FAQ Category: Lumbar Spine

Fracture, infection, or tumors are always a possibility with sudden onset of low back pain. The doctor will look for risk factors that raise the suspicion of a more serious problem.

For example a previous history of cancer such as breast, lung, or colon cancer increases the concern over new onset of back pain. The doctor will also take into consideration red flags such as age over 50, constant pain, and elevated sed rate (lab test).

Most of the time the doctor can tell by the patient’s history and clinical presentation what’s going on. The doctor looks at what makes the pain or symptoms better or worse. Herniated discs present one way and spinal stenosis another. Back pain from a mechanical or nonspecific origin looks different from either of these problems.

The diagnosis is often confirmed by time. If the patient gets better with the prescribed treatment, then no further tests are ordered. But if the patient doesn’t get better with conservative care or gets worse, then X-rays or other imaging tests may be needed.

Spinal stenosis is the narrowing of the spinal canal that often occurs with aging. Pain is worse when standing or walking and better when sitting. Unfortunately this can lead to deconditioning and weakness in older adults. The risk of falls increases under these circumstances. So finding a way to get relief from pain and improve function is important.

Older adults are also at greater risk of complications and problems related to the surgery. This is especially true if they have other health problems such as diabetes or high blood pressure.

Studies show that results from surgery for spinal stenosis are better if the patient has more leg pain compared to back pain. Overall results show success in about three-fourths of the older patients who have surgery for this problem. This means three out of four patients do well with surgery. There’s no clear distinction to predict which patients won’t do well.

A simple laminectomy to remove part of the bone may be all that’s needed to help your mother-in-law get back on her feet again. With or without surgery, a good rehab program is advised. Consider making an appointment with the surgeon and discuss the pros and cons of surgery, the risks, and other possible treatment options available.

Chronic pain is defined differently by different people. For the most part, everyone agrees that pain lasting past the expected time for physical healing is called chronic. Most soft tissue and bone injuries recover in six to eight weeks’ time. Factors like poor health, diabetes, and tobacco use can delay normal healing.

According to most research, pain that persists beyond the expected time becomes ‘chronic’ after three to six months. The doctor’s exam must identify whether this is a new (acute) injury or a recurrence of the old injury.

Subacute chronic pain suggests a new episode of back pain that is in the healing phase. Acute means it has recently happened (first one to two weeks). Subacute refers to the period of time from two to six weeks of the recovery process.

It sounds like you may be suffering from a bout of low back pain (LBP) called nonspecific LBP. Most likely it’s caused by some soft tissue problem but the exact mechanism of pain is unknown.

In cases like this the physical therapist relies on a classification method to decide on treatment. Treatment is determined based on your signs and symptoms. For example if you are 40 years old or younger with full hamstring motion and excess joint motion, then stabilization exercises may be best.

For patients with very recent symptoms and loss of joint motion, manipulation or manual therapy is advised. And for patients whose symptoms are better with certain motions and worse with others, specific exercises may be needed.

The therapist conducts an exam looking at all the various factors known to impact treatment. Specific treatment of this type often speeds up recovery. Once your symptoms start to improve you may be progressed to the next level of exercise.

A program of low-stress aerobic exercise on a bike or treadmill is common. At that point exercises to correct postural faults, muscle weakness, or inflexibility may help prevent future episodes of LBP.

With advances in surgical technique many pelvic and abdominal surgeries can be done without cutting muscles or nerves. The surgeon may be able to use special tools to remove tissue through small puncture holes in the abdomen or through the vaginal canal.

Injuries or just effects of surgery can affect muscle strength and function. Stretching or compression can occur when the soft tissues are pulled out of the way, a process called retraction. Ischemia or temporary decrease in blood supply during surgery can also affect the soft tissues.

Injuries of this type can cause biomechanical changes. Sometimes the recovery of normal motor function isn’t automatic. The muscles don’t contract together at the right time to stabilize the trunk and spine. Pain may be another factor affecting how and when muscles function.

