FAQ Category: Lumbar Spine

Most people return to normal function and work quickly after back surgery. But in the case of Failed back surgery syndrome (FBSS) pain continues indefinitely even with conservative care (pain relieving medications, physical therapy).

The pain is often described as dull, aching, and diffuse. Diffuse pain means the patient cannot point to one spot where the pain is located. Instead, the pain is present over a general area. There may be some abnormal sensations with sharp, pricking, and/or stabbing pain.

The cause and effect of FBSS is not well understood. It is suspected that there are multiple factors and variables contributing to this condition. Many studies of worker compensation patients have consistently shown that this group has worse outcomes than other non-worker compensation patients with the same diagnosis and same (or similar) treatment. Thus, being a patient on worker compensation status is an important factor.

With the new focus on evidence-based treatment, the Department of Labor and Industries is taking a closer look at treatment for FBSS. They are trying to find cost-effective ways to get workers back on their feet and back on the job. Toward that end, in Washington state a study was done comparing the costs of three different treatments for FBSS.

The study was actually the second one done with a focus on worker compensation patients. The first study reported on the results of three separate treatment approaches. The three treatment groups included: 1) spinal cord stimulation, 2) pain clinic, and 3) usual care. This second look compares the costs associated with each treatment method. The most cost-effective treatment is discussed.

In the first study, the authors measured outcomes over a two-year period of time based on pain, disability, and use of opioid (narcotic) medications. They found that five per cent of the spinal cord group reached the treatment goals in these three areas. Only three per cent of the patients treated at the pain clinic met the outlined treatment goals. And 10 per cent of the group receiving usual care had a successful final outcome. Success was defined as at least a 50 per cent improvement in pain, less than daily use of opioids, and a two-point improvement on the disability score using the Roland Disability Questionnaire.

Now taking a look at the costs of each approach, it turned out that the spinal cord stimulation was the most expensive. And the added costs were not offset by better results or fewer visits to the doctor than the usual care approach.

The differences in results could not be attributed by differences among the patients because they were evenly matched by age, sex (male versus female), and other personal characteristics. It was observed that the spinal cord stimulation group had more intense leg pain that had been present longer than in the other two groups.The worker compensation group was also more likely to have a lawyer representing their case.

To give you some idea of the costs involved in treating this patient population, the combined costs of total productivity loss and medical costs for each group was as follows:

Many fears patients have around back pain are unfounded and become an obstacle to recovery. Patients put much more importance on back pain and assume the pain means the spine is weak and vulnerable. This just isn’t true.

Research is pretty clear that movement, activity, and exercise are the keys to recovery from back pain. Rest, inactivity, and fear of movement only lead to greater limitations and increased disability. We know now that patients with low back pain who develop fear-avoidance behaviors (FABs) are at risk for a poor outcome and greater disability. Studies have also shown that when FABs are addressed in treatment, patients have much better results.

Fear-avoidance behaviors (FABs) refer to ways patients change their behavior, actions, movements, and activities based on the fear that their pain will increase or that their actions will cause reinjury. Their thoughts and emotions rule their behaviors because of concerns, worries, and fears that further harm will come to their spine.

Scientists who study the problem of chronic or recurrent low back pain are starting to see a pattern. It looks like physical activity is less likely the cause of spinal degeneration and more likely the result of genetics.

They are working on exploring the theory that instead of an injury model of low back pain, it may be possible that instead genetically predetermined factors influence what happens. The cells that make up the spine may not fail to stay healthy because of physical and occupational exposure to stress and load. They may just have a predetermined time clock that runs out regardless.

Another idea that might explain chronic back pain has to do with something called central sensitization. The spinal cord interprets incoming signals as painful whether they are or not and sends them to the brain quickly without investigating further. The spinal cord becomes highly attuned to any input and channels it all as pain messages.

This may explain why your health care providers are saying that your pain is not a sign that there is further damage to the spine with your activities. Everything we know from studies suggest just the opposite: “motion is lotion.” We have to move in order to keep good spinal health. Another appropriate expression: “use it or lose it” applies here as well.

As you have discovered for yourself, fear-avoidance behaviors (FABs) refer to ways people with chronic pain change their behavior, actions, movements, and activities. These changes are based on the fear that their pain will increase or that their actions will cause reinjury. Thoughts and emotions rule their behaviors because of concerns, worries, and fears that further harm will come to their spine.

For the most part, these fears are unfounded and become an obstacle to recovery. Patients put much more importance on back pain and assume the pain means the spine is weak and vulnerable. This just isn’t true. But without proper education, the patient becomes anxious, depressed, and inactive. They may start using more and more medications and become more like a “sick” person than someone who is going to recover.

It sounds like you have been working through all of this. And you are correct that new theories are being put forth and tested. One of those is that there are subgroups or categories of specific types of FABs. The three identified subgroups include: 1) misinformed avoiders, 2) learned pain avoiders, and 3) affective avoiders. As you can see by the names, these groups are based on the emotions and beliefs held by patients and used to explain why they are avoiding certain movements and activities.

