I’ve been treated for a large disc protrusion in my low back area. So far there’s no change in my symptoms. The doctor is suggesting either a steroid injection or surgery to remove the disc. Which one is better?

Steroid injection has some possible problems. It’s still less risky than surgery. Some doctors advise trying up to three injections before going to surgery. Some patients get
better after only one injection.

Some studies show injection or surgery works best when 25 percent or more of the disc is pressing into the spinal canal. Less than 25 percent usually gets better with nonoperative treatment. Anti-inflammatory drugs, physical therapy, and exercise should be
tried first.

If the injection doesn’t work, you can always have the discectomy. Research shows delaying a discectomy doesn’t affect the results. Likewise, having a steroid injection first doesn’t seem to affect results later after a discectomy.

I’ve had two lumbar discs removed and need another. Is there a disc replacement available yet?

Artificial discs or disk implants have been around since the early 1950s. Today’s more modern technology has allowed scientists to improve the disc replacement.

Today’s disc implants are made of a plastic center with a metal back. Spine surgeons in Europe are starting to report their results from using this generation of implants over the last 10 years.

Researchers have found that the real disc takes the load around the edges of the
endplate, rather than through the center. They’ve tried to mimic this with the artificial implant. The goal is to match the implant to the bone as much as possible. This allows load around the edges and movement through the center at the same time.

As more is found out about how the natural disc works, the artificial disc will change and improve to match it. Its use will probably become more common in the years ahead.

When I take my car in and get a part replaced, the new part usually has some kind of guarantee. When I go in next week for a disc replacement in my spine, are there any guarantees for the implant?

Good question. The medical world doesn’t usually offer guarantees of any kind. In fact before any operation the patient gets a list of all the things that can go wrong and has to sign it to show understanding and agreement.

In 1999 the Texas Health Research Institute reported disc implants last 10- to 12-years in about 63 percent of the disc replacement patients. The problem is knowing which patients will fall into that group and whether you’ll be one of them.

Studies show patient selection for this operation is important. Younger patients with only one disc level involved have the best result. There has to be enough disc space left to let the doctor insert the implant in place. There’s a tendency to stretch the bones
too far apart when the disc space is too narrow. This can cause chronic pain from nerve damage.

Success is measured in different ways by different patients. Some say pain relief is all that’s needed. Others expect pain relief and return to full function. Return to work is a big goal for many patients. Guaranteeing implant success just isn’t possible at this time. As implants improve in design and function, we can expect to see better results.

I had an artificial disc put in at the L3/4 level in my spine. Before the operation I had severe back pain. The back pain is gone, but now I have leg pain I didn’t have before. Is this common?

Leg pain after artificial disc implantation isn’t reported much, but it’s fairly common. Doctors suggest the cause is over-distraction of the vertebral bones when inserting the
implant.

The bones can handle the stretch, but the nerves can’t. In the process, the spinal nerve roots get stretched setting off painful signals that may not go away. The doctor must choose just the right patients for this operation. Age, bone quality, and amount of disc
space are all important factors.

This operation takes a skilled surgeon with technical experience. He or she must be able to place the disc exactly in place with just the right amount of tension on the bones.

What is “preemptive analgesia?” My husband is having back surgery and the doctor mentioned this as a way to control his postoperative pain.

Analgesia is a medical term for pain relief. Stopping pain before it starts is the idea behind preemptive analgesia. In the case of back surgery, this can be done with a single injection of a narcotic mixed with a local anesthetic. It’s injected into
the epidural space around the spinal cord.

Patients still have some pain, but less than if the pain stimulus was allowed to set off the nervous system. The patient won’t be completely numb during the first 24 hours after the operation. Any problems that occur will still cause increased pain and symptoms the patient can report.

How does “preemptive analgesia” work? My doctor used this on me during a recent discectomy. I had very little pain afterwards.

Preemptive analgesia is a way to inject a numbing painkiller into the epidural space around the spinal cord. The patient must be lying face down for this operation. The injection is given at least 20 minutes before the first incision.

It works by allowing local pain killing agents to lock onto the spinal nerve roots. The nerve roots normally signal the spinal cord. The spinal cord then signals the brain about
any problems. However the nervous system is very plastic or changeable. This means that pain signals can get blown out of proportion, leaving the patient with much more pain than is warranted by the condition. Once the signal gets turned on, it’s hard to turn it off.

Doctors can “preempt” severe pain by attaching a local anesthetic to the spinal nerves before pain signals ever get started. The patient still has some pain as a protective mechanism, but not the intense, prolonged pain allowed by central nervous system plasticity.

I was going to have a special method of pain control during my recent back surgery. It was called preemptive analgesia. It never worked out because the doctor couldn’t get a needle into the right spot. What could cause this problem?

