Spine - eOrthopod.com

I’m recently retired and looking to take up a new sport — possibly golf. I’m looking for any suggestions you might have for an “older adult” (I’m 72-years-old) that might help me stay fit without injuring myself while learning a “new game.”

One-fourth of the 26 million golfers in the United States is over the age of 65: welcome to the ranks! Experts agree that avoiding injury among golfers begins “before the golfer ever sets foot on the course.” Prevention education is the most important way to prevent injuries from ever occurring in the first place.

Golf-specific movement screening, performance training, and early rehabilitation for golf-related injuries are extremely important to aid in injury prevention, quick recovery after an injury, and prevent further injury or injury recurrence.

Lumbar (low back) pain is the most common symptom in golfers who stick with the sport over a long period of time. The repetitive motion, rotation, and strain from the golf swing create pressure on the discs of the spine. The increased load and force on the spine are intense enough to damage muscles, joints, discs, and even the ribs. More than one-third (34.5 per cent) of all injuries among golfers results in low back pain.

And in the older adult, the effects of aging decrease spine motion and the ability to handle forces placed on the spine during the golf swing. What can be done to prevent these common low back conditions in golfers? Here are a few suggestions:

Golfers with low back pain should be encouraged to seek help early on rather than wait and see if it goes away. Correction of swing faults, muscle imbalances, or other improper golf techniques can aid in prevention of worsening symptoms or repeated injury.

Breath control during swinging or putting is recognized as an important part of injury prevention in this sport.

Proper clubs fit to body specifications is a must for each individual player.

Simple things can make a difference: push the golf cart rather than pulling it, use a golf bag with dual straps rather than a single strap, and maintain proper body weight for size (being overweight is a risk factor for low back injury).

You may want to see a sports physical therapist for some help early on in your new golf “career”. The physical therapist can assess your range-of-motion, postural alignment, movement patterns, and golf swing mechanics that need correction. Core stability training is an important part of a training or exercise program for golfers at any level (amateur to professional).

According to one physical therapist who treats golf injuries, avoiding injury among golfers begins “before the golfer ever sets foot on the course.” Prevention education is the most important way to prevent injuries from ever occurring in the first place. You are very wise to seek counsel and advise right from the start!

I’m looking for any information you can offer on how to improve my golf swing. I’m starting to have some low back pain and my golfing buddy suggested trying this web site. Evidently, he found some useful tips that helped him last year.

Lumbar (low back) pain is a common symptom in most golfers who stick with the sport over a long period of time. The repetitive motion, rotation, and strain from the golf swing create pressure on the discs of the spine. The increased load and force on the spine are intense enough to damage muscles, joints, discs, and even the ribs. More than one-third (34.5 per cent) of all injuries among golfers results in low back pain.

What can be done to prevent these common low back conditions in golfers? A recent article by physical therapist, Christopher Finn, from the Par4Success Golf Performance Center in Durham (North Carolina) suggests the following:

Breath control during swinging or putting is recognized as an important part of injury prevention in this sport.

Proper clubs fit to body specifications is a must for each individual player.

Core stability training is an important part of any exercise program for golfers. Corrections may be made depending on whether you use the classic swing versus the modern swing. The top three swing faults that can lead to low back pain include hips coming forward into the hand space during the swing, use of the wrong back muscles during the golf swing, and an incorrect spine angle during follow-through.

You may benefit from a screening evaluation by a physical therapist. The physical therapist can assess individual golfers for range-of-motion, postural alignment, movement patterns, and golf swing mechanics that need correction. Specific treatment techniques vary depending on the underlying problem (e.g., facet or spinal joint irritation, disc herniation, spondylolysis or stress fracture of the spine).

I am a Doctor of Physical Therapy (DPT) starting my first job in a spine center. I will probably go on to do an additional year of fellowship training. But until then, I will be doing self-study. I use many of the materials on your website to prepare for my patients each and every day. Right now I’m reading all the material I can find on disc herniation and radiculopathy. Is there anything new or different I should know about in this area? Any new articles you recommend I should read?

There is a new study from physiotherapists in New Zealand that caught our attention and may be one that you would appreciate. They showed that current motor, sensory, and reflex testing used to diagnose disc herniation and specific level of pathology may not be as accurate as previously thought. In fact, after pooling all the data together and analyzing the studies published so far, it looks like the accuracy value of the tests is poor at best.

After searching six of the most relevant electronic databases, they found 14 studies that matched their inclusion criteria. Their search history, search strategy, and algorithm (flow chart) for the studies was presented as an easily readable diagram. Study characteristics (e.g., author names, tests reported, type of physician examiner, herniation type and level) were presented in an easy-to-read table.

An in-depth description of the problems encountered with each study was provided. This helped explain why the neurologic testing to detect lumbar disc herniation and spinal nerve root involvement is not reliable enough to become a standardized test. Here’s a quick summary:

Most of the patients included in the studies had chronic pain with both sensory and motor function disturbances. This makes it more difficult to identify one test that would satisfy all diagnostic criteria.

Chronic pain patients often reduce their activity level and become deconditioned. This patient factor makes it difficult to tell clinically (without electrodiagnostic testing) when weakness is from nerve compression and when it is from deconditioning.

Sensory, motor, and reflex testing was not always consistently performed and/or reported among the various studies published.

The decision to do surgery was not clear in many cases. A clear, consensus- or evidence-based protocol for determining when surgery was needed does not exist.

Half of the studies did not describe testing procedures. For those studies that did describe the tests done, the way in which the tests were performed was not standardized (i.e., not the same from one study to the next).

It is known that the pathology and mechanism of disc herniation can be very complex. As you know, back pain with leg pain caused by disc herniation is a complex problem and not one that is easy to diagnose. People have different responses and symptoms from the same level and degree of herniation. Sometimes there are overlapping symptoms from more than one spinal level. Even when electrodiagnostic tests are done to confirm nerve involvement, severe disc herniation can be present with no signs of weakness or sensory changes.

