FAQ Category: Lumbar Spine

It sounds like your doctor suspects a disc problem. A discogram (also known as
discography) can tell if the disc is really the source of your pain. CTs and MRIs show the anatomy and may show a bulging disc but can’t really confirm that the disc is the problem.

Using a special X-ray to guide the doctor, discogram involves putting a needle into the disc along with a contrast dye. Identifying if the disc is the problem (and which one)helps the surgeon plan the correct surgery. You may even avoid surgery if the discogram disproves the disc theory.

Discograms are done when the patient is in extreme pain and a candidate for surgery. The test itself can be somewhat painful and may make symptoms worse. But it’s the only test that can show for sure that the disc is the source of your pain.

You may be one of the few patients who have problems from the discogram. During the discogram a thin needle is inserted into the disc. By injecting a numbing agent the surgeon can tell if the disc is the source of your pain. If your pain goes away then the problem disc is found.

A contrast dye can also be injected to show the disc anatomy. If any dye leaks outside the disc the surgeon knows there’s a tear in the outer covering of the disc called the annulus.

Sometimes the injection causes a tear to get worse. The pressure from the injected solution can also cause a piece of the disc to be pushed out of the disc space. When either of these things happens, painful symptoms can get worse.

Make sure your doctor knows about the change in your status. You may need to have a follow-up MRI done to see what’s going on. Numbness and changes in the foot can indicate pressure on the spinal nerve. Permanent nerve damage can occur if this isn’t taken care of quickly.

There are two kinds of discograms (also known as discography). Discography is another term for discogram. The first is the analgesic discogram. The second is a
provocative discogram. The patient is awake but lightly sedated for either type.

During the analgesic discogram, the disc is injected with a numbing agent. The idea is to observe the effect of a local anesthetic on pain and function. This helps the doctor see if pressure on the spinal nerve(s) is the source of low back pain. The exact level of the problem can be found.

An analgesic discogram can give useful information for making treatment decisions. Sometimes the patient gets relief from pain just by having the injection. No further treatment is needed. Since this effect doesn’t occur in every patient, analgesic discogram isn’t done for every patient with disc-related back pain.

Other substances such as a saline solution or contrasting dye can be injected into the disc. When this injection causes pain it’s called a provocative discogram. Injecting saline increases pressure in the disc making the pain worse. This method identifies the disc as the source of pain.

Injecting an X-ray dye and doing a CT scan right away lets the doctor see the internal anatomy of the disc. Tears of the outer disc covering (annulus) and/or disc material (nucleus) leaking out can be seen using the contrast dye.

Simply stated, it means your back pain is associated with movement. Certain motions make it better or worse.

Mechanical low back pain usually suggests there’s a problem with one of the moving parts. Perhaps the disc is damaged from trauma or degeneration. Decreased disc height results in a change in the way the spine moves and increases the load on the joints.

Or there may be arthritic changes in the joints making joint movement slow and painful. The ligaments are also affected by the aging process. Sometimes they get thinner but in some cases they get thicker. Such changes affect the way the joint moves, and again, changes the load through the spine.

Mechanical back pain is sometimes called nonspecific mechanical pain when the exact tissue(s) involved can’t be identified.

Spondylolysis refers to a defect in one of the bones of the spine. The vertebrae of the low back are affected most often. Spondylolysis is not something we are borne with. It may be a stress fracture that never completely healed.

In the early stages of spondylolysis there’s a chance that the bone will heal on its own. Wearing a brace or corset keeps the spine from moving and allows it to form a solid line of bone. Immobilizing the spine can also decrease painful symptoms. Sports activity is restricted because of the risk of trauma. Repetitive motions are also a risk factor for increasing the load on the spine.

If the bone doesn’t form a solid union, then surgery may be required. Left untreated the condition can get worse and progress to spondylolisthesis. In spondylolisthesis the body of the vertebrae slips forward over the vertebrae below it. This can put pressure on the spinal nerves and causes instability of the spine.

Follow your doctor’s advice for the full six months for the best results.

Even a small amount of weight in a backpack can cause loaded walking. This means the compressive force on the spine is enough to increase the load on the discs. The discs are fluid-filled to help cushion the spine. Any pressure against them can cause small amounts of the fluid to leak out.

Narrowing the disc space even a little puts more pressure on the joints of the spine. The back muscles respond by contracting to help support the spine. All these factors together can add up to pain or discomfort for some people.

Why are some people affected and others aren’t? There’s no clear answer to that question. It may have to do with individual anatomy. Perhaps some people have smaller disc spaces to begin with and any change causes an immediate problem. Maybe muscle activation is faster in some individuals causing increased compressive forces sooner than in other individuals.

A recent study of back pain patients wearing a weighted vest while walking showed increased pain and a longer recovery time afterward. It took longer for the muscles to relax and the disc spaces to return to a normal height.