You may be referring to an injection given into the epidural space around the spinal cord. A local anesthetic combined with a narcotic is used for pain control. The doctor uses a needle inserted into the epidural space to put the drug in effect.

There may not be any space open for the needle to enter if there is a lot of inflammation and swelling in the area. Sometimes the needle is too large for the patient’s anatomy preventing entry. The doctor can tell if the needle is in the right place. A special test
called the whoosh test is used.

Air is injected through the needle into the space before the drug is used. The doctor listens to the spine with a stethoscope. If the needle is in the right place, the sound of air will be heard. The doctor can also use imaging X-rays to show the placement of the needle.

Is there any kind of surgery that works for sciatica pain? I’d rate my pain an eight on a scale from zero (no pain) to 10 (worst pain). It’s keeping me from regular activities, sleeping, and making my life miserable. I’ll do anything at this point to be pain free again. What do you advise?

The first thing is to find out what’s causing the sciatica. Infection, disc disease, or tumor are just a few things that can put pressure on the sciatic nerve. Treatment works
best when directly specifically at a known cause.

Doctors often start out with pain relievers that also act as an antiinflammatory. This includes ibuprofen, aspirin, and other non-steroidal antiinflammatories. Physical therapy can help if there’s a muscle or joint imbalance putting pressure on the nerve.

If conservative measures don’t help then your doctor may advise surgery. Again this depends on the underlying cause of the problem. For example, a disc pressing on the nerve can be removed. In such cases, pain relief can be immediate.

I’m 52-years old and have a fairly inactive job at the city newspaper. Last week I stood up and got a shooting pain down my leg. Now I can hardly straighten up. The doctor thinks it’s a disc problem. How could this happen? I wasn’t lifting or twisting.

Studies show many different kinds of people with various jobs develop a disc problem. Most are involved with heavy-duty work, but some have light-duty work or are students or
retired.

Heavy lifting and repetitive movements put a person at increased risk of back injury. Smoking or tobacco use are also linked with low back pain. Aging with disc degeneration
is also a risk factor.

Even though your situation seems like it happened all of a sudden, it’s likely that a gradual process of disc degeneration has been taking place over time. An old injury, poor posture, or large abdomen adds stress and strain to an already aging body part.

I’ve heard smoking causes back pain. Is this true?

There is a link between smoking and low back pain (LBP). This makes smoking a risk factor for LBP, but not the actual cause.

Most of the research shows indirect links. For example smoking can lead to chronic coughing which may be linked with back pain. Smokers tend to have other poor health habits. They may be inactive, overweight, and at risk for brittle bones (osteoporosis). Osteoporosis increases the risk of bone fracture.

A recent study compared muscle strength in smokers versus nonsmokers. There were two groups of each: those with back pain and those without back pain. In general, smokers have less lumbar muscle strength. This is true whether or not they have back pain.

I’ve been told I have osteoporosis throughout my spine from smoking. I’m trying to quit smoking, but it’s very hard. Even though I still smoke, would exercise help my back?

Some studies support a link between cigarette smoking and decreased bone density. Less bone puts the spine at risk for fracture and back pain. Exercise has clearly been shown
to make a difference. You may not gain back bone mass lost, but you are more likely to keep what you have.

A new study shows smokers tend to have weaker back extensor muscles than nonsmokers. Smokers with back pain and without back pain were compared. They had about the same amount of muscle weakness. Even nonsmokers with back pain had greater strength than any smoker.

All in all it looks like exercise is the best medicine for many problems including osteoporosis. However, the benefit of exercise while still smoking has not been studied.

I’ve been having some trouble with back pain off and on over the last six months. Right now it’s more on than off. My doctor tells me quitting smoking would help. Is it enough to cut back the number of cigarettes I smoke?

Your doctor has given you good advice. Nicotine in cigarettes closes down the blood vessels. This is called vasoconstriction. The result is a loss of oxygen and nutrition to the back. This includes muscles, tendons, ligaments, bones, and discs.

The risk of disc problems is increased in smokers. Smokers tend to have disc problems throughout the spine, not just at one or two levels. Some studies show that the number of cigarettes smoked each day does make a difference.

Quitting tobacco use is the best for your overall health, not just to reduce back pain. If you can’t quit then cutting back as much as possible is the next best step.

I am the sole breadwinner for a family of six. After injuring my back, I’ve been able to keep working, but just barely. The doctor thinks surgery to remove a disc could help. What are my chances of getting back to work after this type of operation?

A recent study in Canada looked at this question as part of their ongoing research. They found more people went back to work after disc removal if they were still at work before the surgery. They may have taken some time off for recovery, but all but one was able to return to work after the operation.

This study also showed patients who had the operation sooner than later had a better result. Physical function was worse in patients who waited more than 12 months to have the operation. This was compared with patients who had the surgery within the first three months of symptom onset.