Currently, there are no neurologic clinical tests that have been shown to conclusively diagnose disc herniation based on the presence of radiculopathy (symptoms from compression on a spinal nerve root). Physicians (and physical therapists) must rely on the patient’s history, physical examination (including specific neurologic tests), and imaging studies such as X-rays, MRIs, and CT scans.

It would be helpful for examiners evaluating patients with back and leg pain if they knew which clinical tests are the most accurate and reliable. This is especially true if it turned out that one neurologic testing procedure could provide good overall diagnostic accuracy. Future studies are needed to find and standardize clinical tests that are valid and reliable in accurately diagnosing nerve root irritation (radiculopathy) associated with disc herniation.

I think I have back and leg pain from a disc problem. But I can’t seem to get a clear ‘yes’ or ‘no’ (do I or don’t I have a herniated disc) from my doctor. Is it really so tough to figure out? Maybe I should see someone else. What do you think?

Accurate diagnosis of disc herniation can definitely be a complex and challenging process. There is no cookie cutter approach that is reliable. This is because the pathomechanics and pathophysiology of nerve root irritation causing leg pain, numbness, and/or weakness (referred to as radiculopathy) is complex.

For example, two patients can have the same type of disc herniation with pressure on the spinal nerve root from the bulging disc and still have very different symptoms. In fact, the pain patterns and symptom presentation for lumbar disc herniation is often quite variable.

There are several separate components of the problem that must be determined: is there a disc herniation and if so, what level? Is the disc compressing or chemically irritating one (or more) spinal levels? And again, if so, what level(s)?

Currently, there are no neurologic clinical tests that have been shown to conclusively diagnose disc herniation based on the presence of radiculopathy (symptoms from compression on a spinal nerve root). Future studies are needed to find and standardize clinical tests that are valid and reliable in accurately diagnosing nerve root irritation (radiculopathy) associated with disc herniation.

For now, the physician must rely on patient history (what you tell him/her happened and what are your symptoms) along with the results of clinical tests, electrodiagnostic tests, and imaging studies. Even when electrodiagnostic tests are done to confirm nerve involvement, severe disc herniation can be present with no signs of weakness or sensory changes. Sometimes even with all that information, it’s still not entirely clear what the problem is.

Patients who have surgery don’t always obtain relief from their symptoms so the decision to recommend surgery is not made easily or lightly. Conservative care is almost always advised. The physician follows the patient to see what kind of response occurs with nonoperative care. Even this information is diagnostic in nature.

It is possible that you might find another physician who would be more assertive and certain about your diagnosis. And there is nothing wrong with seeking out a second (or even third) opinion (especially if you are facing the possibility of spinal surgery). But give yourself some time to let nature take its intended course (healing) while you pursue a course of recommended self-care via the conservative approach.

I am not a religious person but I know there are religious groups who do not allow blood transfusions. I am scheduled for spinal surgery (fusion) and would like to request no blood transfusion, too. Can I do this without being part of an organized religion?

As a patient and health care consumer, you have the right to make requests of this nature regardless of religious orientation or religious affiliation. Your surgeon will work with you to answer your concerns and meet your needs. But he or she will always keep your safety as number one when making decisions before, during, and after surgery.

During surgery steps can (and will) be taken to minimize blood loss. These measures can include 1) positioning you in such a way as to elevate the area of blood loss, 2) use of a tourniquet, 3) gentle handling of tissues, and 4) minimally invasive technique or MIS (instead of an open incision). The traditional open incision involves cutting through the many layers of spinal muscles and other soft tissue structures to gain access to the vertebral bones.

With minimally invasive surgery (MIS), a tube-shaped instrument is passed down through the soft tissues between muscle groups. The soft tissue structures are pushed aside without cutting them. This technique reduces the risk instability from damage to muscles, tendons, ligaments, and bone. MIS also makes it possible for patients to get up and moving again sooner, allowing for faster recovery. There are also surgical instruments that minimize blood loss such as the harmonic scalpel, argon beam and radiofrequency assisted thermal ablation.

Just before surgery several units of blood can be removed and replaced with a crystalloid or colloid solutions so blood volume is maintained. This process is referred to as Acute Normovolemic Hemodilution (ANH). It can be used when blood loss is expected. With ANH, any fluid lost during surgery contains fewer red blood cells and clotting factors are preserved. At the conclusion of the surgery the blood is reinfused to the patient. The entire process is completed through a closed circuit.

Another way to impact blood loss in the operating room is to avoid hypothermia (low body temperature). Hypothermia can prevent normal platelet function resulting in increased blood loss. During surgery, blood that is lost can be suctioned and saved. It is collected, mixed with anticoagulants, filtered and reinfused to the patient. The use of cell salvage can continue into the post-operative phase through the use of drains.

You will be interested to know that this idea of Bloodless Medicine and Surgery (the use of technological and pharmaceutical techniques to minimize blood loss and avoid the use of allogeneic blood transfusions), has developed in recent years. It is now a well-known concept referred to as Patient Blood Management. Although the community of Jehovah’s Witnesses who seek medical care but decline the use of most forms of transfusions helped spearhead these changes, anyone can benefit from them.

Patient Blood Management uses evidence-based medicine to develop an individualized plan for each person to minimize or eliminate the need for transfusions. Ask your surgeon about this concept at your next appointment before the scheduled surgery.Find out what can be done in your individualized plan to avoid unnecessary blood transfusion.

I have been reading about spinal fusion surgery because I think I may have this done myself. I see there are different arguments about whether to do this from the front of the body or back of the body and whether to use an open incision versus a minimally invasive approach. My surgeon has talked about doing an open fusion from the front then turning me over and doing a similar fusion from the back using the minimal technique. What do you think about this idea?

