FAQ Category: Lumbar Spine

When it comes to low back pain, it can be very difficult to tell what is the problem and where the pain is coming from. Disc disease as a cause of low back pain can be especially challenging to diagnose accurately.

The diagnosis may require more than one single test. MRIs, pain provocation on discography, and pain relief by discoblock are three key diagnostic tools. You are probably familiar with MRIs (magnetic resonance imaging). MRIs use radio and magnetic waves to show details of internal structures like discs and ligaments. Discography and discoblock may be more unfamiliar terms.

Discography is the use of a radioactive dye injected directly into the disc. Your response to the injection is telling. An increase in or reproduction of your pain suggests the pain is coming from the disc. CT scans of the area also show areas where the dye has gone where it shouldn’t indicating tears, fissures, holes, or other damage to the disc and/or its outer covering.

Discography isn’t always reliable and even if it’s positive, that’s not a sure sign that the chronic back pain you are experiencing is caused by the damaged disc. That’s why discoblock may be helpful.

With discoblock, an injection of a numbing agent like bupivacaine (similar to novacaine) is used. Immediate pain relief signals the disc is the problem. The test is accurate and reliable.

The surgeon uses a special real-time X-ray called fluoroscopy to make sure the injection gets to the exact right place (inside the disc). Studies show that patients who have a discoblock and then go on to have disc surgery have improved results from the operation when compared to patients who had a discography instead.

All that is just to diagnose the problem as accurately as possible. Now for the treatment. Walking is a great way to exercise and may be a helpful treatment approach when there is a mechanical problem (e.g., weakness, muscle imbalance, postural alignment). But for disc involvement, you may need some specific type of exercises that will address your particular problem or you may need surgery to remove the disc.

If you haven’t been back to the physician who diagnosed you two years ago, it may be a good time to make a follow-up appointment. With this added piece of information (walking program with weight loss), it may be easier to sort out what are the various factors and where the pain is coming from.

When it comes to treating chronic low back pain, there still remains quite a bit of debate and controversy. That’s because it can be very difficult to tell what is the problem and where the pain is coming from.

Even when studying the same problem (e.g., low back pain from disc disease), researchers often come up with conflicting results. For example, some will show conservative care is effective when dealing with degenerative disc disease. Others conclude surgery gives better results.

In order to narrow the playing field, a group of researchers from Chiba University in Japan studied a very select group of patients with painful disc disease. Each one had confirmed disc disease at one lumbar level (either L45 or L5S1). No one had leg pain — just low back pain.

The goal was to get patients with disc degeneration and only disc degeneration and at only one lumbar level. It’s easier to tell if treatment is effective if everyone has the same exact problem.

They found that the patients in the surgical groups had better overall results compared with the exercise group. The results were actually reported as significantly better for surgery.

When comparing the two types of fusion procedures used, the patients who had an anterior (from the front of the spine) approach had significantly better results than those who had a posteriolateral (from the back and side) fusion.

So you can see that the decision is based on multiple factors. Making sure you have a disc problem and not pain from some other soft tissue structure is the first step. Once that has been determined, then the type of surgery to have will be the next question.

With this information, you should be able to go back to your surgeon and discuss the particular specifics about your situation. Ask about the pros and cons of surgery versus continued conservative care as well as the advantages and disadvantages of any proposed procedures. Good luck!

Many older adults have spinal compression fractures that are painless. Like you, they usually don’t even know they have a fractured vertebra. The diagnosis is made when an X-ray is taken for something else and the damaged bone is seen for the first time.

There’s plenty of evidence that pain doesn’t necessarily come from these fractures. Many people with confirmed compression fractures (as seen on X-rays) don’t have any pain at all. It’s not clear that the bone fracture is the true cause of pain for anyone with this condition who does have pain.

The question of what to do about “old” or “chronic” (healed) fractures is a good one. Unfortunately, there isn’t a lot of evidence one way or the other from high-quality studies to answer the question. It seems there are just too many factors and variable impacting results to make good comparisons.

