FAQ Category: Spine

I have pain that is radiating to both my toes.  My doctor says that I have spinal stenosis and that I need a surgery.  He is recommending a fusion and wants to take some of my hip bone to help stabilize my spine.  Isn’t this excessive?  Why doesn’t he just use some screws?

A recent study looked into this very question and found that it is slightly more cost effective to perform a noninstrumented fusion, or a fusion using a person’s own tissue to stabilize the fusion, than an instrumented fusion This cost effectiveness is taking into account the possibility of need for re-surgery, potential complications following surgery like infection, and medication changes.

What is the difference between a decompression and a laminectomy?  I am in my 70’s and have spinal stenosis and am not thrilled about the prospect of surgery.  

A laminectomy is a type of decompression surgery.  During a laminectomy, the lamina bone is removed which is typically encroaching on the nerve.  The lamina is a bone that bridges the spinous process (pokey part of your spine) and the transverse process, or the side of the vertebra.  If you are not excited about surgery and have not yet done so, physical therapy can often help to minimize symptoms if not alleviate them completely.

I am a 60-year-old male with pain shooting down the backs of both of my legs.  My MRI says that I have lumbar stenosis and my surgeon wants to operate.  What are the risks associated with this surgery?  I have heard some real horror stories.

Any surgery has associated risks.  Many of these can be avoided with proper procedures.  Overall, recent data shows the risk for sentinel events or avoidable mistakes to be .8 per 1000 cases in the U.S., so overall the risk is fairly low.  That being said however, you should have a discussion with your surgeon regarding your concerns and he can give you specifics regarding risks of your particular surgical procedure.

Why am I getting shorter with age?

The exact process to explain the shortening of your spine is speculated in the spine-related research. Two proposed explanations include a cumulative micro-trauma theory at the disc-vertebra interface that creates an inflation process and merging of the cartilage and bone. The second theory suggests a gradual tensioning of the disc pulling on the vertebra that eventually triggers a process of converting the cartilage to bone.

How quickly can I expect to lose my height?

The current research can validly extrapolate that the average middle-aged man is indeed getting shorter, but by only .13 millimeters per year on an annual average. For example, if you are 5 feet 8 inches at age 45, you could safely expect to loose less than an inch by your 60th birthday.

What is the take away from this study?

If you are someone who has a BMI of 25 and above and have chronic low back pain (12 weeks or longer, consistently) reducing your BMI may not change your pain or disabilty. You should contact a skilled health care provider for proper evaluation and assessment of your symptoms.

What can I do to decrease may chances of getting lower back pain?

In this study they found, that for the average overweight American a modest increase in activity time by 17.6 minutes a day (123 minutes a week) reduces risk of lower back pain by 32 per cent and for morbidly obese people an increase of 2.1 minutes can make substantial difference. An example would be adding more time in moderate activity (walking) into your day.

What can I do about my lower back pain and weight?

Exercise has been shown to help both conditions. Speak with your physician or a qualified clinician about your back pain and weight. They can assist you in getting started with a safe, gradual and successful exercise program.

Should I trust that my therapist or practitioner is using a high-quality, research supported methods for treating my back pain?

This is a good question to ask your physical therapist, acupuncturist, masseuse, chiropractor or selected practitioner. A rigorous evidence-based education should provide your therapist of choice with the skills, tools and the body of research to support why they are selecting each treatment. It would not be unwise to have a brief discussion on the rationale behind their treatment choice.

Comparing physical therapy, chiropractic, and osteopathy, what nonsurgical treatment for chronic low back pain helps the most?

In a recent meta-analysis by Dr. Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, he determined in the comparison that getting your spine manipulated in the first six weeks has little influence on the outcome of shortening the duration of your acute pain. Five types of spinal manipulation providers (osteopaths, physical therapists, chiropractors, allopathic medical physicians, and bonesetters) were compared. Spinal manipulation by a physical therapist was found to be most effective, and most variable, in treating both acute and chronic back pain.

Does spinal manipulation help improve my low back pain?