Patients in need of surgery for severe, chronic back pain can benefit by today’s modern surgical techniques, especially minimally invasive surgery (MIS) for spinal fusion. Many studies have been done comparing different methods, techniques, and approaches. Given your situation and specific question, there is a recent study published that you might find of special interest.

In this study from the Rothman Institute Department of Orthopaedic Surgery (Thomas Jefferson University), two groups of patients having spinal fusion were compared. All 162 patients had an anterior lumbar interbody fusion (ALIF) first and then a second procedure. The second procedure was a posterior fusion with either an open incision (group one) or a minimally invasive approach (group two). Some patients (but not all) had a decompression of the nerve tissue as part of the second procedure.

A little information about the advantages of the minimally invasive surgery (MIS) gives a greater appreciation for why this approach is being studied so closely. The traditional open incision involves cutting through the many layers of spinal muscles and other soft tissue structures to gain access to the vertebral bones.

With MIS, a tube-shaped instrument is passed down through the soft tissues between muscle groups. The soft tissue structures are pushed aside without cutting them. This technique reduces the risk instability from damage to muscles, tendons, ligaments, and bone. MIS also makes it possible for patients to get up and moving again sooner, allowing for faster recovery.

Fiber optic lighting and advanced imaging technology aid the surgeon in seeing inside the body to perform the necessary steps. After removal of the disc from an anterior (front of the body/spine), bone graft was placed inside the disc space to maintain normal disc height. Then the patients were turned over and operated on from the back. This was when the spinal fusion was done using either the open or minimally invasive approach.

Results were compared using a variety of measures including amount of blood lost during surgery (and need for blood transfusion), length of surgery and minutes of time exposed to fluoroscopy, length of hospital stay after surgery, and complications (type and severity).

As it turns out, blood loss and the corresponding transfusion rates were greater in the open group. But a second look at this difference showed that it was the patients who had an additional surgical procedure (neural decompression) who experienced these complications. And as expected, the MIS group was exposed to longer periods of radiation exposure due to the increased need for fluoroscopy during the procedure.

The unique aspect of this study was the fact that patients had an open anterior spinal fusion followed by a posterior spinal fusion (either by open or a minimally invasive approach). It sounds like this is the type of surgery your surgeon has proposed for you.

The authors of this study concluded that minimally invasive posterior fusion following open anterior spinal fusion does have the advantages of less blood loss and therefore less need for a blood transfusion. MIS was also associated with a shorter hospital stay (and lower costs). Blood loss was greater in the patients who had open neural decompression.

However, rates of major complications such as blood clots, infection, or need for revision surgery due to problems with hardware were similar between the open and MIS group. The benefit or value of a minimally invasive procedure when performing a posterior spinal fusion with decompression may be compromised. And with the increased exposure to radiation required by the added decompression procedure, it may be that the open incision approach is best when decompression is needed.

Your surgeon will be evaluating your case carefully and making decisions based on many personal factors (e.g., your age, size, general health, presence of other medical problems, smoking/tobacco use history, number of spinal levels being fused, diagnostic reason(s) for this surgery) and so on. If it has not been explained to you why the procedure will be done as described, you may want to ask your surgeon for a more in-depth explanation of what will be done and why.

If I have degenerative spondylolisthesis from aging, should I have surgery to fix or repair the problem? So far, I seem to be managing okay. Not great but not bad. And I really don’t want to go under the knife — especially not on my spine. What do you think?

You may find the information presented through the SPORT studies helpful in answering this question. SPORT stands for Spine Patient Outcomes Research Trial. It is an ongoing long-term study conducted at 13 medical centers across 11 states in the United States. These medical centers provide multidisciplinary treatment to patients with spinal disorders including degenerative spondylolisthesis. Patients are followed at regular intervals and outcomes are measured in terms of pain, function, and disability.

Degenerative spondylolisthesis occurs with aging most often affecting the L4-L5 level in people over 50 years old. Women are affected six times more often than men. Spondylolisthesis alters the alignment of the spine. In this condition, degeneration of the disc and facet (spinal) joints can lead to one of the vertebral bones to slip forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. The spinal canal narrows (a condition called stenosis) putting pressure on the spinal nerves.

Previous SPORT studies have shown that patients have more improvement with surgery compared with a conservative (nonoperative) approach for the problem of degenerative spondylolisthesis with multilevel stenosis. Patients enrolled in a recent SPORT study who had leg pain or discomfort and other neurologic symptoms for at least three months were diagnosed with single-level degenerative spondylolisthesis and single or multi-level lumbar stenosis. This was the first study to compare the results of surgery for single-level degenerative spondylolisthesis accompanied by multilevel stenosis. The patients were divided into two groups. One group (130 patients) had a decompression procedure at more than one level (for the stenosis) and a fusion at one level (for the spondylolisthesis). The second group (77 patients) had the same multilevel decompression but only a single-level fusion.

Because SPORT is an ongoing data collecting type of study, many different pieces of information are collected about the patient, symptoms, insurance, clinical observations and test results, levels and severity of dysfunction, operative problems and results, and so on. This makes it possible to present tables of comparisons for patient demographics, comorbidities, fusion levels, and outcomes.

Although the multilevel fusion procedures took longer and the patients had more blood loss, there were no differences between the two groups in terms of blood replacement, complications during or after the surgeries, or number of reoperations required. Most other comparisons were similar between the two groups. The only real trend was for greater improvement of physical function in the single-level fusion group compared with the patients who had multilevel fusion. But that was only seen after the third year and the benefit evened out between the two groups after the fourth year of follow-up.

This study offers the additional information that surgical results are very similar when treating patients who have single-level degenerative spondylolisthesis and multilevel lumbar stenosis using different surgical approaches. Whether performing a single-level fusion procedure or a multiple-level fusion, the outcomes (measured as bodily pain and function) were about the same (i.e., not significantly different).