For example, with the use of bracing for spinal compression fractures, patient age, type of fracture, spinal level of fracture, type of brace, and amount of time brace is worn are all things to consider. A change in even one of these factors could alter the results.

Likewise, when it comes to exercise, every study agrees that exercise benefits the body in many more ways than we know how to measure. But what type of exercise (stretching, calisthenics, core training, aerobics, dancing, gardening and so on) is best? Is it the same for each person with the exact same type of spinal fracture? These are things we just don’t know yet.

Good, quality research is clearly needed in this area. With so little evidence to support so many different approaches to the problem, there’s room for many future studies.

Spinal instability describes a condition in which there is too much movement or translation of one vertebral bone over (or under) another. The shift of the bone can be seen on X-ray when the spine moves — especially at the end of the spinal movement (e.g., bending forward/flexion or bending backward/extension).

There are clinical tests that are specific enough (able to identify when lumbar segmental instability is NOT the problem). But the tests have low sensitivity meaning they aren’t very good at identifying patients who DO have segmental instability.

According to a recent systematic review of studies published in this area over the last 60 years, the patient’s symptoms (pain with certain movements like rolling over or standing up straight) and the timing of those symptoms (worse when the weather changed) actually have the highest sensitivity/specificity (88 per cent/93 per cent).

The patient suffering from back pain as a result of lumbar segmental instability experiences a “catching” sensation when standing up straight after being bent forward. Another sensation described is one of the spine “slipping out” during spinal motion.

If any of this describes your symptoms, it’s likely your physician has made an accurate assessment of your problem. But if you have any doubts about the diagnosis or recommended treatment, there’s nothing wrong with getting a second opinion.

X-rays may be helpful if you have not already had any imaging studies. X-rays are not required and they do expose the patient to radiation, which is why they are not routinely ordered.

There are exercise programs for lumbar and trunk stability including core training that may be helpful. If you haven’t tried this approach, you may want to seek the help of a physical therapist as well.

You may be describing the classic signs and symptoms of a problem referred to as lumbar segmental instability (LSI). Lumbar refers to the low back region composed of five large vertebrae numbered one through five (e.g., L1, L2, L3, and so on).

Segmental means a specific one of those vertebrae is involved. And instability describes too much movement or translation of the bone. The shift of the bone can be seen on X-ray when the spine moves — especially at the end of the spinal movement (e.g., bending forward/flexion or bending backward/extension).

The patient suffering from back pain as a result of lumbar segmental instability experiences a “catching” sensation when standing up straight after being bent forward. Another sensation described is one of the spine “slipping out” during spinal motion.

The pain is usually worse in the morning. Pain and slippage are key features when the person tries to roll over (just as you described). And like a weather gauge, changes in the barometric pressure also increase painful symptoms.

What can cause lumbar segmental instability? Age-related disc degeneration, surgical spinal fusion, surgical removal of a disc, or a history of trauma affecting the spine. The condition is diagnosed based on the patient’s history, physical exam (clinical tests), and imaging studies. It may be best to make an appointment with an orthopedic surgeon to get an accurate diagnosis and get started on some treatment.

As you already know, both of these conditions affect the spine. Spondylolisthesis is where one vertebral (spine) bone slips in front of another vertebra. In such cases, there’s a forward slip of the the vertebra. But there is also lateral listhesis where one vertebra starts to slide off to the side.

In either case (forward or sideways slide of the bone), the force of gravity shifts over. The spinal muscles try to hold the spine and compensate for that abnormality. These changes often cause mechanical pain in the back. With aging, arthritis in the joints and disc collapse add to the problem.

If the problem of spondylolisthesis occurs in the spine above L1 or L2 (first or second lumbar vertebra), stenosis (a narrowing of the spinal canal) can develop. The shift of the vertebra closes down the canal opening where the spinal cord travels.