The misinformed avoider avoids activities that might provoke pain based on common sense that another injury would cause more pain. Therefore they avoid anything that might lead to another back injury. This group of patients can be swayed in their views with new information based on reasoning and logic.

The second group (the learned avoiders) developed fear-avoidance behaviors based on actual experience. When they moved in a certain way, their pain increased. So they stop any activities that are painful but they never go back to re-try those movements. If they did, they might discover there is no longer any pain associated with the activities they have been avoiding.

And finally, the affective avoiders are patients who are very distressed about their pain. They have an irrational fear of physical movement and refuse to see reason or try any new activities. This group tends to exaggerate any advice or precautions given to them by their physician or physical therapist. All their thoughts are focused on their back pain. They are said to be “hypervigilant.”

Treatment can be focused for each of these groups. For example, the misinformed avoiders must be given new information and guided through stretching and easy movements. This will help them see it is possible to move and engage in physical activities without hurting themselves. They must be convinced that physical activity won’t cause further spine degeneration. Educational brochures, booklets, and videos may be helpful with this subgroup but they must come from spine experts or they aren’t effective. At least that’s what studies so far have shown.

What about learned pain avoiders? What’s best for them? This group is a little more difficult to reach with effective treatment. First of all, when they move, it does hurt. So they aren’t misinformed at all. The panel suggested that research is needed to find better ways to help these patients. Some studies have shown that back pain can be reduced for these patients by repeating the same motion or movement over and over. Why this works to stop the pain signals remains unknown.

The last group (affective avoiders) have fears so strong the fears become phobias. They are deeply entrenched in their beliefs. One program that has worked for this group is to re-introduce activities slowly starting with the least worrisome (and easiest) movements.

Slowly, with repeated actions and exposure, more and more activities are introduced. The patient is guided through the activities slowly and carefully by the physical therapist. Over time, they become more confident and more willing to engage in physical activities once again.

One other approach that seems to have merit for the affective avoiders is called functional restoration. The patient is given a certain number of exercises and activities to do each day. This is a quota-based approach. As the patient completes each task successfully, he or she becomes more confident that “hey, my spine can handle that just fine!”

At the same time, this group of patients is given counseling aimed at reducing and eliminating negative beliefs that result in disability. Studies show that this approach helps people get back to work. For those individuals who are still working, functional restoration helps them reduce the number of sick days.

If you recognize yourself in any of these groups, it may be helpful to adopt some of the techniques described here. See a physical therapist if you need help with specific suggestions. Don’t give up! There’s plenty of evidence to suggest you can be successful in reducing fears and improving function.

Epidural steroid injections (ESI) is one approach to the chronic low back and leg pain experienced by many patients. These injections control pain by reducing inflammation and swelling. They do not cure any of the diseases they are commonly used for, but can control the symptoms for prolonged periods of time. In some cases, the reduced pain makes it possible for the patient to participate in a physical therapy program, become more active, and be better able to control the symptoms with a conservative program.

When doing an epidural injection, the doctor inserts a needle through the skin so that the tip of the needle is in 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.

There are several openings in the bones that surround the epidural space where a needle can be placed. An ESI can be performed by placing the needle in one of these three openings. The three opening sites are caudal, interlaminar, and transforaminal. Each of these three types of ESI injections has advantages.

The caudal injection is performed at the very lower end of the spine through a small opening in the bones of the sacrum. The sacrum is made up of several vertebrae that fuse together during development to form a single large bone. This bone is where the pelvis connects to the spine. The opening at the tip of the sacrum leads directly to the epidural space. Fluid injected through this opening can flow upward through the epidural space to coat the nerves throughout the lower lumbar spine.

An interlaminar injection is performed by placing the needle directly in from the back of the spine between the lamina of two adjacent vertebra. The laminae (plural) form the outer rim of the bony ring of the vertebra. This places the tip of the needle in the back side of the spine. The advantage to this type of injection is that it is easy to do, even without the guidance of a fluoroscopic x-ray machine. The injection is usually done between the two vertebra that are most likely causing your pain. This puts the medications as close as possible to the problem. The disadvantage to this type of injection is that injected medication may stay in the back side of the spine away from the intervertebral disc.

A transforaminal injection is a newer type of injection that is done from the side of the spine, through the neural foramen. The neural foramen is the opening where the nerve root exits the spine.

There are two neural foramen between each vertebrae, one on each side. The doctor places the tip of the needle into the neural foramen using the fluoroscopic x-ray machine to watch and guide the needle into the correct position. The advantage to this type of injection is that it places the medication in the front of the spinal canal, near the intervertebral disc. The disadvantage is that this type of injection requires using the fluoroscopic x-ray to guide the needle placement.

Your doctor is recommending an ESI to try and reduce your pain. The ESI may also reduce numbness and weakness. With this information in mind, you can ask your surgeon which approach he or she is planning to do and perhaps more about why this method is best for you.