Therefore, given that surgery is often very beneficial for this condition, surgeons may want to limit fusion to just the spinal level where instability from the degenerative spondylolisthesis is present. In this way, patients are not exposed to longer operative times. And they are saved from higher levels of blood loss. This is an important consideration for older adults with multiple medical problems. It may be argued that fusing additional levels prevents future adjacent-segment disease but this remains under investigation.

What are the current recommendations for treating people like me who have both spondylolisthesis and stenosis? Both are age-related (not from overuse or injury) and in the lumbar spine (around L45). I’m not an athlete and never have been but I’m also not a couch potato. I’d like to stay active as long as possible. Surgery doesn’t really appeal to me but I’d do it if you thought it would be helpful.

Some of the best information available about the treatment of spinal disorders comes from the results of SPORT studies. SPORT stands for Spine Patient Outcomes Research Trial. It is a long-term study conducted at 13 medical centers across 11 states in the United States. These medical centers provide multidisciplinary treatment to patients with various spinal disorders.

Previous SPORT studies have shown that patients have more improvement with surgery compared with a conservative (nonoperative) approach for the problem of degenerative spondylolisthesis with stenosis. Benefits from the surgery were perceived by patients within the first three months after surgery and maintained for years afterwards. The study groups then turned their attention toward what type/extent of surgery yields the best results.

Most recently, the SPORT groups compared the results of surgery for single-level degenerative spondylolisthesis accompanied by multilevel stenosis. The patients were divided into two groups. One group (130 patients) had a decompression procedure at more than one level (for the stenosis) and a fusion at one level (for the spondylolisthesis). The second group (77 patients) had the same multilevel decompression but only a single-level fusion.

As a result of this study, surgeons may decide to limit fusion to just the spinal level where instability from the degenerative spondylolisthesis is present. In this way, patients are not exposed to longer operative times and saved from higher levels of blood loss. This is an important consideration for older adults with multiple medical problems. Your choice of treatment may depend on your age, severity of symptoms and condition, presence of other medical conditions, and surgeon preferences.

I’m thinking about trying acupuncture for my low back pain. I’ve tried everything else and I don’t want to take pain meds any more. I think I can handle the pokey needle part but are there other side effects I should be warned about?

Acupuncture as an alternative treatment to traditional medicine has been making the news. More and more studies are showing its positive effects on chronic low back pain. But differences in how the studies are conducted have left some lingering doubts as to the true benefit of this treatment. Since patients receiving a placebo treatment seem to fare as well as those receiving the “true” acupuncture treatment, further study is needed.

In the meantime, what has been shown so far has been very promising. One of the valuable “side effects” or benefits of acupuncture is both a reduction in the severity of pain as well as how “bothersome” that pain is for each patient. When pain is reduced, function and ability increase — two additional side effects, if you will.

But you are really asking more about the adverse effects — what some might refer to as the negative effects of acupuncture. Most adverse effects reported are mild and temporary. Some patients say their back pain increases at first and then subsides. Some people do not tolerate the local pain from the needle insertion. There is the possibility of bruising where the needle goes into the skin if a tiny vein is punctured.

Because acupuncture needles are inserted along lines of energy called meridians, it is possible to experience pain somewhere else along that meridian. So acupuncture for low back pain may result in pain in the shoulder or foot. Sometimes patients report feeling sluggish or having overall body aches in the first 24 to 48 hours after the acupuncture treatment. But all of these potential side effects go away in time. And often the person feels much better than before the treatment.

When you meet with your intended acupuncturist, you can certainly ask this question and see what his or her experience has been. There is also some evidence from studies that patients having a positive expectation of the treatment benefit improvement in painful symptoms. This occurs in cases where “sham” acupuncture is delivered. Sham acupuncture refers to nonpenetrating acupuncture. A blunt-tipped needle is used to make contact with the skin but without piercing through the skin.

I am going to see the local Chinese acupuncturist for a series of acupuncture treatments for my low back pain. How many sessions should I expect before I see improvement? And how many total visits should I schedule?

More and more studies are showing the positive effects of acupuncture on chronic low back pain. But differences in how the studies are conducted have made it difficult to narrow down the protocol to a specific number of treatments that is best for everyone. Individual patient differences (e.g., personality, stress and response to stress, socioeconomic) factors, psychological factors, and even workplace-associated contributing factors can affect results.

New information from a recent study from the Department of Korean Rehabilitation Medicine may provide some useful information. They designed a study to compare the results of true acupuncture with sham acupuncture treatment. The two different types of treatment were used in the care of patients ages 18 to 65 who had nonspecific chronic low back pain (cLBP or LBP). Each patient reported pain levels as being a six or higher on a scale from zero (no pain) to 10 (severe pain). Patients were assigned to the sham treatment and the real acupuncture treatment in a random fashion.

In this study, 130 patients received nonpenetrating sham acupuncture or true (penetrating) acupuncture twice a week for more than six weeks. Nonpenetrating acupuncture means a blunt tipped needle was used to make contact with the skin but without piercing through the skin.

This way of providing a sham acupuncture treatment has been shown in past studies to be perceived as genuine by other patients. Points of stimulation used were NOT true acupuncture points to further differentiate the sham treatment from the real or true acupuncture treatment (which was applied to actual acupuncture points).

Results were measured based on patient report of how “bothersome” the chronic low back pain (cLBP) was, pain intensity, general health status, and level of disability and depression. Patients in both groups reported significant improvement in the first two weeks. But the real acupuncture group had a much greater reduction of “bothersome” pain.

Intensity of pain was also reduced more in the group receiving real acupuncture. Patients in the sham group who benefitted from this “treatment” may have been experiencing both physiologic and psychologic benefit from the expectation that acupuncture would help. The group receiving real acupuncture would have the same positive expectation but with the added benefit of a true physiologic (not just perceived) effect.