Then pressure directly on the spinal cord can cause painful symptoms. But usually this condition affects one of the lower lumbar vertebrae. So it’s the spinal nerve roots that exit the spinal cord below L2 that get pinched or compressed.

Stenosis can also develop as a result of other problems. Basically, anything that makes the spinal canal smaller than it should be contributes to stenosis. That could be bone spurs, thickening of the spinal ligaments, and/or thinning of the disc and subsequent narrowing of the disc spaces. With any of these degenerative (age-related) changes in the spine, painful back and/or leg pain can develop because of the nerve compression.

You may have stenosis from the spondylolisthesis. You could also have spondylolisthesis with stenosis from other contributing factors. You would have to have your surgeon explain the meaning of these two terms in your specific case to fully understand the difference (if there is any).

Not necessarily. Studies show that disc degeneration and disc herniation have many factors that when combined together, increase the risk of problems. Age (and age-related changes) is a big part of the picture. Genetics and heredity probably has a role as well.

Although mechanical factors related to occupation is one feature, it only accounts for about 10 per cent of the degenerative changes that occur. We know this because there are so many more people who do not have a work history involving physical loading or resistance yet still develop disc problems.

Genetics has long been suspected in this disease process, but no one has been able to pinpoint the specifics. The hereditary factor has been reviewed again recently using a different research approach.

In this study, researchers used information collected in a genealogical database from the University of Utah to determined the influence of heredity on symptomatic lumbar disc disease.

This study may be the first step in getting closer to our understanding of inheritance as a possible etiology (causative factor). Over a million patients are included in this database. The software makes it possible to search for patients with lumbar degenerative disc disease within the same family.

The results showed a definite genetic link to lumbar degenerative disc disease in symptomatic patients. And because the condition was present in the first- and third-degree relatives, we know it’s not just a matter of shared environment or exposure.

For clarity, we should define the degrees. First-degree refers to siblings (brothers and sisters). Second-degree includes relatives in a different generation such as parents, uncles, aunts, grandparents (or grandchildren). Third-degree relatives can be within the same generation such as first cousins. In fact, first-degree and third-degree relatives are usually in the same generation, whereas, second-degree is a different generation.

Risk of developing disc disease was greatest for the first- and third-degree relatives. So your father and his brothers (your uncles) are in the second-degree with less direct genetic links (at least according to this study).

Twin studies have previously shown the impact of genetics on lumbar degenerative disc disease and disc herniation. Other studies have shown that people who have a family history of disc herniations have more severe disc herniations themselves. Now this study adds support for a familial predisposition to lumbar disc disease.

Are you doomed to repeat the family pattern? There’s an increased risk but it is not a 100 per cent guarantee that your family history and current work pattern spell disaster. Being aware of your risks may help you identify if a problem develops and get early treatment.

We know now from many studies done over the years that back pain is a common problem among adults the world over. Disc degeneration and herniation seem to be the most common diagnosis among back pain sufferers. Efforts to understand disc degeneration and pain associated with the problem are ongoing.

Many people have disc problems and never know it. They have no symptoms of back or leg pain. There is no numbness in the back, buttock, or leg and no change in reflexes or weakness that are commonly reported by patients with symptomatic disease. Is there a reason why some patients develop symptoms and others do not?

Twin studies are often relied upon to sort out differences of this type. They can also be used to look for patterns of heredity. Twin studies have previously shown the impact of genetics on lumbar degenerative disc disease and disc herniation.

But there’s no evidence that twins (as opposed to individuals who are not twins) have a greater risk of back problems. The twin factor comes in that when one twin develops disc degeneration with disc herniation, the other twin is more likely to develop the same condition.

Other studies have shown that people who have a family history of disc herniations have more severe disc herniations themselves. Now a new study adds support for a familial predisposition to lumbar disc disease — not just twins but other members of the same age or generation (e.g., first cousins) seem to have an increased risk of developing degenerative disc disease.

