FAQ Category: Lumbar Spine

Level of fitness may not be linked with low back pain according to a new study from the Netherlands. They compared two groups of adults using a bicycle test of fitness. One group had chronic low back pain. The other group had healthy adults without back pain. The two groups were matched for age, gender, and level of activity.

Most of the back pain patients were in much worse shape than the control (healthy) group. But 14 percent of the back pain patients had equal or a higher level of aerobic fitness.

Doctors still aren’t sure who will get back pain. Age, fitness, and stress are just a few factors tested for. So far, no single factor has been linked in all cases. At least 80 percent do have work or home stresses that seem to contribute to the cause. Perhaps this is true in your case, too.

For a long time people were advised to squat down to lift a heavy load. Hold the load close to the body and use the legs to lift. The squat lift (knees bent, back straight) was said to be ‘safer’ than the stoop lift (knees straight, back bent).

There isn’t enough evidence to support one method over another. More studies are really needed to clear this mystery up. Many people still prefer to stoop over to lift — even after instructions to use the squat lift.

New studies suggest the position of the low back may be more important than the choice of stoop or squat. It seems a slightly flexed low back or freestyle (using any method that comes natural) are better than using a swayback or lumbar lordosis during the lift.

The real issue seems more likely lifting while twisting or lifting repeatedly over and over.

Good question! There are several answers. First the cages have serrated edges that look like little teeth to grip into the bone. As the fusion takes place, bone grows in and around the implant, locking it in place.

Second if the surgeon doesn’t remove it, there’s a strong ligament along the back side of the spine called the posterior longitudinal ligament or PLL. If the implant did slip back, it would be stopped by the PLL.

Sometimes with the anterior cages the surgeon also puts in some screws from the back. This adds an extra degree of stability. The fusion is strong enough to hold the bones from moving. Without movement the implant is even less likely to shift.

And finally, the disc is made up of two parts. There’s the tougher outer covering called the annulus and the softer, inner center called the nucleus pulposus. When the surgeon removes the disc, the back half of the annulus outer covering is left intact. The cage is inserted until it comes up against the posterior annulus, which keeps it from going any further back.

Despite the increase in medical knowledge these days, chronic back pain is still a mystery. What causes it and how to get rid of it are the focus of many studies.

Spinal fusion has been shown to be a better option for some people than conservative (nonsurgical) care. Surgeons have worked hard to make a better fusion. Their goal is to stabilize the spine so that it doesn’t move. For the most part, they’ve been able to do this with cages and screws.

But the results aren’t always what were expected. The spine may be stable but the patient still has pain. Clearly the added stability and increased surgery needed to get it isn’t needed. The next step is to make a fusion device that works without the extra screws.

If that doesn’t work then doctors are back to the drawing board.

Studies show patients can have a wide range of results after lumbar spine surgery for disc-related problems. The goal is to relieve painful leg symptoms and to improve, or at least stop, leg numbness. With these results, walking ability usually gets better. Back pain may or may not improve.

In some cases patients can get worse. There may be nerve damage, infection, or other complications from the operation.

Some of the results may be linked to patient’s expectations. According to one study 86 percent of the patients who expected success after disc surgery were happy with the results. Another 14 percent said they didn’t get the hoped for results but they would do it again for the improvement they did get.

The best way to approach spinal surgery may be to have a positive attitude and high expectations. At the same time keep in mind the final results may not be as expected. You could have a better (or worse) outcome than expected.

Usually we tend to assume that people who expect less are satisfied with less. And as a general rule, people who expect less are more easily satisfied. A recent study of patients’ results after spine surgery differ depending on the type of surgery they had.

They studied two groups of lumbar spine patients. Everyone expected to improve. They hoped for less back and leg pain and numbness. They expected to walk further with fewer problems.

One group had surgery for disc herniation. The other group had surgery for spinal stenosis. The authors reported better results in the disc group despite equally positive expectations between both groups.

They aren’t quite sure how to account for the difference. More study is needed to match up what doctors tell their patients to expect, the patients’ acutal expectations, and the final results.

For now it seems best to advise patients to listen carefully to what the doctor tells them. Sometimes it’s a good idea to have someone else come to the appointments and listen as well. Some patients go so far as to tape what the surgeon has to say. Write down your reasons for having the surgery and review them with the doctor. Knowing what the surgeon thinks may help you in ordering your list.

We have to keep in mind the orthopedic surgeon’s point of view. Cutting someone open with a 12-inch incision and using retractors to pull the soft tissue apart is invasive. The muscles are completely cut through. Sometimes the surgeon saws a bone in half to remove diseased bone. That is invasive.

Making a two or three inch incision and using tiny instruments to perform the operation is much less invasive. The surgeon uses special X-ray guidance. There’s much less blood loss and shorter operating times. Often the patient goes home the same (or next) day.