Acupuncture is considered a safe and effective treatment for chronic low back pain (cLBP). Real acupuncture reduces the intensity and bothersomeness of cLBP more than sham acupuncture. The exact number of sessions needed has not been determined and is likely patient specific. As a general rule based on patient and acupuncturist experiences, expect a minimum of six sessions. See how you are doing and then reassess the need for further treatment.

What do you think works better for spondylolysis in a young teenager? We have been given the options of “do nothing” for now (I think this was referred to as “careful neglect”), bracing, or exercises. Is there any value in doing all three?

This is a very good question and one that has come under debate and discussion as well as study by physical therapists and other orthopedic health care specialists. In an effort to identify the most helpful conservative (nonoperative) care for these patients, a group of physical therapists recently conducted a systematic review and reported their findings.

1) Description of each study (design, patient demographics, training type and duration)

2) Type of injury (acute versus chronic, severity) and type of surgery (decompression, fusion, fusion with or without instrumentation)

3) Comparison of outcomes for nonoperative treatments (bracing versus activity restriction)

4) Comparison of outcomes for nonoperative treatments (bracing and physical therapy versus placebo/control)

5) Results for exercise interventions (core training, back strengthening, postural exercises, general exercise)

Although the information was carefully organized, as it turned out, many of the studies collected (and reported on) different things. There wasn’t enough consistency across studies to make comparisons with meaning. The authors report “limited investigation” and “lack of homogeneity” as the two main reasons there was no consensus on the role of conservative care or on outcomes of nonoperative care versus surgery for this condition.

There was one other major stumbling block in studying the effects of exercise: poor patient compliance. In other words, the patients didn’t do the exercises as prescribed (or didn’t do them at all)! With the limited evidence available, the best that can be said is that exercise to strengthen the core muscles (abdominals and trunk stabilizers) decreases pain and improves function.

No evidence but clear consensus (based on expert opinion or case studies suggest) suggested that bracing works better for healing the fracture when compared with restricted activity for children and teens with spondylolysis (fracture without separation). Some case series studies showed that more young people return to full activity (and sports participation) when bracing was combined with specific exercises.

There is also some evidence that specific core training to strengthen the abdominal muscles and trunk stabilizing muscles can aid conditions like spondylolysis. These findings may offer some direction in your child’s situation. It may be best to work with your physician and physical therapist to identify the most appropriate treatment for your young teenager.

Location and severity of injury, activity level, and likelihood of compliance are all important considerations in the planning process. There’s no sense in spending money on a brace that gets left under the bed or an exercise program that is never carried out. Having a physical therapist involved may provide the incentive needed to ensure or improve your child’s compliance with the recommendations.

We were very surprised when our son (a very excellent athlete) started having low back pain. At first, we just told him to “work through it”. Turns out that was bad advice. He went from having what they call a spondylolysis (spinal fracture) to a spondylolisthesis (fracture that separates and shifts). Now we are being more careful to search the internet for information on the best way to treat this type of problem. What do you recommend?

As you have now discovered, sports athletes are not immune to low back pain. Bony defects such as spondylolysis and spondylolisthesis present from birth or as a result of stress fractures from overuse can be a common cause of painful lumbar instability. In the case of spondylolysis, the supporting bony column (called the pars interarticularis) fractures. As you pointed out, if the fracture displaces (separates) and the vertebral body shifts forward, the condition is referred to as spondylolisthesis.

Most athletes would prefer a nonoperative approach to treatment — but preferably one that gets them back on their feet and returns them to full participation quickly. In an effort to identify the most helpful conservative (nonoperative) care for these patients, a group of physical therapists conducted a recent systematic review and reported their findings.

They conducted a computer-assisted search of articles published in English over a span of 46 years (from 1966 to 2012). After gathering all the acceptable articles and compiling all the information, the authors found that many of the studies collected (and reported on) different things. There wasn’t enough consistency across studies to make comparisons with meaning. The authors report “limited investigation” and “lack of homogeneity” as the two main reasons there was no consensus on the role of conservative care or on outcomes of nonoperative care versus surgery for this condition.

There was one other major stumbling block in studying the effects of exercise: poor patient compliance. In other words, the patients didn’t do the exercises as prescribed (or didn’t do them at all)! With the limited evidence available, the best that can be said is that surgery (over conservative care) seems to be most effective for higher grades of vertebral slippage. And exercise to strengthen the core muscles (abdominals and trunk stabilizers) decreases pain and improves function.

No evidence but clear consensus (based on expert opinion or case studies suggest) suggested that bracing works better for healing the fracture when compared with restricted activity for children and teens with spondylolysis (fracture without separation). In adults, lumbar exercises helped some people recover and return to work. But there was inconsistency in the most effective type of lumbar exercises. For example, some people responded to extension exercises better than flexion exercises and vice versa.

The lack of consensus or evidence-based agreement on the best way to treat these patients must be addressed in future high-quality research. In the meantime, your question goes unanswered as there is no known treatment protocol that yields the best results. The physician and physical therapist who are working with your son will be the best sources of information. Their advice and recommendations will be based on your son’s age, severity of the spondylolisthesis, and goals for return to activity and sports participation.

I’m thinking of taking the plunge and getting a disc replacement for my degenerative disc disease at C56. This is just a little detail but I’m wondering if I’ll need to wear some type of neck collar afterwards. I do have several I already used before, so if I can save a little money, I’ll bring mine with me.

Currently, there are three different disc replacement systems approved by the FDA and available for use in replacing diseased discs. Most surgeons are trained using one type and then they stick with that particular system in order to perfect their technique. In this way, they can also improve patient results.

The rehabilitation program after neck surgery (whether a fusion procedure is done or the alternate, the disc replacement) is not standard. You will find differences from center to center and even from surgeon to surgeon at one surgical site. The decision about whether or not to wear a soft or hard collar after surgery lies with each individual surgeon.

There are several factors that go into making this decision. The condition of your bones and surrounding soft tissues, the amount of surgery required to accomplish the disc replacement, your age, and your activity level will be reviewed. Any complications that may have occurred during the procedure will also be considered.

