FAQ Category: Lumbar Spine

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.

Most doctors will tell patients to stay as active as they can. In medical lingo this is called movement as tolerated. You decide how much you can do and how far you can go based on your pain and symptoms. The main goal is to start moving and keep moving. It doesn’t seem to matter what that includes. Specific exercises aren’t needed and may even be harmful at first.

At the same time you can practice any method of self-care that works. This may be an over-the-counter pain reliever. Or you may find that ice before and/or after activity helps. Relaxation tapes or simply listening to music may help reduce muscle tension and relieve pain.

One of the most effective ways of “staying active” is through breathing. When you move in such a way that the pain increases, stop, and take a slow, easy breath. This helps with relaxation and can reduce pain that is increased by muscle tension.

Studies have shown over and over that bed rest doesn’t help and may even delay your healing. New research also shows patients must be aware that fear of movement will set them up to stop moving or avoid certain motions. This can also delay healing and cause further problems later. Once again, breathing, relaxing, and moving are the keys to staying active.

Each program or clinic approaches chronic back pain a little differently. Some treatment is based on the type of problem you have. In the beginning you may need one-on-one care. Group treatment may be used for chronic low back pain. People in this group have often had pain for months or even years.

Studies show that chronic low back pain can be helped with an intense team approach. Members of the team may include a chiropractor, physical therapist, acupuncturist, and massage therapist. Some centers also include behavioral psychologists, occupational therapists, nutritionist, and others.

Many hours of teaching, exercising, and practicing methods taught by the team members to groups of patients pay off with less pain, better function, and more positive outlook.

A recent study from Finland compared group therapy to individual treatment. All the patients had back pain a year or more. Everyone got better. Group therapy wasn’t better than individual therapy and vice versa.

The research focus is now on trying to find out if some back pain patients get better with one type of treatment over another. If we had ways to predict who will respond best to each treatment we could get patients started sooner with what works for them.

Diskography doesn’t have many complications associated with it. In a very, very small number of people an infection can develop. This is called diskitis. It’s painful but can be cleared up with antibiotics. Newer and better ways of doing diskography have almost eliminated this problem.

Even less often than diskitis headache, nausea, and hematoma can occur. The most common problem is that the back pain gets much worse after the test. This is a temporary but unpleasant drawback. Pain relievers and muscle relaxants may help.

Studies over 20 years’ time haven’t shown any long-term problems or damage to the disc from this test. It’s safe and accurate.

For a long time scientists thought the disc didn’t have a nerve supply and therefore couldn’t feel pain. It’s clear now that the inner part of the disc called the nucleus pulposus doesn’t have nerve endings or a nerve supply.

But the outer covering called the anulus has two different nerve fibers and can therefore “feel” pain. It does so by transmitting pain messages from the nerves to the spinal cord and up to the brain.

Another way pain occurs is through chemical irritation. When the disc is damaged and has tiny cracks or fissures in the anulus, inflammatory cells spill out and irritate the nerve endings.

Tests show that some people have discs that are more chemically sensitive than others. And some people have discs that are more pressure sensitive than others. How or why this occurs is still a mystery.

The mysteries of cancer spread called metastases remain locked up inside the body. We only know the basics. Cancer can spread by direct extension. This means it just moves from one cell to the next.

Or it can spread from one body part to another. For example, there’s nothing separating the abdominal cavity from the rest of the body. Cancer cells are free to move about.

The blood system and the lymphatic system are two other ways cancer can hitchhike throughout the body. Each cancer has its own special way of getting around. Some are more prone to get spread through the blood stream while others are more likely to spread via the lymphatics.

All the blood through the stomach and intestines also goes to the liver for filtering. For this reason colon cancer is often linked with liver cancer. The liver and the colon both rest up against the back of the abdominal wall. Only a sheath of muscle tissue separates them from the vertebrae.