You should know that these injections are often temporary. Pain relief 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. This is something else you may want to discuss with your surgeon before the procedure.

Epidural injections are a common way to treat painful back problems, especially problems caused by degenerated or herniated discs. But this treatment has also been used in patients with spinal stenosis, postlumbar surgical syndrome, failed back syndrome, and other mechanical causes of low back pain.

When doing an epidural injection, the doctor inserts a needle through the skin so that the tip of the needle is in 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.

The epidural space is normally filled with fat and blood vessels. Fluid such as the lidocaine and cortisone that can be injected 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 control pain by reducing inflammation and swelling. They do not cure any of the diseases they are commonly used for, but can control the symptoms for prolonged periods of time. In some cases, the reduced pain makes it possible for the patient to participate in a physical therapy program, become more active, and be better able to control the symptoms with a conservative program.

There are two different types of injections and three locations to give them. The injection solution can be a local anesthetic like lidocaine or bupivacaine. Or it could be one of those two numbing agents combined with a steroid (antiinflammatory medication).

There are several openings in the bones that surround the epidural space where a needle can be placed. The injection can be performed by placing the needle in one of three of these openings (caudal, interlaminar, transforaminal). Each of these three types of ESI injections has advantages.

In a recent study comparing injection of local anesthetic with combined analgesic and steroid, researchers found that epidural injections (more commonly known as epidural steroid injections or ESI) were superior to analgesic injections alone. This study only looked at patients with pain from disc herniations not any of the many other spinal problems injections are used for. And only caudal injections were used so there’s still a need for further studies to evaluate (and compare) results among all three injection sites.

For patients who do not want steroid injections, injection of a local anesthetic can yield good results, too. They should be told that the results may not last as long as with steroid injection and that more injections may be required. Even so, epidural injection of an anesthetic is an acceptable treatment approach.

This information may help you understand the proposed procedure and make it possible to discuss the intended treatment for you. For more information on the treatment of chronic low back pain with epidural (steroid) injections, see A Patient’s Guide to Epidural Steroid Injection.

With over 200 different treatments available for back pain, researchers haven’t come to an end of study on this problem. From the evidence we have so far, finding one simple treatment that works for everyone isn’t likely.

Some of the more common treatments include heat, massage, ultrasound (another form of heat but also a mechanical means of improving circulation and healing), shock wave therapy (also known as vibrotherapy).

Most of these tools are used to increase blood circulation, improve soft tissue stretch, reduce pain and stiffness, and speed up healing. Other potential effects may include enhanced cellular metabolism, muscle relaxation, and increased trunk/spinal motion.

Studies comparing different treatments and combinations of approaches are often of poor or low quality.

It can be difficult making clear comparisons since every study had its own duration (e.g., treatment three times a week for three weeks; treatment daily, five times a week for three weeks; treatment once or twice a week for a total of four sessions, etc). And results or final outcomes are often measured using different tools (pain assessment, function, disability, walking distance, spinal motion, emotional functioning and coping).

What can we say from the studies that have been done? According to the results of a recent systematic review of all studies published, shock wave therapy and ultrasound should NOT be used to treat low back pain (acute, chronic, with or without leg pain). There is plenty of evidence to dispute the use of these modalities in the treatment of low back pain.

The use of lumbar traction and laser do not seem particularly effective either. The positive benefits reported by some patients may be nothing more than people getting better through the natural course of healing.

Some patients with chronic back pain (no leg pain) respond best to spinal manipulation. Research is ongoing to find predictive factors. Predictive factors help identify which patients will respond favorably to a particular treatment method or approach.

Most of today’s experts in the field of back pain suggest a multidisciplinarian approach. This means the patient must pursue a trial-and-error method of finding the right mix of help from physicians, physical therapists, counselors, trainers, and alternative practitioners (e.g., hypnosis, Reiki, BodyTalk, naturopathic or homeopathic remedies, craniosacral therapy, etc).

You may be referring to a form of therapy that causes oscillating or vibrational pressure at low frequencies to the muscles on either side of the spine. The type of shock therapy to the brain is something different altogether. Shock wave therapy for the back/spine is also called vibrotherapy. This is a technique used more often outside the United States.

In the United States, you are more likely to find ultrasound (another form of vibrational frequencies using sound waves) in use. The intention behind both of these vibrational therapies is to increase blood circulation, improve soft tissue stretch, reduce pain and stiffness, and speed up healing. Other potential effects of shock wave and ultrasound therapy may include enhanced cellular metabolism, muscle relaxation, and increased trunk/spinal motion.

But before you get too excited about this as a potential new and improved treatment, you should be aware of a recent report from Spain. Researchers from Spain take a look at the effectiveness of shock wave therapy and ultrasound in the treatment of both acute and chronic back pain.