The next step is to find out exactly what is the genetic link or abnormality. Is it in the cellular material that makes up the discs? Is there some miscoding on a particular gene that alters the biochemistry of the disc? Perhaps there is a genetic abnormality that changes the collagen protein in the disc.

By studying genes that might be involved, it may someday be possible to prevent disc disease before it ever develops or becomes symptomatic (painful).

Psychologists who study chronic pain patients are also trying to understand what’s going on in cases like this. Research is ongoing to find better ways to treat pain or help patients manage their chronic pain. To answer your question, we turned to the experts in human behavior and actions.

There seem to be two different ways people with chronic low back pain respond to their situation. They either avoid activities that might cause pain or they persist in being extremely active despite their pain. Pain experts suggest these behaviors called avoidance and persistence are the result of self-discrepancy.

Your husband is demonstrating avoidance behaviors. Your question is, “Why?” The concept of self-discrepancy may shed some light here. Even without pain, you have probably experienced self-discrepancy at times in your life. Some people refer to this as the “split-mind.” You perceive yourself one way but think you should be (or think) different. There are several different ways self-discrepancy plays a role in our lives.

There’s the actual self or how you really are in your natural state. That is compared with your ideal or perfect self — the way you would like to be. Then there’s the “ought” self (i.e., I ought to be …you fill in the blank here). And finally, the “feared” self. The feared self is the one you are most afraid of being like or becoming (i.e., becoming someone you do not want to be).

Any of these discrepancies or conflicts can result in emotional distress such as anxiety, depression, and pain. In addition to emotional experiences, the person may develop these other behaviors mentioned earlier (avoidance or persistence).

In a recent study from the Netherlands, the researchers tried to explain avoidance and persistence in terms of self-discrepancy and behaviors designed to “self-regulate” (or change). They proposed that people who engage in “I ought to do or be this way” kind of thinking are more likely to be driven to be their “ideal” or “perfect” self. Their behavior would tend toward persistence. And fear-based behaviors are more likely to result in avoidance. Fear of hurting or pain drive avoidance of activity.

The 83 patients included all had chronic low back pain lasting at least three months. Everyone in the study filled out various surveys and questionnaires designed to measure self-discrepancy. Other factors were measured using surveys specific to depression, anxiety, activity patterns, disability, pain intensity, and health-related quality of life (QOL). All of the survey tools were self-report (patients answering questions about themselves and how they think, feel, and act.

Avoidance was associated with a lower quality of life and greater disability. The patients who saw themselves as becoming the person they feared or didn’t want to be increased their avoidance of activities that might increase pain.

This study made the point that patient behaviors (whether towards avoidance or overdoing it) have underlying reasons. One of these reasons is the role of self-discrepancy as either a protective or motivating factor. This information might be helpful in understanding how emotions and behavior are driven by how patients see themselves.

You are asking about comparing the long-term effectiveness of chiropractic care for chronic low back pain against the natural history (what happens without treatment). It’s a good question but somewhat difficult to answer. Without a clone of you (one to get the treatment and one who doesn’t get the treatment), there’s simply no way to know for sure.

Many studies have been done examining the benefit of chiropractic care in the acute (recent) case, subacute (one to three months after first onset of pain), and chronic phase (long-term or pain present more than three months). There is general consensus (agreement) now that chiropractic care does reduce pain for acute low back pain. The benefit does not seem to carry over in the medium and long-term time periods.

In a recent review of chiropractic care compared with other conservative treatments, the researchers doing the investigation made note of the fact that there have been no studies comparing chiropractic care with no care (letting nature take its own course).

There’s plenty of room for more study in this area. Finding out if one modality would work better than another or if all are truly needed to get the desired results would be helpful, too. Looking at subgroups of patients (i.e., treating groups of patients differently because of specific characteristics) is another area for future research.

