News Category: General Spine

Doctors at the Gifu University of Medicine in Japan report three cases of permanent paralysis. The cause in each case was a missed lesion putting pressure on the spinal cord in the middle of the spine. Symptoms of back and leg pain along with muscle weakness led doctors at first to think the problem was in the lumbar spine.

Imaging studies weren’t completely clear. An operation to take pressure off the spinal nerves in the lumbar spine wasn’t enough. All three patients got worse, with loss of bladder function, changed reflexes, and extreme muscle weakness.

More testing and an exam of the spine at a level above the lumbar spine showed a tumor in one case. The other two cases involved a cyst, herniated disc, and hardening of a spinal ligament. A second operation relieved the pressure on the spinal cord. However, the delay in diagnosis and treatment resulted in permanent damage to the spinal cord. All three patients had some ongoing neurological problems.

The doctors reporting these cases say the red flag in these cases was the mismatch of symptoms. The patients’ symptoms and the MRI of the lumbar area weren’t the same. More testing might have shown a loss of sensation higher up. For example, pinprick testing of the trunk would have been positive in at least one case.

Missing a compressive lesion in the thoracic spine doesn’t happen very often. The authors conclude that testing must be complete before doing surgery when the symptoms and the exam don’t match up.

Advances in technology make it possible for doctors to repair broken vertebral bones. This type of fracture is called a vertebral compression fracture. The break can be repaired by injecting cement right into the bone. A special tool is inserted through the skin and soft tissues to the center of the vertebra. This treatment is called a percutaneous vertebroplasty.

This method can’t be used when fractures are severe. In such cases the vertebroplasty can be done using an imaging X-ray called fluoroscopy. A special microscope is also used to guide the doctor. A small opening is cut between the lamina from behind. The lamina is the bone that forms the back arch of the canal around the spinal cord.

With this small opening the doctor can see more and avoid putting pressure on the spinal cord. It’s possible to guide the tool to the right spot and remove any cement that spills over or leaks out. This method gives doctors better control over what happens without fully opening the spine or damaging the nearby soft tissues.

Doctors in Germany report the results of using this approach with 24 patients who had severe osteoporotic fractures. They all had severe back pain. Some had symptoms of nerve pressure such as numbness, weakness, and leg pain. Follow-up showed excellent or good pain relief in 73 percent of the patients. The authors think this is a good success rate given how severe the fractures were.

Severe fractures of the spine can sometimes be repaired without major, open surgery. The microsurgical approach described in this study makes it possible to treat very old patients with severe collapse of the spinal bones.

Low back pain (LBP) is a puzzle. Little is completely understood about its causes, who is most likely to get it, or how to keep it from coming back. Medical researchers are trying to fit together pieces of the LBP puzzle. These authors looked at how physical activity relates to LBP. The general thinking in the medical world is that moderate amounts of physical activity are best for the back. It’s enough activity for good fitness, but not enough to cause intense strain on the back. However, research gives no clear answer.

What makes this study unique is that all the subjects lived in the same town in Israel. About 2,000 adults between the ages of 22 and 70 took part in a survey. Most of the subjects were white-collar workers who had middle or high incomes. The survey asked questions about back pain, general health, lifestyle, and jobs. Physical activity was divided into three categories: activities of daily living, job activities, and recreation and sport activities. Sports activities were rated by the intensity and the amount of time subjects did them per week and per year.

About half the subjects took part in regular sporting activities. This group was generally more educated, smoked less, liked their work better, and had jobs that involved less heavy work. They also suffered less LBP than subjects who didn’t do regular sporting activities. Most of the subjects involved in sports did moderate-intensity activities. The study results didn’t show that any particular sports were related to LBP in any way.

The authors weren’t sure exactly why the group who took part in sports had less LBP. They note that this group had healthier lifestyles in general. The authors also say that it is possible that LBP would cause people to do fewer sports activities. Still, the authors conclude that moderate sports activities seem to be good for everyone, including people with LBP.

Many people suffer from disc-related back pain. How the disc is damaged and degenerates is still under study. Researchers in Sweden are using animal models to understand the chemical and biological changes that occur with disc damage and repair.

The disc is made up of two main parts. There’s the outer covering called the annulus and the gel-like center called the nucleus. In this study, they damaged the discs of six pigs by poking a hole through the disc. After puncturing the discs, the pigs were returned to the lab for three months. Then the scientists looked at the effect of increasing constant loads on the healing discs.