They conducted the study as a systematic review. This means they searched all the currently published literature looking for studies on either of these two treatment methods. They found a total of 13 studies but only four randomly controlled trials.

The reported results then are based on the experiences of 252 patients. Various treatment methods were used and compared with ultrasound and shock wave therapy such as lumbar traction, low power laser, electrical stimulation, and spinal manipulation. Here’s a summary of the results:

You make a very good point and one that is backed up in research. Studies show that findings of degenerative disease, malalignment of the spine, and other anatomic problems or deformities don’t always cause symptoms. And the opposite is true, too — patients with severe pain may have very normal looking X-ray, CT scan, or MRI results. Successful, evidence-based treatment may not depend on imaging results.

In fact, sometimes like you, patients who see the changes on imaging studies (or who are told about them) end up worse off. Their perception of health deteriorates. They start avoiding certain activities or movements that “might cause pain.” The end-result is worse pain and decreased function. Not only that but the rates of surgery have increased two to three times what they were 10 years ago.

X-rays and other imaging studies have their place. But experts advise everyone (patients, primary care physicians, surgeons, physical therapists) that whatever imaging studies show, this is a snapshot at a single moment of time. And it’s a fact that many, many people with back pain and “positive” X-rays showing disc or other spine degeneration recover fully from their painful symptoms even when the X-ray doesn’t change.

Future studies will continue to provide information that will help people with low back pain understand the role of self-care, get the right kind of treatment when needed, and save money in the process. Staying active, engaging in movement of all kinds, stretching, and maintaining flexibility are all valuable ways to maintain good spine health and an active, pain free lifestyle. And this approach can be followed successfully without the need for X-rays in most cases.

You are absolutely right — many people think X-rays or other imaging studies are the answer when we should really be evaluating each patient on an individual basis. In 2007, the American College of Physicians and the American Pain Society published three basic guidelines to help with the decision of when to get X-rays.

Their recommendations were based on numerous quality randomized clinical trials and remain appropriate today. Despite these evidence-based recommendations, studies show that one-third to one-half of all referrals for advanced imaging are inappropriate.

So, what are the guidelines? First, physicians are advised not to order X-rays (or other imaging studies) routinely. Second, diagnostic imaging studies should not be ordered unless there are strong clinical signs that surgery or steroid injections may be needed. And third, imaging studies should be used when there are severe neurologic signs and symptoms that could result in permanent neurologic damage (including permanent loss of strength, sensation, or even paralysis).

Exposure to radiation is an everyday occurrence. There is radiation all around us, and radiation exposure has been linked with diseases including cancer. This alone is why we must limit additional excess exposure to radiation. To give you an idea of what we now know about radiation exposure, one X-ray of the lumbar spine exposes the human body to the same dose you would receive from background radiation over a six-month period of time. And one lumbar spine X-ray is equal to 75 chest X-rays.

To determine what treatment might be best for you, the Virginia Mason Medical Center in Seattle has studied and now practiced a helpful diagnostic model that is evidence-based and will reduce costs. Anyone with low back pain is seen by a physical therapist first.

Therapists have done their own research and developed evidence-based strategies for evaluation and treatment of low back pain patients. So they know what type of conservative (nonoperative) care is likely to work best for each patient based on the history and physical examination.

Physical therapists know how to screen patients for these more serious problems (e.g., tumors, fractures, infection) and what to look for that might suggest a higher likelihood of any of these problems. Anyone with low back pain can be confident that seeing a physical therapist first will save them money in the long-run. The therapist also monitors patients over a period of time and can see changes (or lack of change) to help assist in the decision-making process.

Magnetic resonance imaging (MRI) is one of the best ways to take a look inside the spine and see what’s going on without actually opening the body. The brain, spinal cord, discs, ligaments, bones, blood vessles, nerves, muscles, and joints can all be evaluated with this tool.

Information gained from MRIs is different than what is seen on X-rays or CT scans and is sometimes “complementary” to these others types of imaging studies. Multiple sclerosis plaques, loss of blood flow or blood hemorrhaging, edema (swelling), and torn spinal nerves are just a few of the other types of pathologies MRIs can reveal.

One of the best advantages of MRI (a pearl) is that it does not expose the body to ionizing radiation like X-rays and CT scans do. And it provides the only real way to look at the spinal cord. MRIs are better than X-rays for finding subtle or difficult-to-spot bone fractures. MRIs also show bone bruising and tumors that aren’t readily seen on X-rays or CT scans.

One of the biggest downfalls (a pitfall) is the appearance of artifacts. Artifacts refer to anything that shows up on the MRI that isn’t really there. An error on the part of the technician conducting the test can create artifacts. But so can the pulsations of blood or cerebrospinal fluid as they flow through the body.

Dental implants show up as dark spots. Fat and water in the body shift position causing artifacts. Even chemicals shifting in the body can become artifacts. Any of these factors creating artifacts can also result in a false positive meaning the MRI suggests a problem that doesn’t exist.