You aren’t the only one who wonders about these things. With the high cost of health care, many medical practices (including chiropractic care) for low back pain have come under closer scrutiny. In a recent study, the type of combined treatment you describe that is usually offered in a chiropractic clinic is the focus. Combined treatment refers to the spinal manipulation along with patient education, massage, heat or cold, exercises, bracing, and pillows. Advice on nutrition and lifestyle changes are also part of the patient education piece.

The researchers asked, does combined treatment work as well (or possibly better) than spinal manipulation alone? How does chiropractic care compare with other interventions? What short-, mid-, and long-term outcomes are seen with combined care? Are there any adverse effects of combined chiropractic care? And finally, how do the results of chiropractic care compare with having no treatment?

Pain, disability, and general health status were used to measure progress. Studies included in the analysis had to describe patients in such a way that comparisons could be made between studies. The treatment or plan of care used had to be clear enough to make the same type of comparisons from one study to the next.

This criteria was met in 12 of the studies reviewed. There was a total of 2887 low back pain patients in those 12 studies. Each study was a randomized controlled trial (RCT) meaning patients were assigned to treatment groups randomly (usually generated by a computer).

After collecting all the data from the 12 studies and making comparisons, there simply wasn’t a significant or measurable difference in results between combined chiropractic care and other interventions when used alone. Other interventions included heat, cold, massage, education, medications, bed rest, and exercise.

Some patients got pain relief faster in the chiropractic care group at the start (short-term) but the improvement in pain over other treatment wasn’t considered statistically significant. At the end (long-term), this edge was no longer present. That’s pain, what about disability? Same story: no significant difference in disability at any point between combined chiropractic care and other treatment approaches.

The final outcome measure (general health) was no different between combined chiropractic care and other types of care in the short- and mid-term. Long-term results weren’t available in any of the studies published so far. That leaves rate of improvement and adverse effects.

Once again, no difference in rate of improvement in the short-, mid-, or long-term. And no major or serious adverse effects of chiropractic care were reported. There were some cases of increased pain and other symptoms with chiropractic care but nothing was permanent or lasted more than a few hours to a few days.

In summary, according to this systematic review, chiropractic care does not provide any long-term benefit over other types of conservative care in terms of pain relief, disability, or general health. Whether or not chiropractic care is better than no treatment has not been explored yet. Comparing a single manipulation with more than one and/or more than one manipulation along with other treatments would be important areas for future study.

It sounds like you are trying to make a decision about whether or not to have surgery for this problem called listhesis (or lateral listhesis to be more precise). You may have heard of a condition called spondylolisthesis where one vertebra (spine bone) slips in front of another. With listhesis, one vertebral bone starts to slide off to the side of the next vertebra. Spondylolisthesis is more of a front-to-back shift of the bones. Listhesis (also known as lateral listhesis is a shift from side-to-side.

When one vertebral bone shifts in any direction, it tends to pull on the nerve tissue. Depending on the location in the spine, the shift could increase pressure on the spinal cord or spinal nerve roots as they exit the cord. The result of compression on these nerve tissues is back and/or leg pain.

Surgery to take pressure off the nerve tissue is often recommended for this problem. And research supports this idea as results are better with surgery for this problem than with conservative (nonoperative) care. Conservative care includes physical therapy, education, and medications (usually anti-inflammatories). You can always try one or more of these but give it a good six months to see the full effect.

It sounds like your surgeon is planning to use the new minimally invasive technique to perform your spinal fusion. Instead of making a long open incision and cutting through all the layers of muscle, tendons, ligaments, and other soft tissues, a smaller cut is made. The long, round tube you saw is inserted through the layers of tissue down to the bone.

The tube has an expandable retractor that pushes away the soft tissues surrounding the area. This gives the surgeon a better view of the area and more room to navigate the surgical tools. At the same time, there is a magnifier on the end of the tube that gives the surgeon a bigger view of the area.