Small blood vessels supplying the vertebra with oxygen and nutrients can also deliver tiny cancer cells to the bones of the spine. Knowing the typical modes of cancer metastases helps doctors trace the cancer to its origin.

Lidocaine is a short-acting local numbing agent (anesthetic). Injecting it into the sacroiliac (SI) joint can help prove that’s where the pain is coming from.

Sciatica or paralysis of the sciatica nerve can occur if any of the injected anesthetic fluid leaks out of the joint. This can happen if the needle isn’t angled exactly right. The problem doesn’t usually last long. The injection can be done again using a more anterior position of the needle.

Orthopedic surgeons, osteopathic physicians, chiropractors, and physical therapists are trained to test for sacroiliac joint (SIJ) pain. They use a series of tests called pain provocation tests. By using certain positions or movements, the pain is reproduced to confirm the diagnosis. If three or more of the tests are positive, then it’s likely the SIJ is the problem.

To know for sure you can also use an injection of a short-acting local anesthetic right into the joint. If you get at least 50 percent reduction of pain for one hour, then the injection is proof that the cause of the pain was the SIJ.

Treatment is then aimed at the SIJ. Sometimes this means using a second, longer acting anesthetic. In other cases posture or movement problems causing the SIJ problem may be treated by a physical therapist.

Not to worry. This is a common problem. Usually the doctor who ordered the test is part of the team giving the test. Make sure you tell your concerns to the doctor or the staff at the test site.

There are ways to modify the test in such cases. You can still get the test results you need without harming yourself. When you arrive at the test area, the doctor or staff will explain what to expect. You can ask them to lower the speed (intensity) if needed. Report any pain or symptoms during the test.

If worst comes to worst the test can be stopped early. There are other less physically stressful tests that can be done. They are usually more expensive and harder on the patient. The exercise stress test is still the simplest, least expensive way to assess your heart function.

Injecting the sacroiliac joint (SIJ) with a numbing agent similar to novacain may reduce some or even all of your pain. The injection is both diagnostic and a treatment at the same time. If other words, your pain is better and now you know for sure the SIJ is the problem.

If the injection doesn’t help, then your doctor knows to look somewhere else for the source of the pain. It’s a win-win situation whether or not it works.

Physical therapists (PTs) are studying ways to examine low back pain patients that will guide treatment. The idea is that patients with specific groups of signs and symptoms have better results when treatment is based on exam results.

So if two PTs do the same exam but get different results, then your treatment might be different too. The most popular method used today puts patients in one of three classification groups based on the exam findings. Some patients get better results with manipulation treatment. Others need a program to stabilize the spine. A third option is specific exercise.

This method of classifying or grouping patients was started as a result of ongoing studies. The classification system is both reliable and effective. Reliable means it can be used with the same results each time tested. Effective means it works!

You may be talking about the Fear Avoidance Belief Questionnaire or FABQ. It’s a group of questions that helps the therapist see if you are avoiding activities and movement out of fear of increased pain.

There is a natural tendency to stay away from work and physical activities if you think they will increase your pain. This is called fear avoidance behavior. Fear of reinjury is another reason for FAB.

Having this information can help the therapist design the best program for you. Fear avoidance behaviors can be dealt with and eliminated without harm to the patient. Be honest when answering all the questions. It’s not a test of your personal faults or psychologic problems.

Most physical therapists (PTs) are very interested and willing to teach and educate their patients about the cause and treatment of low back pain. Don’t hesitate to ask your PT again about the goals and treatment plan for you. In the meantime we hope this explanation will help.

Back pain that goes into the buttocks and down the leg is often called sciatica. There are many causes of sciatica. One of the most common is a disc pushing out of its space and pressing on the sciatic nerve.

The goal in physical therapy is to help the patient keep the pain in the center of the low back area without going down the leg. This is called centralization. It’s a sign that the movement is helping the disc move back where it belongs. Positions and movements that cause pain to go down the leg are avoided. It’s as simple as that!