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In a study by Seo-Young Kim, MD, et al, they found 1/3rd of the studied subjects with overactive bladders had their highest level of spinal cord injury at or above the 2nd lumbar spine level. Two-thirds of the studied subjects thus had underactive bladders and had their highest level of spinal cord injury at or below the 3rd lumbar spine level.

This important nerve bundle gives sensation and motor supply to the pelvic organs and lower limbs. When injured, persons with CES often have many functional problems with their bladder and/or bowels, experience decreased sensation in their crotch area, and may have sexual dysfunction.

There is a lot of evidence that increasing abdominal strength can help to decrease low back pain. This increased strength improves lumbar spine stability and can decrease the effect of sudden loads on the muscles, joints, discs and ligaments in the spine which is often the cause injury and pain. According to a recent study by Aleksiev in 2014 there is new evidence that performing abdominal bracing for every day movements that involve the whole body can decrease pain. He found that over a ten year study the groups doing the abdominal bracing had decreased intensity and frequency of pain by more than one and a half times over the group doing exercise alone. The hypothesis by Aleksiev is that performing the abdominal brace frequently through out the day greatly increases the frequency of said exercise, and thereby improving the strength gains. Doing this exercise also seemed to have the effect of reminding people to do their other exercises, again increasing overall abdominal strength.

According to a recent study by Aleksiev the type of exercise, strengthening or flexibility, does not matter. Both caused a similar pain decreasing effect for patients with low back pain over a ten year period. The most important aspect of the exercise, according to this study, was the frequency, the more the better. It was also shown in this study that the use of an abdominal brace during daily whole-body movements or exercises also further increased the pain reducing effect of exercise over a ten year period.

Patients with failed back surgery syndrome are typically treated with conventional medical management, which mostly includes medicines for pain and depression, physical therapy, and psychosocial therapy. Other treatments may include epidural injections, nerve blocks, and home based electrical stimulation units (TENS). If these usual courses of treatment continue to fail, the last options are either to perform another back surgery or to implant a spinal cord simulator. According to a recent report by Shivanand et al, repeat back surgery has poor outcomes ranging from only twenty-two to forty percent success rate. Repeat surgery also increases the risk for complications and is very expensive. Spinal cord simulator implantation has been shown in several studies as a viable option and Shivanand et al have shown it to have less than half the complications, shorter hospital stay and similar total cost over the first two years compared to repeat back surgery.

Spinal cord stimulation is the use an electrode implanted into the spinal cord to help control chronic pain. This implanted electrode provides stimulation to the nerves that come from the source of the pain. This electricity changes the impulse of both the excitatory and inhibitory neurotransmitters to effectively block the sensation of pain. Since its inception in the 1960s many innovations such as smaller and more effective electrodes, and better surgical techniques have made SCS an increasingly viable option for treating chronic back pain.

Spinal stenosis is the narrowing of the spinal canal which can lead to pressure on the spinal cord or nerve roots, resulting in pain in the back and legs. This condition is usually caused by changes related to aging in the disc, lumbar vertebra, and supporting structures. Surgery to relieve this pressure accesses the spine through the back and then the excess bone, thickened ligaments and degenerative disc tissue is removed to create space. This improved space often decreases the cause of pain and may relieve back and leg pain, however these results are very inconsistent. In a recent review article by McGregor et al, the authors looked to see if active rehab improved outcomes more than usual care. They did find that there was moderate evidence to support that active rehab following a spinal stenosis decompression surgery increased the long term improvement for leg pain.

A recent review by McGregor, et al, mentions a few studies that support pre surgery rehabilitation. There is a suggestion by McGregor, et al, that the older age of spinal stenotic patients puts them at greater risk for comorbidiites and have a greater need for rehabilitation to improve outcomes. Along the same lines there is evidence from Nielsen, et al, whose study included both pre and post operative rehab with good results. This included both length of stay in the hospital and functional recovery. McGregor, et al, suggest that there is usefulness in looking at the entire care pathway in a more holistic way rather than simply focusing on the surgery. Based on these few examples there is evidence that pre surgical rehab can improve surgery and there is a need for more research in this area.

While there seems to be an increasing amount of interest related to this topic the authors of this review conclude that there must be research efforts that focus on “higher quality trials with pre-determined cost values and longer follow up”.