There was a delayed response in the damaged disc when the spine was loaded and unloaded. The scientists also studied what happened to both parts of the disc. The annulus lost its water content, and the nucleus lost its gel-like structure. The nucleus became brown and discolored. Sub-units of protein called proteoglycans also shifted toward the back of the disc. Looking closely at the fibers of the disc, both parts showed a change in the way the collagen fibers were lined up.

Other changes included a loss of disc height. The border between the annulus and the nucleus disappeared. And many of the layers of the annulus were separated. Pressure within the damaged disc was much lower compared to the disc next to it.

The authors report that the changes from disc injury in a pig are much like the changes that happen in a damaged human disc. Pigs provide a useful model for understanding human disc degeneration. Some differences exist, but several changes that happen with disc damage are similar between pigs and humans.

Studies show good results when using special cages to fuse two or more vertebrae in the spine. These cages are barrel-shaped and fit between the vertebral bones. They hold the bones apart and keep the spine stable. They also resist the compressive load through the spine. Bone chips are placed inside the cage to form a bone graft that “grows into” the spine.

This treatment method is now being tested with other problems. This study looks at the use of titanium mesh cages after bone is removed because of fracture, infection, or tumors. X-rays are used to see how stable the implants are after bone removal and surgery to reconstruct the problem area of the spine.

Half the patients in this study had a vertebral fracture. One-third had surgery after the spine collapsed from trauma. The rest had a tumor or spinal infection. All patients had one level removed and replaced with a cage packed with bone. In some cases the doctor also used a metal plate or screws to help hold everything in place.

The authors report that cages used for problems other than disc-related fusion had good results. The spine was held stable without further deformity. They conclude that cages can be used to reconstruct the spine after fracture, tumors, infection, and other trauma.

About 80 percent of Americans have back pain at some point in their lives. And for most of us, it is a recurring problem. This is why back pain accounts for a huge chunk of health care spending in the United States.

Exactly how much do we spend on back pain in a year? That’s not an easy question to answer. These authors used a huge national survey done in 1998 to find out. They sifted through the data and sorted out all back pain patients. They uncovered a lot of eye-opening information:

Can we tell ahead of time who will suffer from back pain? Not yet, but studies like this are identifying risk factors among men and women. Once these risk factors are known, maybe we can work on preventing the problem.

Researchers from the University of British Columbia and the Canadian Arthritis Research Center did this study. They used the Canadian National Population Health Survey to look for predictors of chronic back pain. Other studies have looked at risk factors within specific occupations. This one looks at the general adult (18 and older) population.

They found more back pain in adults ages 40 to 60 than any other group. Different factors were linked with back pain in men compared to women. For men, poor health was the strongest risk factor. Other risks included age, chronic stress, height, and doing yard work or gardening when they’d rather be doing something else. For women, limits to activity ranked as the top risk factor. Other risks included personal stress, arthritis, and a history of psychological trauma.

The authors give us an example to show how this works. An active woman with low stress, no history of psychological trauma, and no arthritis has about a six percent chance of back pain over a two-year time period. On the other hand, a woman with arthritis who can’t do her daily activities and who has a history of traumatic events in childhood has a 32 percent chance of back pain within two years.

This study showed there are different risk factors for back pain in the general population based on gender. General health and psychosocial factors are also important for both men and women. General health is more important for men and functional status is more important for women. General stress is a risk for men. Personal stress is linked with back pain in women.

Except for gender, all of these risk factors can be changed or modified. The next step is to see if changing any of these factors reduces the risk of back pain.

What happens when a nurse or other trained health care worker is lifting a patient who falls? The worker tries to catch the patient. This puts a sudden, heavy load on the worker’s back. How does the body protect itself in these cases?

That’s the focus of this study from the National Institute of Occupational Health in Denmark. Studies have been done in the past using small loads. The pressure inside the abdomen has been measured in different lifting situations for healthy subjects and for people with low back pain. This pressure is called intra-abdominal pressure (IAP).

In this study, the IAP was measured in 10 well-trained judo and jujitsu fighters. There were five women and five men in the study. Each one was subjected to a trunk load that shifted during lifting. This is like handling a patient who falls. IAP was measured by putting a catheter inside the stomach. A specific math formula was used to calculate the load on the low back during the patient fall.

The researchers found high IAPs during the lifting activity with load shifts. Both the size and the speed of the IAP help stabilize the spine and protect it from injury. Judo and jujitsu fighters are used to throwing the full weight of another person to the ground. They do this with the spine twisted and bent in an awkward position. Yet they don’t have a high rate of back injury.

The authors conclude that trained workers with strong abdominal muscles can cope with sudden loads. They don’t think the average nurse has enough strength to do that. On average, the women in this study were 53 percent stronger than an untrained female of the same age. Anyone with back pain is at greater risk for injury when exposed to sudden load shifts either in sports or at work.