MRIs provide valuable information but findings must be viewed with caution. The patient’s history and clinical presentation (signs and symptoms) must be considered along with the imaging results when planning, assessing, and modifying treatment. Continued advancements in improving MRI systems may eventually eliminate artifacts. But until then, false positives and false negatives may delay or disguise an accurate diagnosis for some patients. Being mindful of artifacts is helpful in reducing diagnostic errors.

Your concern is shared by many people within the medical world as well as consumers and patients like yourself. As you have pointed out, the development of the X-ray machine followed by more advanced imaging tools such as CT scans, fluoroscopy, and MRIs has changed the way medicine is practiced. And with any diagnostic tool that can look inside the body, there are plusses (advantages) and minuses (disadvantages).

X-rays and CT scans do expose the body to ionizing radiation. That’s the type of radiation that has the ability to (potentially) disrupt cell structure and function, including disruption of your DNA. Unless there has been a traumatic injury or there is a strong suspicion of spinal fracture, infection, or tumors, imaging studies such as X-rays may not be needed. One reason to order imaging studies is when one of the treatments being considered is surgery.

With MRIs, there is no exposure to ionizing radiation. MRIs provide the only real way to look at the spinal cord. When you look at an MRI of the spine, you can easily see the bones, discs, spinal cord, ligaments, and even the cerebrospinal fluid in shades of black, white, and gray. Varying structures show up in different shades based on signal intensity picked up by the MRI.

MRIs are very helpful after trauma to the spine to look for neurologic damage. Likewise, vascular damage with blood loss or internal bleeding can be seen with MRIs. Pressure on the spinal cord or spinal nerve roots show up clearly. Injuries to the ligaments and other soft tissues can also be seen. Changes in size, shape, and orientation of the muscles are also visible. Any part of the spine from the head down to the tip of the spine (the coccyx) can be viewed.

There is one website we can direct you to for more information on radiologic testing including specific effects on the body and accumulation of radiation dosage: http://www.radiologyinfo.org. This website is provided by two groups: the Radiological Society of North America (RSNA) and the American College of Radiology (ACR). You will find a wealth of information there to further answer your question about measuring radiation dosage and safety.

Chronic low back pain remains a problem without a good solution. No single type of treatment works for everyone. Most patients end up combining multiple different treatments until they find the right mix that is effective for them. This may include medications, counseling or behavioral therapy, physical therapy, and surgery.

Medications often include pain relievers (analgesics) such as tylenol and antiinflammatories such as ibuprofen, naproxen, or other prescription nonsteroidal antiinflammatories (NSAIDs). Sometimes mild narcotics such as codeine or tramadol are prescribed.

A new drug called Tanezumab developed as a treatment for pain has been shown effective in patients with osteoarthritis, interstitial cystitis (bladder pain), and bone pain from cancer. Tanezumab is a monoclonal antibody (mAb) that works to alleviate pain because it neutralizes nerve growth factor (NGF).

Nerve growth factor sets up pain signals and even heightens the body’s responsiveness to painful stimuli. This means the nervous system responds faster to smaller inputs creating larger pain responses. Tanezumab stops nerve growth factor activity.

Results of a recent U.S. study may be of interest to you. Over 200 patients with chronic low back pain caused by osteoarthritis were included in the study. They were randomly divided into three groups. Group one received a single intravenous dose of (real) tanezumab and a placebo (sugar pill) naproxen (antiinflammatory). Group two were given an intravenous tanezumab placebo with real naproxen. Group three received placebo tanezumab and placebo naproxen. Group one was labeled the tanezumab group. Group two was the naproxen group. And group three was the placebo group.

The patients each kept a daily electronic diary recording pain levels and the use of any “rescue” medication. Rescue medication refers to any pain reliever used when painful symptoms were intolerable. Pain intensity and rescue meds were two of the measures used before and after to compare results. Questionnaires were also used to measure function and disability.

The effectiveness of tanezumab for chronic low back pain was measured using these outcomes. Safety was also a concern and was assessed by reviewing adverse effects reported by the patients. Review and analysis of the data showed that everyone in all three groups had measurable pain relief. The tanezumab group had the best results, naproxen second best results, and placebo ranked third after the other two.

These were the results during the early weeks (zero up to six weeks). After eight weeks, the naproxen and placebo groups were equal. The tanezumab group continued to report the best results throughout the 12 week treatment period. That answers the question of efficacy or effectiveness — tanezumab clearly outperformed the other two (naproxen and placebo).

What about safety? What were the side effects (if any) in the tanezumab group and how did they compare to the other two groups? There were reactions in all three groups but the tanezumab-treated group did have the highest incidence of problems. Joint pain, headaches, muscle pain, and painful responses to stimuli (e.g., touch) that shouldn’t be perceived as painful were reported in the tanezumab group. These side effects were temporary and all gone by the end of the study.