The future may be here now. Researchers at the Dartmouth Spine Center are testing a dynamic stabilization system called the fulcrum assisted soft stabilization or FASS. The goal is to hold the spine steady while taking pressure off the discs and allowing normal motion.

A special two-piece system of fulcrum and ligament is being tested. Stainless steel screws are placed into the pedicles of the vertebra above and below the damaged disc. The pedicles are bony stalks that project out behind the body of the vertebra. It helps form the arch of bone that curves around the spinal cord to protect it.

A plastic fulcrum is inserted between the two screws. Behind that at the end of the screws, a rubber “O” ring is wrapped around the ends of the two screws and acts as a ligament. By adjusting the tension of the screws, pressure can be taken off the discs and motion can be loosened or stiffened up.

Researchers are just at the prototype stage of study right now. Finding the right materials and testing for device fatigue are the next steps.

Lumbopelvic refers to the lumbar spine where it attaches to the pelvic bones. Lumbopelvic rhythm is used to describe the coordinated movements of the joints of the pelvis and lumbar spine during trunk flexion.

As you bend forward the spine and pelvis move in a smooth path to make flexion possible. It’s actually a bit more complicated than just described because the pelvis also rotates around the hip joints during forward flexion.

One other place in the body where the bones move together in a coordinated fashion is the scapula (shoulder blade) on the rib cage as the arm moves overhead. This is called the scapulohumeral rhythm. For every two degrees of shoulder motion, the scapula moves one degree in a tilting motion. This rhythm allows the arm to move smoothly up overhead.

Restoring the lumbopelvic rhythm often involves working with the joints and muscles of the spine, pelvis, sacrum, and hips. If the muscles in any of these areas are weak or in spasm, they can prevent this natural rhythm from occurring. The same is true if the joints are out of alignment or “stuck” and not moving smoothly.

If there is a medical reason for your pain, then a medical doctor should be the first choice. Any of your choices (medical doctor, chiropractor, physical therapist) can examine you and rule out any serious problems.

Let’s look at some of today’s research results on this topic. Studies comparing these three treatments for nonspecific back pain report the following:

You raise a good question. Unfortunately, one treatment doesn’t fit all who have back pain. Many scientists are trying to answer the question of which treatment is best for each problem. There are many areas in the spine that can cause pain–joints, ligaments, discs, cartilage, muscle, and so on.

But say two people do have the same problem exactly. Which is better? A doctor’s counsel and advice or manual therapy and exercise? Researchers in Helsinki, Finland, studied this question. They found that patients got better in both groups.

Patients in the treatment group were more satisfied with the results compared to the advice-only group. The cost of care was less for those who only saw the doctor. There was also less sick leave used in the doctor-only group.

There isn’t a simple answer to your question. Many studies are trying to find solutions to the chronic problem of back pain in adults. Stay tuned!

Modic changes are found often in MR imaging. They are signal intensity changes in the vertebral body right next to the endplates of damaged discs. Vertebral endplates are the fibrocartilage portions of the intervertebral disc. The end-plate is a possible source of disc-related low back pain.

The word modic comes from the doctor who first wrote about these changes in 1988 (Michael T. Modic, MD, professor of radiology and neurology at Case Western in Cleveland).

There are three kinds of modic changes. Type 1 is a decreased signal intensity and means there’s edema or swelling in the area. Type 1 modic changes can also mean there’s a tumor or infection.

Type 2 modic changes are the most common type reported on MRIs. With Type 2 modic changes there is an increase in the MRI signal. It means the first layer of bone under the cartilage is starting to turn to fat. It’s a sign that the problem has been there for awhile. Type 1 modic changes can convert into Type 2 changes.

Type 3 modic changes occur with bone sclerosis, a hardening of the bone. As the body tries to heal the damaged disc, extra bone cells are formed. The defective bone growth results in sclerosis.

Modic changes on MRI have been linked with discogenic back pain but pain can occur where no modic changes are seen.

MRIs have made it possible to see many abnormalities in the spine that couldn’t be seen before. MRI is best for detecting tumors, infections, and disc herniations. It’s used most often when surgery is being considered.

Reduced signal on MRI is used as a sign of disc or bone changes. The MRI shows irregular disc shapes, narrow disc spaces, and tears in the outer covering of the disc. It also shows changes in the joints and narrowing of the spinal canal called stenosis.

All in all, MRIs reveal many things about the spine and its condition. The problem is that many people with changes on MRI don’t have any pain or other symptoms. And the opposite is true as well. Patients with back pain may have normal MRI findings. So we can’t assume that abnormal findings seen on MRI are the cause of the problem.

Back pain affects many people each year. With or without MRI we don’t always have an explanation for the symptoms. There are just too many possible sources of pain in the lumbar spine that don’t show up as “abnormal.”

The disc is a soft, spongy material between the bones of the spine. Each disc is made up of two parts. The outer covering is called the annulus. The inner core is the nucleus.