These days spinal fusion can be done with a much smaller incision and less damage to the muscles, ligaments, and nerves. The term “invasive” is really relative compared to the past ways of doing this operation.

There are three main curves in the spine. One is along the back of the neck. It dips inward and is called a cervical lordosis. The second is the upper-to-mid back, which is more of a hump-curve. This is called kyphosis. The third is the lumbar lordosis of the low back. Some people call this a “swayback.”

The low back becomes flat if there’s not enough curve or lordosis. The lordotic curve places each bone at just the right angle to keep the disc spaces open. It also maintains the right amount of tension on the ligaments, joints, and muscles.

Kyphosis of the lumbar spine causes an increase in the amount of pulling load on the posterior soft tissues. The muscles respond by tightening up or increasing their tone. The constant tension of the protective muscles can cause even more low back pain called tonicity lumbago.

Studies show that eight out of 10 adults will have back pain sometime in their life. Most people get better without treatment. A small number of folks will go on to have chronic low back pain.

Many aging adults have back pain from degenerative disc disease. The discs wear thin. Sometimes they herniate causing pressure on the spinal nerves and constant pain. Surgery is an option when conservative care doesn’t help. Spinal fusion is the most common operation.

Researchers are trying to design an implant to replace all or part of the disc. It’s not likely that everyone with disc problems will need or want a disc implant. This form of treatment is still in its very early stages of development.

Right now replacement is suggested for anyone with pain that has not gotten better with at least six months of active treatment. Imaging studies must also show a major loss of disc space height. The facet joints must not be fused or severely arthritic. Unless you meet all these criteria, it’s not likely you’ll need a disc implant yourself.

Back injuries have been the subject of many studies. Over the years it has been determined that physically heavy work, frequent bending, and lifting are linked with low back pain. It seems lifting while bending or twisting is a common cause of work-related back injuries.

Heavy lifting and awkward postures are reported as two strong factors in lifting injuries. Even the speed of lifting can make a difference.

Lifting posture remains under investigation. It’s not clear what low back position or posture works best. In a recent study from Canada with 15 healthy male volunteers the freestyle lift had the best results. Freestyle means the person lifts with whatever posture seems to work the best for him.

So in answer to your question, how you lift does make a difference. Posture may not be as important as the speed, repetition, and whether or not you’re twisting or rotating during the lift. Use those friendly reminders to check yourself. Good lifting methods do reduce back injuries.

Another way to think about spinal stability is to look at how stiff are the spinal segments. A lack of stability or unstable spine is loose, possibly with slipping and sliding of the vertebral bones against one another. A lack of this type of stability results in greater shear forces.

A stable spine is one that is held in place by the ligaments and muscles without a lot of extra motion. Compressive forces are greater with a stiffer spine.

Stability can come from the core muscles or from the global back muscles. Core muscles are the deep, short extensor muscles that attach the vertebral bones to each other. Some of the abdominal muscles are also part of the “core.”

Global muscles are the larger, longer extensor muscles of the back. Using the global muscles for repetitive lifting can result in fatigue and injury. That’s why there’s such a focus now on strengthening the core muscles.

Core training is offered on video and at health clubs around the country. You may even be able to find such materials at your public library. Pilates is a popular version of core training. A physical therapist or pilates instructor can help you get started.

A recent study from Kobe University in Japan reviewed the results of conservative care for lumbar spinal stenosis (LSS). They reported a good to excellent outcome. A closer look at this study is warranted.

They started out with 263 patients 70 years or older who had painful LSS. Each one was treated in the hospital for at least two weeks with traction, body cast, and/or injections. Less than half got better. The rest ended up having surgery.

Of the patients who did get relief from their symptoms only one-third were still “improved” at the final follow-up. The rest were unchanged or worse. Some went on to have surgery.

The study was able to show that the patients most likely to have a good result without surgery have radicular symptoms from pressure on the spinal nerve roots. These include pain and numbness down the leg.

Patients who ended up having surgery had numbness in the groin area with changes in bladder function. For these patients a myelogram showed a complete block of nerve messages. This points out the need to look at the location and effects of LSS when choosing conservative over surgical care. The type of care offered in Japan isn’t anything new or different from what’s been tried in the U.S.

Lumbar spinal stenosis is a common problem in the aging adult population. Degenerative changes in the spine cause narrowing of the spinal canal. This leaves less room for the spinal cord and spinal nerve roots. In the lumbar spine, pressure on the nerve roots can cause very debilitating symptoms.

At the bottom of the spinal column the nerve roots converge together in what’s called the cauda equina. This literally means “horse’s tail” because that’s what the bundle of nerves looks like. Stenosis causing blockage of the nerves in this area can cause bladder changes and severe muscle atrophy and weakness.