No one in any of the groups had serious complications (i.e., permanent paralysis or death). Overall, tanezumab provided better pain relief and resulted in better function than either naproxen or placebo. Adverse side effects of the tanezumab were mild-to-moderate and temporary.

The problem is that studies using tanezumab were halted in June 2010 when some patients with osteoarthritis got much worse after taking tanezumab and ended up needing hip replacements. If/when the ban on its use in studies is lifted, then its use with chronic low back pain can be further evaluated.

Long-term studies are needed to see if recurrence of back pain (common among back pain sufferers) can be changed with tanezumab and if there are any long-term side effects such as bone necrosis. The possibility of having an effective nonnarcotic medication for patients with chronic low back pain that has been unresolved with other treatments is worth pursuing.

As you have personally experienced, chronic low back pain remains a problem without a good solution for some people. No single type of treatment works for everyone. Most patients end up combining multiple different treatments until they find the right mix that is effective for them. This may include medications, counseling or behavioral therapy, physical therapy, and surgery.

Medications often include pain relievers (analgesics) such as tylenol and antiinflammatories such as ibuprofen, naproxen, or other prescription nonsteroidal antiinflammatories (NSAIDs). Sometimes mild narcotics such as codeine or tramadol are prescribed.

The new drug you received called Tanezumab was developed as a treatment for pain. It has been shown effective in patients with osteoarthritis, interstitial cystitis (bladder pain), and bone pain from cancer.

Tanezumab is a monoclonal antibody (mAb) that works to alleviate pain because it neutralizes nerve growth factor (NGF). Nerve growth factor sets up pain signals and even heightens the body’s responsiveness to painful stimuli. This means the nervous system responds faster to smaller inputs creating larger pain responses.

Tanezumab stops nerve growth factor activity. Tanezumab was undergoing Phase II and III clinical trials for the treatment of various pain problems, including chronic low back pain, bone cancer pain, and interstitial cystitis. But as you discovered, studies were halted when some patients with osteoarthritis got much worse after taking tanezumab and ended up needing hip replacements.

The reports included 16 patients who had X-ray evidence of bone necrosis (bone death) that required total joint replacement. It is possible that joint failure occurred as a result of excess wear and tear on the joint when pain was absent. In a sense, tanezumab as a pain reliever may have been too effective for these patients with painful hip and knee osteoarthritis. Eliminating the pain did not stop the degenerative processes and the increased activity further damaged the involved joints.

So for the moment, tanezumab is on regulatory hold due to the adverse effects in osteoarthritis patients. In the meantime, there is enough evidence from other studies that the use of tanezumab is safe and effective with chronic low back pain patients. Many people hope studies of this medication for chronic low back pain will resume if/when the ban on its use in studies is lifted.

Many people do get relief from their painful back and leg symptoms caused by a herniated disc with conservative (nonoperative) care. They may not ever need surgery. Some of the results depend on the severity of the disc problem.

For example, discs can be classified as protruding, extruding, or sequestered. Protrusion describes a situation where the inner disc material has pushed into (but not past) the outer covering. The amount of disc material is equal across the base of the protrusion.

Extrusion refers to the central disc (nucleus) that has pushed through and past the outer covering. The base of the extrusion is narrower than the amount pushing out. Sometimes this is also called a disc prolapse.

If the disc material gets pinched off and separated from the rest of the disc, it’s called sequestration. The free-floating fragment can create serious problems if it presses against the spinal cord or spinal nerve roots.

Emergency surgery for disc herniation is rather uncommon. Disc sequestration may be the one exception to that guideline. Most surgeons still recommend that patients try conservative care first for symptomatic lumbar spine disc herniation.

If surgery is going to be done, results will be better if the disc is removed sooner than later and possibly before six months has passed. That is the conclusion of a recent study of over 1200 patients enrolled in a study on disc herniations.

Participants were from 13 multidisciplinary spine practices across the United States. By combining patient information, studies like this make it possible to get more statistically accurate analysis of risk factors and variables (like duration of symptoms) that might affect treatment results.

This study along with others confirm that even late treatment (one to two years after the start of symptoms) offers patients some benefit by way of pain relief and improved function. But the best results are achieved when treatment begins within the first six months of symptom onset.

Many people with lumbar disc herniations opt for a wait-and-see approach to treatment. And that approach is usually recommended by most surgeons. But can you wait too long? Does the duration of symptoms have an unfavorable effect on final outcomes? A study conducted as part of the Spine Patient Outcomes Research Trial (SPORT) may provide you with some helpful information.

The SPORT database provides information and data from 13 multidisciplinary spine practices across the United States. By combining patient information, studies like this make it possible to get more statistically accurate analysis of risk factors and variables (like duration of symptoms) that might affect treatment results.

In fact, it’s studies like SPORT that have made it possible to see that surgery for lumbar disc herniation yields better results than conservative (nonoperative) care. But the question of when it’s best to have that surgery remains unknown.