More and more research is showing the positive value of core training to ‘reset’ spinal stability. Physical therapists teach patients specific exercises for the abdomen and trunk. This kind of rehab program may be helpful for you.

Research has shown that normal muscle activity between the abdominal muscles and trunk muscles is needed to provide core stability. Stiffness, support, and strength of the trunk and spine are another way to define “core stability”.

These muscles must contract with strength but at the right time and in the right sequence for each movement. That requires strength as well as proper motor control. Back pain can occur when deep abdominal and pelvic floor muscles are either not contracting or are not in sync with one another.

Spinal stabilization exercises are often called core training. Programs offering core training, Pilates, or spinal stabilization come in a wide variety of choices. Local health clubs often provide core training or pilates classes. You may be able to find some videos at your public library with any of these titles.

Two very popular and easy-to-follow books are available for the average consumer. The Core Program and Instant Relief were both written by a physical therapist (Peggy Brill) who has devoted her professional life to developing an exercise program for women. These are available at: www.brillpt.com.

Men and women are both finding the benefits of core training for many problems including pelvic pain, back pain, and incontinence.

About half of all new mothers report low back pain after childbirth. Another 25 percent report problems with leaking urine called incontinence. Both of these conditions are caused by pelvic and abdominal muscle weakness.

There may be motor control problems too. The muscles may contract too late for the motion. In normal muscle function, some muscles start to contract as soon as the person thinks about doing a movement. The muscles start stabilizing and preparing the body for movement before the person starts moving.

Most of these symptoms go away for first-time mothers. Women who have had more than one pregnancy are more likely to have chronic problems with back pain and pelvic dysfunction.

New research shows that an exercise program to restore muscle strength and motor control can help take care of these problems. You may have heard of core training, Pilates, or stabilization exercises. Ask your doctor if you are safe to begin such a program.

A physical therapist can help you get started and then you can continue on your own at home. This type of exercise program is especially important if you are planning on having any other children.

There are many ways to measure success of an operation. Pain relief is one. Many patients are expecting complete pain relief when often there is only partial relief or none at all.
Some patients even report more pain after surgery.

Quality of life (QOL) is another measure. If pain relief isn’t delivered, then QOL often goes down. Disability goes up as pain levels increase and function goes down.

In a recent study at the Productive Rehabilitation Institute of Dallas for Ergonomics (PRIDE), patients with extreme pain after rehab were more likely to seek further medical care. The risk of post-rehab surgery was 11 times greater in this group compared to patients with mild pain.

The authors of the study pointed out that chronic pain patients with work-related injuries were less likely to return to work after surgery if their pain level was ‘extreme.’ This was especially true for patients who were disabled for one to two years.

They suggested taking a careful look before doing surgery on anyone with extreme chronic low back pain.

For most soft tissue or bone problems healing does take place in six to eight weeks. Pain, swelling, and loss of motion usually resolve by the end of this time. The patient can get back to work or regular activities.

Recovery may take longer if there is nerve damage. And sometimes the pain cycle gets turned on and the body can’t turn it off. Scientists aren’t really sure what happens in cases like this. Pain becomes chronic and can be mild, moderate, or severe.

Studies show a better result for patients who have rehab. A multimodal form of rehab is best. This means the patient is evaluated very careful from a physical, social, and psychologic point of view. Rehab to address needs in all three of these areas is advised.

Patients do better in the long-run if rehab has included patient education, fitness, and counseling. Both occupational and physical therapists provide exercises and management techniques. Close supervision over a longer period of time is also linked with better results. For patients who have extreme chronic pain, early treatment is better than waiting for months before getting started.

TLIF stands for Transforaminal lumber interbody fusion. The surgeon goes in from an angle from the back and side. The entire disc can be removed from one side with TLIF. Other methods like the posterior lumbar interbody fusion (PLIF) require two incisions and entry into the disc space from both sides of the midline.