Movement of the surgical tools is further aided by a special type of real-time, 3-D X-ray called fluoroscopy. Fluoroscopy is a moving X-ray giving the surgeon details of the vertebral bones. The entire system gives the surgeon a focused view of the anatomy magnified for easier recognition of the structures.

Knowing anatomy, and practicing identification of the bones, muscles, tendons, discs, joints, and so on using these special surgical tools takes time. But using cadavers (bodies preserved after death for study) and practicing under the supervision of other trained surgeons gives the surgeon a clear idea of what is being seen.

There are many different ways to fuse the spine. The surgeon must get to the spine before performing the actual fusion. The anterior approach (from the front of the body) avoids the spinal cord and spinal nerve roots but involves moving large blood vessels out of the way without damaging them. The <i
posterior approach requires the surgeon to cut through muscles and soft tissues close to the spinal cord and other nerve tissue.

Both the anterior and posterior approaches have definite disadvantages. That’s why the lateral approach was developed. It sounds like you may be having a fusion procedure referred to as a transforaminal lumbar interbody fusion or TLIF. The word “transforaminal” is what is meant by “lateral”.

The TLIF method of lumbar fusion has many advantages. The lateral approach gives the surgeon access to the disc and disc space without applying excess pull or traction on the nearby spinal nerve. With a lateral approach, it is only necessary to remove one spinal joint (rather than the joints on both sides of the spinal level being fused) in order to get to the disc space.

Once the surgical approach and method are selected, then the surgeon decides whether to do this procedure as an open (oTLIF) or minimally invasive (mTLIF). Just as it sounds, an open incision is done by cutting through the skin, muscle, and other soft tissues in order to give the surgeon a full view of the spine.

In a minimally invasive TLIF (mTLIF), a long thin tube is passed down through the skin, fascia, and muscle down to the spine. It is not necessary to dissect (cut through) all these layers of soft tissue. Surgical instruments and hardware (cages, screws) used to fuse the spinal segment are passed through this tubular retractor system.

A minimally invasive approach reduces blood loss during the procedure and postoperative pain afterwards. Hospital stays are shorter with the mTLIF, which means lower costs. Other advantages of the minimally invasive approach have been reported. For example, there is less damage to the muscles and less tissue trauma overall. Fusion rates are equally good between the open and minimally invasive methods with lower costs and complication rates for the minimally invasive technique.

For almost 30 years surgeons have been fusing the lumbar spine using the popular transforaminal lumbar interbody fusion (TLIF) technique. The surgeon approaches the spine from the side rather than from the front (anterior approach) or the back (posterior approach).

The procedure was first done with an open incision approach called an open transforaminal lumbar interbody fusion or TLIF. This procedure required cutting through the spinal muscles to get to the spine. Trauma to the muscles and soft tissues with this method created lots of complications with infection, bleeding, and poor wound healing.

Over time, surgical technology and equipment have improved and advanced so that the procedure could be done as a minimally invasive (MI) approach. Minimally invasive means a very small incision is made.

In a minimally invasive TLIF (referred to as mTLIF), a long thin tube is passed down through the skin, fascia, and muscle down to the spine. It is not necessary to dissect (cut through) all these layers of soft tissue. Surgical instruments and hardware (cages, screws) used to fuse the spinal segment are passed through this tubular retractor system.

The surgeon also uses 3-D navigational (surgical) tools that allow him or her to see the correct pathway and avoid injury to nerve tissue. Fusion rates are fairly equal between the open and minimally invasive approaches. And according to a recent meta-analysis, the complication rate for the minimally invasive transforaminal lumbar interbody fusion is also less.

More and more adults are living longer and reaching that magical age of 80, which puts them in the octogenarian group of seniors. But aging doesn’t always come without a price. Often, the effects of degenerative spine disease create painful disabilities that interfere with enjoyment in life.

At 82, your father has lived just slightly past the average expected lifespan for an American male. But that isn’t a death certificate — many people (both men and women) are living well beyond 90 these days! Surgeries like spinal fusion that wouldn’t have been considered possible even 20 years ago are now available.