This largely depends on how wide of a search beam you project into the years of research. For example in a recent meta-analysis by Dr. Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, found very little supportive evidence in his meta-analyses on comparative effectiveness of various manual therapies, that include spinal manipulation in his review of the existing literature. “A comparative effectiveness meta-analysis” was performed to compare the relative effectiveness of various spinal manipulation treatments (from the ancient bonesetter to the modern back cracker), medical management (READ: drugs, injections, etc), physical therapy, and exercise for acute (less than a month) and chronic (more than 3 months) nonsurgical management of low back pain.

The good news is most pain originating from the muscles and joint in the
human body is self-limiting, meaning slowing down, protecting your
injury, and letting the body heal will often suffice. Research supports the notion that sixty to seventy per cent of acute low back pain settles in six weeks without any medical treatment. Chronic low back pain sufferers get better in a year without treatment 40 to 70 percent of the time. Pain whether short-term or long-term is indubitably unpleasant, so why suffer any longer than you have to if effective treatment is available.

I am a fourth-generation of back pain sufferers. My wife’s family doesn’t seem to be bothered by this problem at all. But my brothers, uncles, father, grandfather, great grandfather (and myself) have all dealt with this issue all of our lives. Has anyone come up with a reason for this and/or a solution??

Despite spending more than 86 billion dollars a year on treatment for back pain in the United States, Americans continue to struggle with this problem. It has become a national epidemic. Twenty-five years ago, prominent medical doctors called for new ways to diagnose back pain and measure outcomes of treatment. Today, very little has changed. In fact, there is evidence to suggest that Americans with spine problems are worse than ever before.

What have we learned from these last 25 years of scientific inquiry and study? In a recent editorial, Dr. R. G. Hazard from the Department of Orthopaedics at Dartmouth Geisel School of Medicine offers some perspective on this question that may be of interest to you.

First, it should be noted that in 1987, researchers started using scientifically validated measures of low back pain and subsequent disability. And second, the focus shifted from looking for a specific pathologic reason for the back pain to an understanding of the biopsychosocial factors accompanying back pain.

Stress at home and at work, feelings of being out of control of life situations, and self-perceptions were some of the biopsychosocial aspects mentioned at that time. Along with these two new approaches came awareness that treatment at that time was driven by patient complaints, distress, and behavior.

On the medical side of things, it is clear that finding a clear and accurate diagnosis to label each patient is often impossible. Imaging studies with X-rays, CT scans, and/or MRIs are often “negative” (no findings of anything “wrong” in the bones or soft tissues). Even knowing this, physicians continue to use steroid injections, narcotic medications, and surgical procedures to address the problem of back pain.

Not only that, but when clear-cut diagnoses can be made (e.g., lumbar disc herniation), patients with this diagnosis respond differently to treatment. Finding one single approach that works for everyone just hasn’t happened. Some experts even recommend providing patients with amenu of (treatment) options and letting them pick their treatment of choice. This idea is labeled a shared decision-making model. However, results so far have not been any better than with physician-prescribed treatment.

So, where are we today? There is a shift toward emphasizing ability (function) rather than disability (limitations). Instead of focusing treatment on pain relief, rehab programs aim to improve flexibility, endurance, and strength in the presence of ongoing pain. If pain is relieved in the process, well then, so much the better.

Recovering function (daily activities) and the ability to return to work are the main goals of today’s treatment for chronic low back pain. This approach is referred to as the Goal Achievement Model for the treatment of low back pain. Efforts to reduce disability from back pain based on patient goals is a new way of thinking about the problem of back pain.

Concepts such as setting “acceptable targets” and forming “patient-based action plans” are the new words attached to current treatment ideas about chronic low back pain. Health care providers can still use the biopsychosocial model (working with patient values, attitudes, and beliefs) while the patient gets the results he or she is after. This approach has worked quite well with other health problems (mental health and chronic diseases that lead to severe disability). In time, we will see how patients with low back pain fare.

I am very unhappy with the way my doctor and my physical therapist are treating the problem of my back pain. It’s like they are in cahoots with each other. No one talks to me about my pain. It’s all about “doing more with pain” or “getting back to work despite the pain”. All I can focus on is how much it hurts and the pain is why I can’t do more. What can I say or do to get their attention and more important to me: their response?