The term prolapse means that the nucleus moves and presses against the annulus but it doesn’t escape outside the annulus. A prolaps can produce a bulge in the disc. It can be large enough to actually press against the nearby spinal nerve causing painful symptoms.

Herniation describes a nucleus that has moved out through the annulus. This usually occurs because of a tear in the outer covering leaving an opening. A herniation can come in physical contact with the nerve root or send chemicals to irritate the nerve.
The end-result is the same and may involve pain, muscle weakness, and sensory changes–such as numbness or tingling.

If a piece of the nucleus breaks away from the disc it can enter the spinal canal as a loose fragment. This is called sequestration.

This may depend on your overall health status and age. Slowing down is a natural part of the aging process, especially after an injury. But if at age 30 you’re at a snail’s pace or moving like a 65 year old, then you may start to experience physical deconditioning. Deconditioning can lead to disability.

Patients who fear pain or think it’s going to hurt before it does, often start avoiding activities. Or they may perform tasks more slowly and less vigorously. If there’s not permanent disability it may be best to get back to your former level of activity and function. Your future health may depend on it.

You are describing three standard tests used to assess physical function. Most of these tests are timed. Patients are asked to do the same task over and over as many times as possible in a limited amount of time.

These three tests include commonly performed tasks. When compared against other adults of the same gender and same age, the results can give the therapist an idea of what you can do. Studies have shown these particular tests give a reliable measure of physical function. The same tests are given after treatment. Before and after results are compared.

The value of an exercise diary may depend on your situation. Are you doing exercises for a specific reason such as to lose weight or to reduce back pain? Perhaps you are in good health and just want to stay there.

No matter what your reasons, an exercise diary has some good benefits. It keeps us honest. Reporting all our exercises means we really did them and not just once but several times each week. Humans seem to be more likely to do something and do it well if we write it down.

We are more likely to keep up good habits when we keep a record. Once we miss two or three days, the red flag goes up in our minds. Now we may be more motivated to get back on track. The American Heart Association offers an on-line exercise diary. Log on to:
http://www.justmove.org/diary/login.cfm
. You’ll have to register, but it’s a free service.

For those who are trying to lose weight by increasing their activity and exercise, Weight Loss Resources offers a website that helps calculate calories burned. There’s also some useful exercise information and a walking progress chart. You can calculate your body mass index (BMI) and find exercise ideas to boost your routine. Check it out:

http://www.weightlossresources.co.uk/exercise.htm.

Research shows over and over that exercise helps reduce low back pain (LBP). Positive results are reported when exercise is done correctly and on a regular basis.

Patients with chronic LBP who exercise have better function with less pain than those who don’t exercise at all. Patients who are given motivational tools and emotional support
have twice the results of those who just follow a standard exercise program.

Physical healing usually takes place in about six to eight weeks after injury or trauma. Unless you are doing work or activities that cause microdamage or reinjury, your tissues have probably healed long ago.

Back pain that keeps coming back is often a sign of stress. Exercise is a great stress reliever and has many, many other health benefits. Keeping up a daily exercise habit will benefit your back and much more!

You may be a unique individual who can grasp the concepts and move ahead without much supervision. Most people seem to need additional support and encouragement to stay the course.

In fact several studies have been done to show that most adults don’t stick with an exercise program for their back pain. This is true even when exercise has been shown over and over to reduce back pain.

At the University of Vienna in Austria, researchers recently reported on a long-term study with chronic back pain patients. Two groups were included: exercise only (control group) and a group that did exercise and received motivational counseling.

The motivational group had twice the results of the exercise-only group. Five years later they still had better function, less pain, and better work ability. Evidently there’s something about the rah-rah that works!

Stabilization is a way to steady a spine that moves abnormally. When the disc is damaged, one vertebra may slip and slide over the vertebra above or below it during motion. This type of movement is called translation and can cause back pain.

Fusion holds the spine steady but doesn’t allow motion. Dynamic stabilization does both. A special device is implanted into the spine to bring this about. It consists of screws, fulcrums, and ligaments to unload the disc and facet joints during motion.

Unlike disc replacement, dynamic stabilization saves the disc and the bony vertebral structure. With this type of treatment, a device is attached to the back of the spine to help stabilize the motion segment while leaving the intervertebral discs intact.

There are two different kinds of back pain: mechanical and nonmechanical. Mechanical back pain occurs when some part of the soft tissue or bone structure isn’t moving normally. There may be a damaged or degenerated disc or a torn ligament or a fractured bone.

Mechanical low back pain can be caused by abnormal motion. The vertebra may move in the wrong direction or slide too far in one direction. The result is to increase the load across the disc space and into the joints. A fusion puts a stop to this kind of problem.

Nonmechanical pain means that there’s no evidence of a structural problem. Psychologic and emotional stress has been proven to be a major part of this type of back pain. Surgery of any kind is not usually advised. Behavioral therapy and exercise seem to work the best for nonmechanical low back pain.