Most patients leave the hospital after this surgery under their own steam. They get up and walk on the same day. The surgeon is really the one to make this decision knowing what was done and the condition of your neck. You can always bring your collars with you to your preoperative visit and bring up this question at that time. But the final decision may not be made until after the procedure has been done.

Can you help me figure something out? I’m trying to decide if I should have a disc replacement or fusion. The surgeon has gone over the pros and cons of each procedure. She seems to be leaning more towards the disc replacement but it sounds like I could have that surgery and still end up with a fusion if it doesn’t work. What do you tell your patients?

There are many ways to evaluate the pros and cons (and results) when comparing cervical fusion or disc replacement for severe neck pain and instability. Change in symptoms (numbness, pain, loss of motion, loss of function) is a common source of information about what works well and what doesn’t (and therefore, which way to go).

A recent study was done that might add some helpful information for you. The surgeons chose the rate of reoperation after five years as the main means of evaluating and comparing results between disc replacement and neck fusion. The type of disc replacement system they used was the ProDisc-C.

The type of fusion procedure was the anterior cervical discectomy and fusion (ACDF). ACDF involves removal of the diseased disc with a bone-packed spacer (bone graft) placed in the space left by the missing disc. The use of hardware (plate and screws) along the front of the spine provided support and stability until healing took place.

Just over 200 patients with single-level disc disease between C3 and C7 were randomly divided into two separate treatment groups. Half (103 patients) received the disc replacement. The other half (106 patients) had the fusion procedure. As you probably know, the main difference between these two treatment types is the effect on neck motion. Fusion prevents movement at the level that was grafted together. Disc replacement allows for motion (though not usually completely full, anatomic motion).

Besides the five-year reoperation rate, they also took a look at the effect of the two procedures on the next vertebra. The incidence of adjacent segment disease (ASD) has been known to be increased after fusion compared with disc replacement. ASD refers to increased pressure in the disc spaces next to the fusion site. There can also be increased motion at those levels observed with ASD.

The concern is that fusion (or perhaps disc replacement) will increase the speed at which the next disc/vertebra starts to degenerate and break down. By comparing the five-year results in two groups of matched patients, it is possible to compare the durability of the disc replacement and the rate of adjacent segment disease with both procedures.

Although disc replacements help maintain spinal motion, they are devices that can break, shift, or sink down. Any of these problems can result in return of painful neck and/or arm symptoms and the need for a second surgery (referred to as a reoperation). Other studies have shown that the fusion procedure does have a much higher (two to six times higher) rate of reoperation compared with disc replacement.

Let’s look at what happened with these 200+ patients. Data was collected at six weeks after the surgery and again after six and 12 months. The last collection point was after five years, although the authors intend to recheck everyone seven years after the primary (first) surgery.

A dozen patients in the fusion group had at least one additional surgery (three of those 12 had more than one reoperation). There were problems with pseudoarthrosis (movement at the fusion site creating a “false joint”) and movement of the hardware (plate) lifting off the spine. This “lift-off” of the plate then caused pressure on the esophagus resulting in difficulty swallowing.

Only three of the ProDisc-C had revision surgeries. Two of those three had the disc replacement removed and the neck fused after all. None of the implanted discs broke or failed. Overall, fusion procedures had a much higher reoperation rate (five times more reoperations). The two main reasons for reoperations in either group were persistent pain and significant adjacent-segment disease (ASD).

The authors concluded that the advantages of disc replacement continue to exceed those of the fusion procedure, which has always been the “gold standard” for treatment of degenerative disc disease. In time, if motion is spared with the disc replacement and there is less adjacent segment disease and lower reoperation rates, then disc replacement may replace fusion as the “gold standard” treatment.

These results support similar findings in other studies comparing these two treatment approaches for degenerative disc disease in the cervical spine (neck). If you are still deliberating and debating in two more years, watch here for continued (the seven-year) results of this study.

I am the director of a fairly large and well-attended senior citizen center. One of the members of our board of directors in a gerontologist specializing in the care of older adults. He suggested we hold a screening clinic to help identify seniors who have scoliosis. We are investigating the idea. What can you tell me about this problem? I need more information before presenting it to the membership at large for a vote.

You may find our pamphlet on adult degenerative scoliosis (Patient Guide to Adult Degenerative Scoliosis) a helpful tool in educating yourself and your seniors. By definition, <iscoliosis is an abnormal or exaggerated> curve of the spine when observed either from the side or from the front or back.

Adult degenerative scoliosis is different from the type of scoliosis that occurs in teenagers. Adult degenerative scoliosis occurs after the spine has stopped growing and results from wear and tear of the spine. The condition most often affects the lumbar spine.

In adult degenerative scoliosis, the spine loses its structural stability and becomes unbalanced. This imbalance of the spine causes changes in the way the forces of the spine are directed. The larger the scoliotic curve becomes, the faster these changes cause degeneration of the spine. This creates a vicious cycle where increasing deformity causes more imbalance, that in turn causes more deformity. While this process occurs very slowly, it usually continues to slowly progress until something is done to restore the balance in the spine.

Degenerative scoliosis is more common the older we get. As our population ages, adult scoliosis will be even more common. It will be an increasing source of deformity, pain, and disability. It is estimated that 35 per cent of older adults have scoliosis. This would represent slightly more than one-third of your group. Early detection and treatment can help prevent disease progression. A medical examination with X-rays is usually the most reliable method of diagnosis.

Can you help me understand something? I had a spinal fusion surgery for degenerative disc disease six months ago. The surgeon gave me a thumbs up based on some test scores that showed improvement for me. Maybe I’m being a spoiled person but I’m actually disappointed in the results. Maybe I should have stuck with giving it some more time and trying other nonsurgical methods of treatment. What would you have advised?

