems including joints of the spine. These two methods of treatment are called manual therapy.

Research has shown that spinal manipulation works well for many patients with acute low back pain (LBP). As evidence mounts for this treatment method, more and more PT schools are including manual therapy as a core course of training. Therapists who graduated years ago may have learned this skill at a continuing education course. Not all therapists have manual therapy training.

Let your therapist know the results you had with the alternate treatment and your interest in trying this method again. The goal is always to improve patient function. Your therapist will be interested in knowing about anything that will help you reach your goal.

Physical therapy students have very good training in assessing and treating low back pain. They may not have years of experience but they are up to date on the latest methods that are known to be effective.

During their training as students, they have been given all the tools needed to help you. Their first step will be to find out what’s the underlying mechanical problem causing your back pain. Their studies have helped them see which treatment approach works best with each type of problem.

While learning how to treat patients, PT students have been observed closely. They have to demonstrate proficiency in each skill before moving to the clinic and treating patients.

They know the importance of measuring the results of their treatment. You won’t be treated without some testing to see if the treatment is having a positive benefit. A more experienced therapist is always there to supervise the student’s work so you really get the best of both worlds.

General common sense advice is often offered by surgeons for patients following a simple discectomy. You can get back to your normal, daily activities as soon as possible. Use pain as your guide. Don’t lift anything heavy for the first six to eight weeks. Avoid lifting anything if it involves twisting and bending.

Some physicians don’t place any restrictions on bending or lifting. Others suggest a rehab program to help the patients gradually regain function, strength, and overall fitness. A physical therapist can help patients with posture, lifting and bending, strength training, and return to fitness/function.

If you have a disc removed along with a laminectomy (bone removed) and spinal fusion, then actvitiy restrictions may be slightly different for a longer period of time. Be sure and ask your doctor what advice he or she feels is best. Ask about the role of exercise and activity. When evaluating what you are told, let good common sense guide you as well.

Lumbosacral radicular syndrome (LRS) is a common cause of low back, buttock, and leg pain. The disc protrudes from its space and puts pressure on the closest nerve root. Sometimes chemicals released by the damaged disc irritate the nerve root, too. Either way, the result is pain, numbness, and tingling. If the problem persists, muscle weakness and atrophy can also occur.

When conservative care doesn’t work, then surgery to remove the disc called a discectomy may be needed. The last 10 years has seen a trend away from discectomy combined with a laminectomy (removal of bone) and fusion. Now a simple discectomy is done to avoid further problems from the spinal surgery.

Studies report there’s still a 10 to 40 per cent rate of complications after a simple discectomy. Failure to correct the problem could be caused by a variety of factors. Some are patient-caused, while others are surgeon-derived. Work and legal status and psychologic state of the patient, and surgical skill and technique on the part of the surgeon are part of this equation.

Your son’s surgeon has probably advised him to have a simple discectomy based on the results of X-rays and MRIs. The doctor also takes into consideration the person’s general health, overall attitude, and work situation. His chances of getting back to work and daily life are better with the less invasive surgery.

Lumbosacral refers to the low back area where the lumbar spine meets the sacrum.
Radicular indicates that the low back pain travels into the buttock and/or down the leg because of pressure on the nerve root as it leaves the spinal canal.

Syndrome tells us that there is a group of symptoms. Most patients with this problem have pain, numbness, and tingling. If the condition lasts a long time, then muscle weakness and wasting can also occur.

The cause of the problem is often a disc pressing on the nerve root. Bone spurs from arthritis can also cause it in some patients. A tumor or other space-occupying lesion can also cause lumbosacral radicular syndrome.

In about 80 per cent of the cases, the symptoms go away without treatment or with conservative care. The remaining 20 per cent usually need surgery. The disc material is taken out. Sometimes bone around the nerve root is also removed. This is called decompression surgery.

Patients who do not get better either on their own or with surgery can end up with chronic pain and disability. This affects about 30 per cent of the people in this category. There’s some evidence to suggest attitude and other psychologic factors may make a difference.

For example, patients who are afraid to move because they might re-injure themselves tend to have more disability and pain after surgery. The same is true for patients who are pessimists who expect the worst. Having a positive attitude will go a long way toward a good recovery.