With TLIF there is less blood loss, less chance of nerve injury, and a shorter operative time. Only one side of the spine is weakened using the TLIF to remove the bone that protects the disc. Other methods compromise the stability of both sides of the spine. Likewise the soft tissues (muscles and ligaments) are only disrupted on one side with TLIF compared to PLIF.

The goal is to reduce complications and improve recovery time. The surgeon is able to use a minimally invasive operation and still get a good fusion for the patient.

MaXcess Transforaminal Lumbar Interbody Fusion (TLIF) uses a special retractor system to give the surgeon access to the spine. The surgeon can use a small incision with minimal disruption to the muscle tissue while still being able to see what he or she is doing.

Time in the hospital may be much shorter with MaXcess TLIF (one day compared to three to five with traditional spinal fusion). Physical recovery is about the same (or faster) for the MaXcess TLIF compared to the other methods of TLIF. Patients report being pain free and back on their feet in a few days. It takes about four to six weeks to recover fully.

The surgeons would like this too. Using an arthroscope or endoscope to see inside the spine while viewing a computer screen is a challenge. The surgeon must move the tools without damaging nearby nerves and blood vessels. They must avoid cutting through soft tissues such as muscles and ligaments as much as possible.

A new retractor system is being tested for use with transforaminal lumbar interbody fusion (TLIF). With the minimally invasive operations, the surgeon inserts tiny tubes through the skin down to the bone. Special tools are then slid through the tube to remove the disc and nearby bone.

The MaXcess blade retractor slides down over the outside of the tube forming what’s called an operative corridor. The blades of the retractor then move the tissue out of the way so the surgeon can see what he or she is doing. Only a small incision is needed but the surgeon gets the full view without using microscopes.

You’re right, of course. The disc implant must be anchored in place just like a total hip or total knee replacement.

Some of the steps used to hold the implant in place depend on the type of artificial disc replacement (ADR) used. For some, the surgeon chisels out a groove in the bone. A special anchoring keel in the center of the ADR settles into the groove. Bone grows around it to hold it in place.

Other ADRs have a different locking mechanism to hold it in place. Special “teeth” on the outside of each part dig down into the bone to hold it in place. A small amount of motion of the implant is needed to allow normal spinal movement. If the ADR is implanted too tightly, then shear forces may cause a problem. The locking mechanism can break or the implant can come loose.

Researchers are still working to tweak the design of their ADRs. Each new problem (or success) helps them decide how to improve the implant. Early on there were many problems with plates breaking or moving. New designs seem to have taken care of these problems. For now there are very few reports of implant migration. In the short run, it appears they are holding in place just fine. Long-term studies are next.

Artificial disc replacement (ADR) is a fairly new treatment for disc problems of the low back or lumbar spine. As with any surgery, problems can occur. Nerves or blood vessels can get damaged during the operation. The implant itself can break or sink down too far into the bone. In a small number of cases, the implant has reportedly moved out of the disc space.

When a total hip or total knee replacement fails, the surgeon tries to revise the implant. Sometimes this means removing a portion of the new joint and replacing it. In some cases the entire joint must be taken out and a new one put in.

ADR is a little different in that it is a fairly new procedure. Long-term results from studies carried out over 10 or 20 years aren’t available yet. Indications for revision aren’t entirely clear yet. Some surgeons may be more likely to remove the implant and fuse the spine.

As time goes by and more studies are done, ADR revision will become more common. Surgical technique and instruments to do the revision will be developed. The implants will also continue to improve in design and use. Fewer problems will be encountered.

There’s a lot of confusion about spine surgery right now. There aren’t enough studies to show what works best or how long the results last.

Research does show that there’s a wide range around the country of what’s done and how successful it is. Some surgeons just do a discectomy. Others perform the decompressive laminectomy you described. A third option is to have a spinal fusion after discectomy. The idea is to reduce the need for a second operation later by doing both procedures now.

The problem is that studies show patients who have spinal fusion surgery aren’t less likely to have another operation. In fact, just having back surgery of any kind increases the risk of reoperation at a later date.