Improved surgical techniques, advances in technology, and minimally invasive procedures have opened up many more treatment possibilities for seniors than ever before. Of course, your concerns are valid. Any surgery (including spinal fusion) has risks. But surgeons are better able today to weigh the risks against the benefits and offer patients options like surgery.

Age is no longer the most limiting factor. Yes, they do take the patient’s age into consideration. But they also look at bone quality and number of levels that need fusion. General health is evaluated including the presence of other health problems such as diabetes, high blood pressure, heart disease that could cause complications. If there are unreasonable risks of complications, then surgery is not advised.

Quality of life, independence, and staying active are three important aspects of life in later years. Older adults like your father with disabling, degenerative back and/or leg pain, don’t have to give up. It sounds like his surgeon thinks he is a candidate for a procedure like the minimally invasive lumbar spinal fusion. If your father will agree, it might help you to talk to his surgeon about the specific risks and benefits for your father. With more information, you might see it in an entirely different light.

More and more older adults are passing that 80 year old mark that puts them in the category as an octogenarian. Degenerative disc disease and other degenerative conditions of the spine are putting a hamper on even the most active seniors. But the good news is they don’t have to suffer.

Studies show that spinal fusion in the older crowd can be done safely and effectively. With the newer technologies and minimally invasive surgeries, patients are in the hospital fewer days. They are more likely to go directly home rather than to a skilled nursing facility. With less blood loss, complications are down (including fewer deaths).

To help illustrate the advantages of minimally invasive lumbar fusion, a recent study from Spine Midwest out of Jefferson, Missouri compared patients 80 and older having lumbar spinal fusions. Half the group had an open incision procedure. The other half was operated on using a minimally invasive approach. Minimally invasive means a smaller incision is made. Using a special retractor system, the muscles and soft tissues can be pulled aside instead of cutting away from the spine.

The hospital stay was four days shorter for the minimally invasive group. Only three of the patients who had the minimally invasive approach were sent to skilled nursing facilities. Those who had the open posterior lumbar interbody fusion (PLIF) were all discharged to the skilled nursing facility for further care and rehab. They were unable to return home.

The PLIF group had more serious complications such as infection, poor wound healing, and bone fracture. Even the number of deaths in the first six months after surgery was higher in the open PLIF group (six deaths in the PLIF group compared with only one in the minimally invasive group). Infection and blood loss were the reasons most patients died.

The surgeons also found that with the minimally invasive extreme lateral approach to fusion, they could insert a larger implant into the disc space compared with the posterior approach. A larger implant helps maintain the proper disc height between two vertebrae and improves spinal alignment. And with larger implants and greater stability, they could reduce what might have been a multi-level fusion down to only one-level.

Their results showed once again that surgical treatment for older adults suffering from severe, chronic low back doesn’t have to be withheld because of their age. Careful selection of patients and use of minimally invasive techniques can make the difference between a life of pain and suffering and maintaining an active, pain free quality of life. That’s important if you are 80+ years old but still have many more good years to live!

This would be a good question to ask your surgeon. Usually, the surgeon wants to gain access directly over the area being operated on. This pathway down to the L34 spinal segments is called the surgical corridor. Making an incision at that level is most likely the way it will be done. Every effort is made to avoid cutting into muscles, tendons, ligaments, and other soft tissues whenever possible.

As a result of studies published on this topic, surgeons have started to adjust the way this procedure is done. For example, the procedure was originally done using an incision along the middle of the spine. But this midline approach cut through an important spinal muscle (the multifidus). Muscle weakness resulted in loss of function of this important spine stabilizer.

Surgeons started making incisions on either side of the spine in order to avoid cutting the attachment of the multifidus muscle to the spinous process. The spinous process is the bump you feel along the spine, often referred to as your “back bone”.