Twenty-five years ago, the focus shifted from looking for a specific pathologic reason for low back pain to an understanding of the biopsychosocial factors accompanying back pain. By then, it was clear that finding a clear and accurate diagnosis to label each patient was often impossible. Imaging studies with X-rays, CT scans, and/or MRIs are often “negative” (no findings of anything “wrong” in the bones or soft tissues).

Stress at home and at work, feelings of being out of control of life situations, and self-perceptions were some of the biopsychosocial aspects mentioned at that time. An awareness that treatment at that time was driven by patient complaints, distress, and behavior started to change things.

There was a shift toward emphasizing ability (function) rather than disability (limitations). Instead of focusing treatment on pain relief, rehab programs today aim to improve flexibility, endurance, and strength in the presence of ongoing pain. If pain is relieved, well then, so much the better. But pain relief is no longer the main treatment objective.

Recovering function (daily activities) and the ability to return to work are the main goals of today’s treatment for chronic low back pain. This approach is referred to as the Goal Achievement Model for the treatment of low back pain. Efforts to reduce disability from back pain based on patient goals is a new way of thinking about the problem of back pain.

Concepts such as setting “acceptable targets” and forming “patient-based action plans” are the new words attached to current treatment ideas about chronic low back pain. Health care providers can still use the biopsychosocial model (working with patient values, attitudes, and beliefs) while the patient gets the results he or she is after. This approach has worked quite well with other health problems (mental health and chronic diseases that lead to severe disability).

Pain can be a real deterrent to accomplishing anything from the simple task of brushing your teeth to getting a good night’s rest. Clinical and research efforts are underway in an attempt solve the dilemma of chronic low back pain. In today’s modern practice, you can expect to find yourself in a goal-oriented program that takes into consideration physical, emotional, psychologic, social, and spiritual aspects of care.

Lowering costs, meeting patient expectations, and providing successful outcomes and patient satisfaction are all important but complex factors that must be taken into consideration. Pain relief is part of that approach but only a small piece of the pie. Give this approach a fair try and see what you might be able to accomplish in the long-run rather than having a short-term focus on pain relief. It can be a challenging way to treat back pain (for the patient!) but still very effective.

Have you ever heard of a double-door laminoplasty? This is what the surgeon is saying I should have done for my severe neck problems. My formal diagnosis (at least on paper) is cervical myelopathy. The procedure won’t touch the bone spurs that are causing the problem, so how is that going to help me?

Problems in the neck that can cause severe pain, numbness down the arms, and sometimes even paralysis are referred to as cervical myelopathy. Cervical myelopathy can be caused by several changes that occur over time. Bone spurs along the front of the vertebrae are included in that list. Ossification (hardening) of the ligament that goes down the back of the spine (posterior longitudinal ligament or PLL) is a second potential cause of cervical myelopathy. Another is the herniation of several discs in the cervical spine (neck) with resultant spinal canal stenosis (narrowing caused by disc material pushing into the canal).

A successful treatment for this problem is laminoplasty surgery to take pressure off the spinal cord and stabilize the spine. A double-dooor laminoplasty splits the spinous process down the middle and then opens them up like french doors or two windows that open towards you. The spinous process is the bone along the back of the vertebra that you feel as a “bump” down the spine.

The effect of this procedure is to allow the spinal cord to shift backwards or “move away” from the front of the spine. The result is to take pressure off the spinal cord (called decompresson). Relief of painful (or other) symptoms with improved motion and function can be expected. This posterior approach has more advantages than disadvantages when there are protruding discs at several levels.

Likewise, this posterior laminectomy works well when there are bone spurs along the front of the vertebral bones or a stiff, tight ligament along the back of the vertebrae. With the posterior decompression, pressure is removed from the spinal cord without removing the discs, spurs, or ligaments. With this surgical approach, normal structures (ligaments, muscles) are preserved so there are fewer complications related to the operation.