And the rate of complications goes up when discectomy is done with a spinal fusion compared to discectomy without fusion. Age is a factor, too. Older patients have a higher risk of problems after spine surgery. They are more likely to end up in a nursing home after a spinal fusion.

Talk to your doctor about your case before making a final decision. Take into consideration your general health, diagnosis, age, and research findings to date. So far it looks like the more conservative surgical approach is just as good as combining several operations together.

You might get exactly the same treatment you’ve received in the more urban populated area. A recent study of trends in treating back pain came up with some surprising findings.

For example, the rate of spine surgery is much higher in western states compared to the East Coast. There’s a wide range of treatment offered across the U.S. but the same is true just within individual states, too.

Overall trends show that spinal fusion has risen dramatically in the last 20 years. MRIs have made it possible to identify disc problems more readily. Along with this has come increased reliance on surgery to correct the problem.

In the U.S. the number of people with back pain is about the same as in other developed countries. The difference is that surgery is used two to five times more often here than in other countries like England or Scotland.

More studies are needed to find out what works and why. Choosing the right treatment for each patient and having the best outcome is the only way to solve the problem of overuse of surgery.

Both conditions seem to respond to anti-inflammatory medications. If you haven’t already tried this, ask your doctor if it would be a good option for you. If you’ve used a mild antiinflammatory with some results but want better pain relief, then a stronger prescription might help.

Exercise and activity are known to help with arthritis. Sometimes the movements that are good for arthritis flare up the stenosis. A physical therapist can help you learn what to avoid with each.

A more invasive treatment option might be spinal injections. Some patients get immediate and long-lasting relief with corticosteroid injections to the joints. Epidural injection of corticosteroids has also been used successfully with lumbar pain syndromes from spinal stenosis.

It takes time to sort out what works for each patient. Give each treatment option a fair chance. Keep a diary or journal of your symptoms, treatment, and activity level. See if you can chart improvements to help you find out which treatment or combination of treatments works best for you.

Simply put, just because something shows up on an MRI doesn’t mean that’s the cause of the patient’s symptoms. For example, many studies have been done now that compare MRIs of healthy, “normal” adults with MRIs of back pain patients. They found there’s no big difference between the two groups.

The people who don’t have any back pain have just as many age-related changes in the spine. They have just as many pinched nerves and bulging discs. Using MRIs as the only diagnostic tool isn’t realistic. The doctor must combine patient history and clinical exam with results of X-rays, MRIs, CT scans or other imaging studies. Lab values are sometimes helpful too.

It’s clear that we don’t understand what causes back pain in one person and not another. In fact it’s not even clear why one patient would be pain free one day and develop painful symptoms the next.

Until this can be sorted out, when it comes to back pain, doctors don’t have one tool to use as their “gold standard”.

You have just discovered the dilemma patients and doctors face every day. Evidence-based medicine requires that treatment applied must be proven effective — otherwise what’s the point of spending time and money on something that doesn’t work?

But study after study either shows the treatment didn’t make any difference or one study says ‘Yes’ it helped and another says ‘No’ it didn’t.

Recently a group of researchers did us all a favor. They carefully reviewed the results of traditional, alternative, and surgical treatment for lumbar disc herniations. What they found mirrors your own discovery. Here are a few highlights:

Women aren’t exempt from disc disease or problems from herniation. But they are far less likely than men to have low back pain from a lumbar herniated disc (LHD). In fact studies show men are three times more likely to have a LHD compared to women.

It’s not clear if there is a genetic basis for LDH. It’s possible that the structure of a disc and the surrounding tissues puts some people at greater risk than others. And maybe this at-risk structure is passed along genetically.

Other risk factors that may be linked with LDH include lifting heavy loads and engaging in strenuous physical activity. Driving motor vehicles for a living is another potential risk factor. These are activities men are more likely to do than women.

Clearly the aging process contributes to disc degeneration. But do men and women’s discs age differently? Scientists agree more study is needed to identify who is at risk and what can be done to prevent disc herniation.