One other factor in the return to work equation is complications. Poor health, continued back and leg pain, infection, or poor wound healing can keep a patient from getting back to work. In some cases, the job is too hard and retraining is needed.

I heard that people in countries like Canada with national health insurance have far fewer operations than anywhere else. Is this true?

In general, this is true. Patients are not treated on a first-come, first-served basis. They are seen based on how serious the condition is or how sick they are.

With limited funding, many operations are considered “elective” and not required. The patient can wait to reach the top of the waiting list for this operation, or he or she can go outside the system and pay for it privately.

A recent study on lumbar disc removal called discectomy from Canada reports rates for this operation. The reported rate of discectomy in the United States is 70 out of every 100,000. The rate is only 24 per 100,000 in Canada.

I had an ultrasound treatment for low back pain. It only took five minutes and I didn’t feel any better afterwards. Should I keep getting this treatment?

Ultrasound (US) can be a very effective method of heating deep tissues. Heat from the US
promotes relaxation and improves circulation. Pain relief is often a result of both.

Standard US is applied with an applicator called a soundhead. The soundhead is moved slowly in small circles. Each circle overlaps the last one. A five-minute treatment
is about right for a patch of skin two to three times the size of the soundhead. This gives the tissue underneath time to heat up.

Treating the entire low back area in five minutes is not effective. Be sure and ask your therapist about the treatment. Report your lack of progress, but give it some time. It may take three to five sessions to feel a difference.

I’m going to have a spinal fusion at the L4/5 level. I’d like to do everything possible to have a good result. Are there any tips you can offer?

A positive attitude and desire to get well are always helpful. Good nutrition is needed to help the body heal. Use of tobacco products is known to delay or reduce bone healing.

If you smoke or use any tobacco products, talk to your doctor about quitting before the operation. There are many programs to help you with this.

Studies also show the use of NSAIDs prevents bone fusion. NSAIDs are nonsteroidal anti-inflammatory drugs such as aspirin and ibuprofen. They are used to reduce pain and swelling. If you have problems with pain after the operation, talk to your doctor about other ways to control this pain in order to promote healing.

Follow your doctor’s guidelines about rest, physical activity, and exercise. This is an important part of the recovery process.

I just had a disc removed two weeks ago. I’m finally pain free and I feel great. How soon can I drive my motorcycle and go back to work?

Your doctor would be the best one to answer this question with your specific situation in mind. It may depend somewhat on your general health, the type of surgery done, and the kind of work you do.

Many doctors suggest a two week wait before returning to light-duty work. Four to six weeks is more appropriate for heavy-duty work or vigorous activity. A low back corset may be advised during the early weeks of recovery. This can help unload the spine slightly and give you reminders about your restrictions. It can also help remind you to keep good posture.

Riding a motorcycle is also a matter for your doctor’s consideration. The main concerns are bumpy roads and hitting pot holes. The sudden unprotected motion can put pressure through the healing spine. You’ll most likely want to wait the full six weeks before any long distance travel.

I heard a report that people who work at night are more likely to see a doctor for back pain than day-time workers. Is there any particular reason for this? I work at night but I’ve never had back pain while on the job.

A simple and common sense reason may be accessibility. Workers who are free during the day can get to the doctor’s without taking time off from work to go. It is possible that there are fewer workers available at night to help lift, carry, or haul heavy objects.

There aren’t any studies on this factor in looking at workers with low back pain. The answer to your question may remain a mystery until more research is done in this area.

My father was in terrible pain for six years until he finally had his back fused. He’s definitely better, but he’s not pain free. Did he wait too long or are we expecting too much that he wasn’t cured?

Scientists aren’t sure the answer to this question. Perhaps there’s a little of both. Pain lasting more than six months is called chronic pain. Chronic low back pain is complex and poorly understood.

It’s clear that the changes take place in how chronic pain is transmitted. Surgery may not change the pain pathway. In fact it could make things worse instead of better. Since the cause of back pain is often unknown, the best treatment is also unclear.

A recent study in New Zealand reported that improvement–but not cure–is a common response to surgery to fuse the spine. Patients didn’t have great functional improvement, but their pain levels and drug use were less. Many were able to return to work. Most were
glad they had the operation.

I saw a report that only 30 percent of people with back pain seek help. Isn’t that good to keep down costs?

It may depend on who’s looking for help. Costs may go up if patients wait too long and end up with expensive complications.

A recent study from the Netherlands suggests many workers with back pain wait it out and treat it themselves. Only workers with severe, intense pain sought help.

Researchers want to find out more about who does and who doesn’t seek help. This may help us find ways to reduce costs early and maybe even prevent back pain in the first place. Doctors want to know who seeks help so they can gear their exam and treatment toward those patients.