You didn’t mention why you aren’t happy with the results or what tests the surgeon used to measure “success.” Some studies do have ways of determining the minimum amount of change in test scores that are considered significant (and therefore a sign of “success”). You may find some help from a recently reported systematic review comparing the results of fusion surgery with results for nonoperative care for this condition known as degenerative disc disease.

They used careful selection criteria to get the best evidence possible. Studies included had to use validated patient assessment tools to measure outcomes (e.g., the Oswestry Disability Index, Short Form Health Survey). Perhaps you completed one of these two patient self-report tools. Patient satisfaction and X-ray results were also acceptable measures of clinical outcomes.

Articles considered unacceptable for review (inclusion) and therefore excluded were: 1) based on opinion, 2) only reporting on surgical technique, or 3) included patients receiving a fusion at more than two spinal levels. In addition, studies that were too small (less than 20 patients) or too short (follow-up was less than one year) were not included.

Twenty-six (26) studies with a total of over 3,000 patients met the necessary standards to be included. All patients had pain and loss of function as a result of degenerative disc disease in the lumbar spine (low back). Spinal surgery done was fusion at one or two levels.

Specific information used to compare results included length of follow-up time, patient age, baseline back pain information, change in outcome scores, fusion rates, reoperation rates, and level of patient satisfaction.

Pain relief and improved function were reported for the fusion patients in the majority of cases. Overall patient satisfaction was 75 per cent for patients who had the fusion procedure, while patients in the nonoperative group reported a much lower rate (55.6 per cent) of satisfaction. The percentage of patients who had a successful fusion was 84 per cent. Seven per cent (7%) of the total group had a second surgery due to a failed first surgery.

Patients evaluating results of surgery versus nonoperative care for degenerative disc disease should keep in mind that these two treatments are not really competing with one another. Patients aren’t usually given the opportunity to choose between them.

Instead, treatment is offered in a series: first conservative care with medications, physical therapy, and rest. Then, if the treatment fails, follow-up surgery (spinal fusion) is advised. Surgeons who seek the best evidence available to support their clinical decisions may rely on systematic reviews like this one to direct and guide them.

Which is a better way to deal with painful degenerative disc disease: give it more time and stay with the conservative approach without surgery or go for the spinal fusion (which is kind of a final no going back step for me).

Patients like yourself with chronic, persistent low back pain from degenerative disc disease (DDD) will be interested in the results of of a recent study. The authors (surgeons from four well-known Spine Centers in the U.S.) collected, reviewed, and summarized data from studies comparing surgical fusion with nonoperative (conservative) care.

They used careful selection criteria to get the best evidence possible. Studies included had to use validated patient assessment tools to measure outcomes (e.g., the Oswestry Disability Index, Short Form Health Survey). Patient satisfaction and X-ray results were also acceptable measures of clinical outcomes.

The authors provided several summaries of data from studies that compared results of surgery versus nonoperative care for this condition. Information was compiled for both randomized and nonrandomized controlled trials. They included length of follow-up time, patient age, baseline back pain information, change in outcome scores, fusion rates, reoperation rates, and level of patient satisfaction.

Overall patient satisfaction was 75 per cent for patients who had the fusion procedure, while patients in the nonoperative group reported a much lower rate (55.6 per cent) of satisfaction. The percentage of patients who had a successful fusion was 84 per cent. Seven per cent (7%) of the total group had a second surgery due to a failed first surgery.

Pain relief and improved function were reported for the fusion patients in the majority of cases. Type of fusion technique and age of the patient (young versus old) did not seem to affect success of the fusion procedure.

Summary: Collecting information on treatment results like in this review (especially success and failure risks and rates) is important today because of the large number of people missing work or seeking medical care for chronic low back pain. The high cost of fusion surgery also warrants knowing if surgical care is the best way to go.

As this systematic review showed, patients who do not get relief from their painful, disabling symptoms with nonsurgical treatment may find surgical fusion is a very good next step in the treatment algorithm (clinical decision pathway).

Our five-year-old grandson had a major fall onto the back of his head and now they are saying he needs surgery to correct a swan neck deformity. The only thing I can find on the internet about this problem seems to deal with the hands not the head. Can you help me understand what’s going on here?

If you look at the average person from the side as they look forward, the neck appears straight up and down. But, in fact, there is a backward curve called lordosis that helps keep the head and neck in perfect alignment. Injury such as you described for your grandson can change this head-neck relationship causing a condition referred to as swan neck deformity.

Ligamentous damage causing laxity looseness) can lead to instability and even dislocation of the cranium (head or C0) on the first cervical vertebra (C1). This is also known as atlantoaxial dislocation (again, referring to the abnormal movement of the head (skull) over the first cervical vertebra).

As a result of these cervical spine changes, the upper portion of the neck becomes kyphotic (develops a forward curve of the neck opposite of lordosis). The lower portion of the cervical spine then compensates by becoming hyperlordotic. The resulting changes in alignment are referred to as a swan neck deformity.

From the side view, the neck looks like the curve of a swan’s neck. These changes occur as the head, neck, body complex attempts to keep the head balanced over the neck and the eyes on a straight plane to protect vision. A similar curvature and reverse curvature of the fingers can occur in people with severe rheumatoid arthritis of the hands. Swan neck deformity of the hands is far more common than the swan neck deformity of the head and neck.

Surgery can be done to fuse the head and neck (C0-C2) and stop the abnormal movement of the atlantoaxial junction. Recently, a report was published for a series of patients (total of 68 people ages four to 68) who had this procedure under the care of one single surgeon. The goal was to see (and report on) changes in overall neck alignment with this procedure. X-rays viewing the cranium (skull) and neck and change in function and neurologic status were used to measure before and after results.

The surgery was successful for all but two patients who continued to have painful and neurologic symptoms that continued to get worse over time. In all the other patients, posterior fusion of the upper cervical spine actually resulted in the body auto-correcting the lower (subaxial) cervical spine (below the level of the fusion). This was a hoped for but uncertain favorable outcome.