The treatment of LSS remains a hotly debated topic in medical circles. Studies have not been able to show one treatment works best for all patients. It’s more of a trial-and-error basis at this point. What works for one person may not work for another.

Encourage your mother to keep going back to her doctor and/or physical therapist. There’s a good chance they will be able to find the right combination that works for her. Surgery works best for some patients. Anyone with motor and bladder problems from the cauda equina is a good candidate for surgery before permanent damage occurs.

Intradiscal electrothermal (IDET) therapy started gaining popularity after an article was published about it in the year 2000. Since then more than 40,000 people have been treated in the U.S. and Canada.

So although it’s no longer “brand new,” it’s still in its infancy stages. Most studies only have one or two years’ worth of data to report on results.

Perhaps more importantly for you is to ask how many times the operator or technician at your facility has done this procedure. It’s more likely you are trying something new in your area that has been around in other places much longer.

A study on intradiscal electrothermal (IDET) therapy was first published in the year 2000. The results were very promising. Patients were able to sit for longer periods of time. Their physical function improved as their pain went down.

Since that time many other researchers have tried to repeat the results found in the original study. The results have varied from success to failure and anywhere in between. A review of those studies helps explain some of the differences. For example, the treatment wasn’t always carried out in the same way. The measures of success weren’t always the same.

The most recent study out of South Australia compared IDET with a sham (placebo) group. They found that although the treatment was safe, there was no difference in results between the two groups. They did not recommend the use of IDET for chronic low back pain from disc disease.

The cauda equina is a group of nerves at the end of the spinal cord starting in most people around L1 or L2. Pressure on these nerves from a protruding disc, bone spur, or spinal stenosis (narrowing of the spinal canal) can cause a group of symptoms referred to as cauda equina syndrome including:

Lumbar refers to the low back area. The last five vertebral bones in the spinal column make up the lumbar spine. The canal is a round, open space that allows the spinal cord to go from the brain down to the start of the lumbar spine. Stenosis refers to a narrowing of that canal.

Stenosis often occurs with the degenerative aging process. The bones start to collapse. The discs in between the vertebrae thin out and may even fuse to the bone. Ligaments along the back of the vertebrae to support the spine become thickened. All of these changes cause narrowing or stenosis of the spinal canal. Bone spurs around the joints are another change that can cause lumbar stenosis.

The pain and weakness come from pressure on the spinal nerves as they exit the spinal canal. Sometimes exercise helps and people try that first. Anti-inflammatories are frequently used with success in about 50 percent of the cases. Surgery to decompress or take pressure off the spinal nerves may be advised.

Laminectomy is the removal of part of the vertebral column that forms a circle around the spinal cord. The idea is to take pressure off the spinal cord or the spinal nerves leaving the spinal canal.

In order to get to the bone, the surgeon must cut through the muscles and ligaments on alongside the spine. If the surgeon can’t see the area well enough to complete the decompression, then part or all of the facet joint is also removed.

There are several reasons why you may not be able to regain your full strength. There can be atrophy of the paraspinal muscles on either side of the spine. Local nerve damage and loss of support from the facet joints can make a difference, too.

An MRI might be helpful to show a cross-section of the muscles to look for atrophy or wasting of the muscle fibers. This is more helpful if you had an MRI done before the operation to compare before and after.

Depending on how far you want to pursue this question, you could also talk to your doctor about EMG studies. Electrodes used to pick up electrical signals from muscles can be measured to look for abnormal or weak patterns.

A shoe insert goes inside the shoe and doesn’t change the appearance of the shoe. A shoe lift is applied to the outside of your shoe, usually to the heel. It has several disadvantages.

Each pair of shoes must be altered to benefit from the lift. One shoe is always going to look slightly different from the other shoe. It’s not easy to add a heel lift to a tennis or sport shoe. The heel lift also puts the ankle into a slightly flexed position. This can cause shortening of the Achilles’ tendon and lead to other problems.

The advantage of shoe inserts is that they fit into most shoes including dress shoes and tennis or sports shoes. They don’t work well in sandals.

With either choice research shows that the major effect starts soon after you begin using one or the other. The effect is maintained as long as you wear them. Both types must be replaced when they wear down or wear out.

First of all, we should tell you that scientists aren’t even sure why a small leg length difference would cause low back pain…but it does! Maybe the angle of the pelvis gets tilted enough to change how the muscles of the spine work together. Given enough time the changes lead to low back pain.

Having said that, we can also tell you it’s not clear why a thin shoe lift gives people relief from their pain…but it does! A recent study compared two groups of back pain patients who all had one leg mildly shorter than the other.

One group had a shoe insert inside the shoe of the shorter leg. The other (control) group did not have an insert to correct the length difference. The group with the shoe insert all reported less back pain. There was no change in pain or symptoms for the control group.