The surgeon who is going to treat my neck problem (I’ve been diagnosed with cervical myelopathy) told me my cervical spine is “too straight.” So I might not be able to have the surgical procedure he originally had in mind (double-door laminectomy). What does having a spine that is too straight have to do with it? I’m confused.

You will want to ask your surgeon this question to get the clearest answer possible. But perhaps the results of a recent study will help provide some helpful information.

First of all, as you now know, problems in the neck that can cause severe pain, numbness down the arms, and sometimes even paralysis are referred to as cervical myelopathy. Cervical myelopathy can be caused by several changes that occur over time. The first is ossification (hardening) of the ligament that goes down the back of the spine (posterior longitudinal ligament or PLL). Another is the herniation of several discs in the cervical spine (neck) with resultant spinal canal stenosis (narrowing caused by disc material pushing into the canal).

A successful treatment for this problem is laminoplasty surgery to take pressure off the spinal cord and stabilize the spine. In the study we mentioned, surgeons from Korea examined the effect of doing a double-dooor laminoplasty in 58 patients diagnosed with cervical myelopathy. This type of surgery splits the spinous process down the middle and then opens them up like french doors or two windows that open toward you. The spinous process is the bone along the back of the vertebra that you feel as a “bump” down the spine.

The effect of this procedure is to allow the spinal cord to shift backwards or “move away” from the front of the spine. Many people who have cervical myelopathy have a cervical spine that is too straight referred to as kyphotic. The natural (normal) alignment of the bones in the neck is a slight backward (lordotic) curve.

With these other degenerative changes (disc herniation, ossification of the ligaments), the straighter-than-normal (kyphotic) cervical spine can put enough pressure on the spinal to cause cervical myelopathy. But not everyone has cervical kyphosis associated with symptomatic cervical myelopathy. Some patients have the more normal neck curve.

The question this group of researchers asked was whether or not this kyphotic alignment would compromise surgical results. There is less room for the spinal cord in the canal when the spine is so straight. The posterior shift made possible by the laminoplasty may place the already (posteriorly) shifted spinal cord too far back to achieve (and maintain) the positive benefit of the procedure.

They studied 58 patients with cervical myelopathy who were all treated with this double-door laminoplasty. Patients ranged in ages from 32 to 74 years old. X-rays were used to measure the amount of cervical spine curvature. The patients were divided into two groups: those with cervical lordosis (normal curvature) and those considered “nonlordotic” (abnormal curve).

Patients with 10 to 15 degrees of lordosis were in the lordotic group. Angles less than 10 degrees were nonlordotic. Anyone with more than 15 degrees of kyphosis was not included. They found that the degree of lordosis didn’t make any difference in results. In other words, preoperative cervical alignment (how straight or curved the neck was) was not a factor in how well patients maintained the benefits of the double-door laminoplasty procedure.

The authors noted that there are many different ways to perform a laminoplasty to decompress the spinal cord in the presence of cervical myelopathy. This posterior approach has more advantages than disadvantages when there are protruding discs at several levels. Likewise, this posterior laminectomy works well when there are bone spurs along the front of the vertebral bones or a stiff, tight ligament along the back of the vertebrae. With the posterior decompression, discs, spurs, and ligaments remain untouched.

Cervical nonlordosis (i.e., the presence of kyphosis or reverse cervical curve) was once considered a reason to avoid the double-door laminoplasty. The results of this study suggest preoperative alignment may not be as important as some other factors.

For now, it looks like laminoplasty can be done on patients with milder forms of cervical kyphosis. Knowing how your curve measures (i.e., how severe is the kyphosis or “straight neck”) may help explain why you may not be a candidate for this procedure.

It is my job at our local hospital and medical center to keep abreast of all clinical practice guidelines (CPGs) for orthopedic conditions. Most recently, I heard that the CPGs for lumbar stenosis were updated and published. Do you have a place on your website where I can access this information?

The 2006 clinical practice guidelines for degenerative lumbar spinal stenosis (DLSS) have indeed been reviewed (based on published studies up to and including July 2010) and revised. In a recent article from The Spine Journal, members from the Degenerative Lumbar Spinal Stenosis Work Group of the North American Spine Society (NASS) provided a summary of the new guidelines. This update is now considered the most recent evidence-based clinical practice guideline (CPG) on LSS.