The authors concluded that reversal of subaxial cervical alignment does occur in patients of all ages who have atlantoaxial dislocation that is stabilized with posterior fusion of C0 to C2. The amount of change in the lower cervical spine (C2-C7) was significantly and directly linked with the amount of change at the C0-C2 levels.

This was the first study to report on the effect of such a correction in patients with this complex swan neck deformity. The type of fusion hardware used (screw and plate system) has been approved in China but not by the United States Food and Drug Administration (FDA). This may be why you were unable to find more information about thisp problem. We hope this information helps you.

You may not be able to help me but I thought it might be worth asking. I’m having surgery for an unusual problem: my head dislocates off my neck. This is happening because I injured my neck years ago AND I have severe rheumatoid arthritis. The combination of the two has resulted in a very unstable head-neck relationship. They call the neck a “swan neck.” What are my chances for a good recovery from this type of surgery?

Abnormal movement of the head (skull) over the first cervical vertebra is referred to as atlantoaxial (A-A) dislocation. Ligamentous damage causing laxity (looseness), vertebral fracture, or deformity from rheumatoid arthritis can lead to this type of instability.

If you look at the average person from the side, the neck appears straight up and down. But, in fact, there is a backward curve called lordosis that helps keep the head and neck in perfect alignment. Injury, deformity, or arthritis can change this head-neck relationship causing a condition referred to as swan neck deformity.

As a result of the cervical spine changes associated with a swan neck deformity, the upper portion of the neck becomes kyphotic (develops a forward curve of the neck opposite of lordosis). The lower portion of the cervical spine then compensates by becoming hyperlordotic. These changes occur as the head, neck, body complex attempts to keep the head balanced over the neck and the eyes on a straight plane to protect vision.

Surgery to fuse the head and neck (C0-C2) is done to stop the abnormal movement of the atlantoaxial junction. Recently, a report was published for a series of patients (total of 68 people ages four to 68) who had this procedure under the care of one single surgeon. The goal was to see (and report on) changes in overall neck alignment with this procedure. X-rays viewing the cranium (skull) and neck and change in function and neurologic status were used to measure before and after results.

The surgeons concluded that reversal of subaxial cervical alignment does occur in patients with atlantoaxial dislocation that is stabilized with posterior fusion of C0 to C2. The amount of change in the lower cervical spine (C2-C7) was significantly and directly linked with the amount of change at the C0-C2 levels.

This was the first study to report on the effect of such a correction in patients with this complex swan neck deformity. Auto correction and reversal of the swan neck deformity in these severe and complex cervical spine deformities may occur as a result of the body attempting to achieve global (overall) alignment or to maintain visual orientation required for upright posture. Future studies are needed to determine the exact mechanism by which the subaxial alignment of the lower cervical spine improves when the upper cervical area is surgically fused.

Tell me if my thinking is right here. I have significant degeneration of my neck at the C56 level. I’m thinking if I go with a disc replacement, I could keep as much motion as possible for as long as I can. Then, if it doesn’t work or it starts to break down as I get older, I could always have the other option of fusion. Is this a reasonable way to go? Or am I missing something here?

One of the main concerns after cervical (neck) fusion or disc replacement is the risk of adjacent segment disease (ASD). Adjacent segment disease refers to breakdown of the vertebrae next to a spinal fusion or disc replacement implant.

Studying the causes and ways to avoid adjacent segment disease (ASD) after fusion or disc replacement become a major focus of research these days. But with the ever changing surgical tools and techniques, it is difficult to compare studies from 10 years ago with current studies. And that dilemma will continue into the future as treatment strategies change with evolving technology.

Even so, efforts are being made to study the problem of adjacent segment disease (ASD) and ways to avoid it. Focusing on the causes of the problem may help surgeons identify avoidance strategies.

Currently, there are three known causes of adjacent segment disease. They are: 1) the natural history (what normally happens) in the disc at the next level, 2) the biomechanical stress and increased motion placed on the next level because of the fusion, and 3) anatomical disruption of the vertebral segment at the next level from the surgery.

Available evidence suggests that strategies to avoid ASD seem to be working better for the cervical spine than for the lumbar spine. And ASD may be less likely to develop after disc replacement compared with spinal fusion. This is especially true for younger patients who may be at less risk for degeneration from the natural aging process compared with older adults.

Matching strategies with causes isn’t easy. For example, to know for sure if natural history (the natural tendency for the spine to degenerate over time without surgery) is the real problem is difficult to study. Providing needed surgery for one group of patients while comparing them to a control group (those who don’t have the surgery) isn’t ethical. So the true incidence of ASD linked with natural progression of disc degeneration is likely to remain unknown.

Studying the biomechanical changes at the adjacent levels is a bit easier. Researchers can measure the increased motion at the next vertebral levels and measure the increased pressure on the disc in between the vertebrae.

These kinds of changes are more likely after fusion (because of loss of motion) than with disc replacement where motion is preserved. Determining the exact biomechanical changes that contribute to ASD and finding ways to change that relationship are the focus of many current studies. To date, there has been a wide range of conclusions about this variable. Some studies show that the natural tendency for discs to degenerate over time is the main cause of the problem while others point to the change in biomechanics as the most important factor.

But there’s no mistaking the fact that the surgery has an effect as well. Whether fusion or disc replacement, the structures are changed, the normal anatomy is altered, and the result could be aggravation of the adjacent levels. Studies are needed to show what anatomic parts must be preserved and not disrupted during surgery to prevent adjacent segment disease. Likewise, determining technical strategies during the procedure that might help avoid adjacent segmental disease will be important.

Given all the information we have so far, there is nothing wrong with your thinking/strategy. Taking into consideration your age, your surgeon’s opinions, your current (and hoped for) activity level, and the pros and cons for each procedure will give you the best guidance in making this important decision.