A second change that has come about is the use of tubular retractors used to hold the soft tissues apart after the incision is made. The retractors are attached to the table. There are two advantages to this tool: 1) a surgical assistant no longer has to hold the retractors steady for the entire length of the operation and 2) pressure on the soft tissues, nerve, and blood vessels can be minimized.

These new table-mounted retractors are a great improvement over the self-retaining retractors used before. During long periods of retraction, pressure from the table-mounted retractors can be released from time to time. This feature reduces force and load on the muscles and tendons and helps maintain good blood supply to those areas. With shorter retraction times and periodic release of pressure, there are also fewer nerve injuries contributing to muscle weakness.

As you have discovered, the good news is that long, open incisions to perform surgery on the lumbar spine (low back area) are no longer needed. New surgical tools and techniques make it possible to complete decompression and fusion procedures with several smaller incisions. This new approach is referred to as minimally invasive surgery (MIS).

The main advantage of the minimally invasive approach is less trauma to the bones, muscles, tendons, and other soft tissues of the spine. There is less bleeding and a faster recovery time. But even so, this technique requires the use of retractors to pull the tissues apart in order to give the surgeon access to the spine.

Even with a smaller incision, there is still the risk of trauma (cutting or crushing) to the soft tissues when using a minimally invasive approach. There is a learning curve that may contribute to problems. Studies show that surgeons have much greater success as their level of experience with this procedure increases. Reports of complications and problems are much higher at the beginning when surgeons are just starting to use this method.

Efforts are being made to find alternative ways to use the minimally invasive approach in order to do away with the kind of complications and problems you experienced. Based on studies done so far, change in location of the incisions (from the middle of the spine to either side of the spine) and safer ways to retract the soft tissues are now advised.

Anything that can be done to reduce trauma to the soft tissues will provide a better result with fewer complications and problems. Patient can still benefit from the minimally invasive procedure without the added loss of spinal stability you had as an unfortunate side effect of the technique.

Before performing the fusion, your surgeon will review problems that can develop as a result of any surgery and specifically for this particular procedure. Perhaps you have already heard some of this but let’s start with general complications. There is always a risk of blood clots and infection with any procedure. Poor wound healing or delayed wound healing is also possible.

Some complications are strictly dependent on the type of surgery being performed. In the case of a lumbar fusion, failure to form a solid bone fusion can result in movement at the spinal segment that is not supposed to move. If hardware such as metal plates, cages, screws, or pins are used, they can come loose and migrate or move.

Each approach to spine surgery (anterior from the front, posterior from the back, or lateral from the side) comes with its own potential problems. For example, entering the spine from the back increases the risk of dural tears, nerve damage, and even paralysis from spinal cord injury.

Dural tears refer to damage of the very thin lining around the spinal cord. This can be a serious complication resulting in cerebrospinal fluid (CSF) leaking out. Cerebrospinal fluid is the fluid that bathes and protects the brain and spinal cord. Any leakage can lead to much more serious problems. Dural tears were most often reported in association with posterior lumbar fusion.

Trying to reach the spine from the front of the body means moving large blood vessels like the aorta out of the way and avoiding organs such as the kidneys, bladder, or intestines. The risk of bleeding is much higher with an anterior approach to fusion.

A lateral approach means the surgeon enters the body and spine from an angle between the front and back. A new twist on reaching the spine from the side is called the extreme lateral approach. The surgeon comes in from the front and side of the spine. A special tube is placed through the lateral abdomen, through the psoas (anterior hip muscle), and to the spine. With this portal (pathway), the surgeon avoids major blood vessels, organs, the spinal cord, and nearby spinal nerve roots.

There can still be some problems with the lateral approach. The most likely one associated with the extreme lateral approach is thigh pain and muscle weakness from a psoas abscess. The psoas muscle is a hip flexor that the surgeons pass their instruments through when using the extreme lateral approach. Fortunately, most patients who have this problem recover fully within the first two months after surgery.