Sixteen questions were posed and answered in the 2006 Clinical Practice Guidelines. The questions covered topics ranging from natural history of LSS to diagnosis and treatment of this condition. All questions were reviewed and responses provided in this 2013 update. The levels of evidence were indicated for each response using grades labeled A (recommended), B (suggested), C (an option), and I (insufficient evidence to recommend for or against).

The working group also provided a consensus statement when there wasn’t enough reliable evidence to provide a guideline. This consensus statement is the opinion of the group based on all currently available evidence and expert opinion. Here is a sampling of the questions and some of the updated responses:

  • What is the best working definition of degenerative lumbar spinal stenosis (DLSS)?
  • What is the natural history of symptomatic DLSS?
  • What are the most appropriate diagnostic tests for DLSS?
  • Does medical treatment improve results (compared to the “do nothing” approach)?
  • What happens in the long-term (four to 10 years) with surgical treatment compared with conservative care?

    No grades of recommendation were available for the first two sample questions. Instead, the Working Group provided consensus statements. In the case of the definition and natural history of lumbar spinal stenosis, they described the condition as follows: Degenerative lumbar spinal stenosis describes a condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal.

    The group agreed that the natural history (what happens over time) with this condition is a picture of mild to moderate symptoms (e.g., low back, buttock, and/or leg pain, difficulty walking, fatigue). About one-third to one-half of all affected adults will get better (with or without treatment).

    Physicians cannot really rely on patient history and reports of symptoms to make an accurate diagnosis. Pain that is not made worse when walking is probably not caused by stenosis. MRIs provide the best opportunity for identifying the characteristic narrowing of the spinal canal or nerve root impingement typical of lumbar spinal stenosis. Evidence to support these statements was listed as a Grade B (suggested). Evidence regarding other types of diagnostic testing (e.g., CT scans, electrodiagnostics, electromyography, motor-evoked potential) is also reviewed and updated.

    Many treatments considered for lumbar spinal stenosis such as acupuncture, bracing, traction, electrical stimulation, and steroid injections are considered options (Grade C). But the evidence for or against each one is limited by insufficient research/evidence. The Working Group identified these areas as in need of further research in the future.

    Surgery can improve the symptoms and quality of life in carefully selected patients. The choice of surgical procedure (e.g., decompression alone, decompression with spinal fusion, fusion with or without instrumentation) is based on age and type and severity of symptoms. Patients with moderate to severe symptoms are considered most often for surgery based on current evidence (Grade B; suggested).

    To read the full report and review all the references, you can go to the North American Spine Society’s website at www.spine.org.

    • My 83-year-old mother was recently diagnosed with spinal stenosis. She mostly suffers from back pain and sometimes pain down her leg. In order to avoid the pain, she stays bent forward most of the time. Would a brace help her?

    Lumbar spinal stenosis in this age group is usually caused by the natural degeneration of the spine over time. The condition is described as a narrowing of the space available for the spinal cord, nerve roots, and blood vessels in the spine. The lumbar spine (low back area) is the region affected most often by this condition.

    Bending forward helps take the pressure off the neural segments (spinal cord, spinal nerve roots) but this compensatory posture has some obvious drawbacks. The use of a corset or brace has been shown to aid patients by decreasing the pain, thus making it possible to stand upright and walk unassisted. However, once the brace is removed, the benefits are gone as well. In other words, wearing a brace is not a long-term answer.

    Other types of treatment have been tried and results reported. Acupuncture, electrical stimulation, and traction are just a few examples of treatments investigated. But not everyone responds well and there is insufficient evidence to direct and guide who is most likely to respond to each treatment type.

    Surgery is advised for patients with moderate-to-severe symptoms that persist over time. But keep in mind that patients with mild-to-moderate symptoms have a 30 to 50 per cent chance of improvement over time without treatment. Symptomatic relief with short-term bracing is considered acceptable, especially if there is a chance for symptom resolution without surgery.