Patients in this study were divided into two groups: those who had symptoms for six months or less and those who had symptoms for more than six months. The researchers compared these two groups within two larger groups: those who had surgery and those who didn’t. And in case you are wondering, surgery consisted of a traditional open incision discectomy (removal of the disc). Conservative care included physical therapy, antiinflammatory drugs, education, and/or counseling.

Results were based on change in pain, other symptoms (e.g., leg pain, numbness, weakness), and physical function. Comparisons were made from baseline to follow-up four years later. They found worse results in patients who waited more than six months to get treatment. This was true for both groups (operative versus nonoperative). But the duration of symptoms did not seem to be a factor or reason why patients responded better to surgery.

Patients who had surgery sooner had more severe symptoms early on. The patients who had surgery were also more likely to show more than just a protruding disc on MRIs — the discs were often more out of the disc space than in. There were also a higher number of patients with severe symptoms less than six months’ duration with sequestered types of herniation.

Sequestered means a portion of the disc has been pinched off and separated from the rest of the disk. The free-floating fragment can create serious problems if it presses against the spinal cord or spinal nerve roots.

The authors of this particular study concluded that symptom duration is a factor that should be paid close attention to. Whether treatment is conservative or with surgery, patients who had intervention of some kind within the first six months had better results.

It is still recommended that patients try conservative care first for symptomatic lumbar spine disc herniation. If surgery is going to be done, results will be better if the disc is removed sooner than later and before six months has passed. In agreement with the results of other studies, this study also showed that even late treatment (one to two years after the start of symptoms) offers patients some benefit by way of pain relief and improved function. We hope this helps you sort through your own situation.

You have certainly distilled down the information that has been published on this topic. Though there have been studies with conflicting results, a recent study from the UCLA Comprehensive Spine Center at the University of California (Los Angeles) provides some clarity on the subject.

By following 107 patients for five years or more, they found that the extended fusion did NOT improve clinical results. They concluded there is no need to fuse the L5-S1 segment as a preventive measure against developing adjacent segment disease. However, the authors did suggest that lumbosacral fusion should be used for patients with instability at the L5-S1 level (not just for disc degeneration).

Clinical results (improved pain and function) and patient satisfaction were good-to-excellent in 82 per cent of the patients. The incidence of adjacent segment disease (ASD) was actually less in this group (the lumbar floating fusion group) compared with the (extended) lumbosacral fusion (LSF) group.

The higher rate of adjacent segment disease in the lumbosacral fusion (LSF) group may be the direct result of a longer fused rigid segment. With a longer area fused, there is an increased load and stress on the normal segments above. Some researchers have concluded from their studies that increasing age is a risk factor for ASD but age was not statistically significant in this study.

The UCLA surgeons involved in the study concluded that extending spinal fusion to include the sacrum for patients with degenerative spondylolisthesis is not helpful. In fact, the extended fusion increases the risk of adjacent segment disease above the start of the fusion. Without this extension, the surgery is shorter and with less blood loss. There is also the advantage of less bone graft and a lower risk of pseudoarthrosis (failed fusion with spine motion still present).

Given this information, it would still be good to find out the surgeon’s rationale for recommending extended fusion. There may be issues of instability or other mechanical problems to consider that you or your brother are not aware of.

Low back pain from degenerative spondylolisthesis is often treated with spinal fusion when conservative (nonoperative) care fails to improve symptoms or function. In this condition, one of the vertebrae (spine bones) slips forward over the one below it.

Normally, the bones of the spine (the vertebrae) are neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis alters the alignment of the spine and creates a narrowing of the spinal canal. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. Low back pain and leg pain are the main symptoms but there can be sensory changes with numbness, tingling, and loss of sensation as well.

The degenerative aspect of spondylolisthesis tells us the condition develops over time as we age. Adults over age 50 are affected most often. There are degenerative changes in all parts of the spine including the joints, discs, and soft tissues. Slippage at the L4-L5 segment is the most common in this age group with this condition.

Without the normal alignment, spacing, and proper shock absorption, load is transferred through the spine. The disc at the L5S1 spinal level takes the brunt of it, so this is the area where degenerative disc disease is the worst in many patients.

Removal of the disc between L4-L5 with fusion of the same segment is referred to as a lumbar floating fusion or LFF. LFF is separate from a lumbrosacral fusion (LSF) where the L5 segment is fused to the main body of the sacral bone.

The procedures are used to reduce pain, increase activity level, and improve daily function. There is some speculation that extending the L4-L5 floating fusion down to include the L5-S1 segment (making it a lumbosacral fusion) might improve the results.

But according to a recent study comparing these two fusion levels, the extended fusion increased the risk of adjacent segment disease above the start of the fusion. Without this extension, the surgery was shorter and with less blood loss. There is also the advantage of less bone graft and a lower risk of pseudoarthrosis (failed fusion with spine motion still present) with the lumbar floating fusion.

Men involved in heavy manual labor worry they may end up with a herniated disc. How likely is this occurrence? Who is at risk and why? These are the questions asked by a group of researchers at the Copenhagen Male Study.

The Copenhagen Male Study was started over 30 years ago. Over 5,000 men participated in the study. They started by completing a survey with questions about the presence of back pain. Many other individual characteristics were also collected (e.g., age, social class, working conditions, height, weight, lifestyle).

By comparing men who reported back pain at the start of the study with men who did not have back pain, they were able to identify risk factors for disc herniation. It’s natural to assume that heavy lifting, carrying heavy objects, and sustained postures required by work conditions could contribute to low back problems.

It’s also logical that these kinds of problems should decline with age as men perform less strenuous work activities. But that may not be the case in situations like your husband finds himself. According to the Copenhagen Male Study, there seems to be a continued (cumulative) effect of heavy lifting, pulling, and pushing.

In other words, over time, the effects of these activities build up and influence disc health even after the man is no longer involved in those activities. Exposure will certainly change for most men over time. After 30 years in this study, many men were past retirement age and no longer engaged in heavy manual labor. Yet, their rate of disc herniation was higher than the younger men who were also involved in heavy physical activity.

More study on this topic is definitely required. And, in fact, efforts are being made to find ways to prevent problems such as back pain associated with disc herniation in manual laborers. The Copenhagen study is also looking for other risk factors that might be reduced or modified to offset the cumulative effects of workload.

Reducing psychosocial stress may help as dissatisfaction with work conditions or the job seems to also increase the risk of back pain. It’s possible that participation in leisure physical activity (even activities that involve heavy load on the spine) may reduce the risk of disc herniation.

Well, at least according to one recent study, height does put some men at a disadvantage for disc problems. The Copenhagen Male Study was started over 30 years ago. Over 5,000 men participated in the study. They started by completing a survey with questions about the presence of back pain. Many other individual characteristics were also collected (e.g., age, social class, working conditions, height, weight, lifestyle).

By comparing men who reported back pain at the start of the study with men who did not have back pain, they were able to identify risk factors for disc herniation. It’s natural to assume that heavy lifting, carrying heavy objects, and sustained postures required by work conditions could contribute to low back problems.

It’s also logical that these kinds of problems should decline with age as men perform less strenuous work activities. And there are some experts who suspect height and weight may be predictive risk factors.

The Copenhagen Male Study evaluated a dozen potential risk factors associated with disc herniation in men 40 years old or older. These risk factors included load to the back (low, medium, or high), strenuous work (seldom/never, occasionally, often), and leisure time physical activity (low, medium, high). The effect of other factors such as social class, mental stress (at work, during leisure time), and the use of sedatives, alcohol, or tobacco were also assessed.

One assumption was proven right. The other was not. Physical load and strain were considered risk factors for disc herniation. Reduced risk with age was not the case. Rather, there seems to be a continued (cumulative) effect of heavy lifting, pulling, and pushing.

In other words, over time, the effects of these activities build up and influences disc health even after the man is no longer involved in those activities. Exposure will certainly change for most men over time. After 30 years in this study, many men were past retirement age and no longer engaged in heavy manual labor. Yet, their rate of disc herniation was higher than the younger men who were also involved in heavy physical activity.

There was one other key predictive factor of interest and that was physical height. Whereas we once though height and weight measured by the body mass index or BMI was predictive of low back problems, this study highlights the greater influence of height over weight. The taller the person, the greater the risk of disc degeneration.

Knowing that men without a history of back pain but engaged in lifting activities can be at risk for hospitalization for disc herniation is an important finding. With height as a separate, independent risk factor men in jobs requiring manual labor can be identified early. Finding ways to reduce the risk is the next step.

Bone morphogenetic protein known as BMP-2 or BMP for short is a growth factor (protein) that helps bone heal and promotes bone fusion. BMP reportedly helps speed up the recovery rate after spinal fusion. BMP is designed to promote bone formation by setting up an inflammatory reaction. This type of enhancer was developed to avoid problems that occur with traditional bone grafting.

This type of product has been around now for at least 10 years. It first came out in 2002 when the Food and Drug Administration (FDA) approved its used for lumbar fusions. There are three distinct advantages to BMP: 1) improves success of fusion, 2) fewer problems because bone is not harvested from the patient, and 3) lower costs with a one-step surgical procedure that doesn’t involve bone harvest.

There are two types of BMP products available for use in spinal fusion. It is definitely no longer “experimental.” In fact, according to a recent (very large) study sponsored by the Scoliosis Research Society, about one-fifth (21 per cent) of all spinal fusions are done with BMP. It can be used with children and adults, though the most likely candidate is the older adult who may not produce enough new bone for healing.

The surgeon most likely explained the various options: bone graft harvested from your own bone, bone graft material from a donor bank, and/or the use of BMP. The pros and cons of each type of bone material may not have been discussed with you. Don’t hesitate to bring this question up to your surgeon for a better understanding of the procedure planned for you.