Parents face some tricky decisions. Back pain is on the rise in children and teenagers. A lack of physical activity may be linked to back pain. But safety concerns sometimes lead parents to drive their children everywhere.

Researchers in Norway compared back pain in eighth and ninth graders. Results were compared for two groups. The first group actively got themselves to school by walking or biking. The second group used passive transport (bus or car).

Back pain was measured in each child. Other measures included number of hours in front of the television or computer. Students were also asked about social class, well- being, and parents’ back pain. They found that students spent about seven hours on leisure physical activities. They spent more than twice that amount (15 hours) in front of the computer or television. These measures were the same for all students regardless of whether they lived in the city or country. Boys and girls also had the same results.

The authors report that even short but frequent walking or biking may promote good back health. The results support the guidelines for 30 minutes of daily activity given by the United States Surgeon General. Riding in cars and buses may increase low back pain because of long sitting times, the vibrations, and the loss of physical activity.

Even though this study was small, the researchers say the results are similar to other study results. The data offers some general information about how often back pain occurs in children and teens: about 50 percent have back pain at some time. It also points out the need to encourage more active forms of transport. Providing safe walking routes and teaching parents about the benefits of physical activity may improve back health in young people.

Recovering from disc surgery can be difficult for some patients. Doctors don’t know why some patients get better quickly while others don’t. Doctors and therapists are looking for ways to help make rehabilitation quicker and more effective after disc surgery. Recent studies have focused on the mental part of rehab. The theory is that it may not be enough to fix the physical problems. Doctors and therapists need to help patients lose their fear of pain and of doing certain movements.

The theory is good, and some research looks promising. These authors in the Netherlands tested such a program for patients who had surgery for a herniated lumbar disc. The patients were still in pain six weeks after surgery. The rehab program was called behavioral graded activity (BGA). The BGA program involved exercise training. The training was designed to teach patients that it was fine to move. Exercises were designed for each patient. The exercises got slowly harder over time. Therapists and doctors gave lots of encouragement to patients.

The BGA patients were compared to a group of similar patients who got the usual care. The authors compared pain, function, fear, and opinions between the two groups. They found no major differences. The authors note that usual care may not have differed as much from BGA therapy as was expected. Many doctors and therapists giving usual care encouraged their patients to move without fear. And BGA therapists often turned to traditional care. Still, the authors found no reason to recommend BGA therapy to patients having problems after disc surgery.

Some pain patterns are hard to figure out. Take for example this case study of one-sided testicular pain. A 36-year-old policeman had back pain for five years. Sometimes he also had testicular pain with it. He was unable to wear a bulletproof vest because of back and groin pain.

His symptoms got worse with sharp buttock pain and leg numbness. Pretty soon he couldn’t wear his police belt. He couldn’t lie down flat to sleep at night. Long periods of sitting and standing made his symptoms worse. He was unable to run and couldn’t do his job.

An MRI showed a small disc problem at the bottom of his thoracic spine. This section at the bottom of the rib cage is called T12/L1. He was sent to physical therapy to help manage his pain. The therapists report the findings in this case study. The buttock pain was caused by pressure on the T12/L1 spinal nerve as it passed through the muscle.

A similar problem caused the testicular pain. The nerve to the scrotum travels up and passes through the psoas, a hip flexor muscle. A treatment program was started to improve spinal movement and hip flexibility. Mobilization of the spine and stretching were used.

The patient’s buttock and groin pain went away after the fourth treatment session. The patient was taught how to use trunk and stomach muscles correctly. Trunk and leg strengthening were also included. By the end of 12 sessions, the officer could wear his police belt and vest for an entire eight-hour shift with no pain. Two months later he was still pain free and back to work full-time. He was also able to resume his workout schedule at the local gym.

The therapists conclude that knowing anatomy and nerve pathways made it possible to find and treat the problem correctly. This case shows how problems in the spine can cause testicular pain. Physical therapy can play a vital role in cases like this.

Without muscles and ligaments, the spine would collapse. When the stomach muscles and the diaphragm contract, there’s an increase of pressure inside the abdomen. This is called intra-abdominal pressure (IAP).

What’s the effect of IAP on the spine? According to physical therapy researchers in Australia, IAP increases the stiffness of the spine. Increased stiffness means greater stability and more control of the spinal motion. Pigs were used to measure how much motion occurs between the vertebrae when the diaphragm or abdominal muscles are stimulated. The diaphragm is a dome-shaped muscle that separates the chest from the abdomen. It moves up and down when breathing.

Only one of the abdominal muscles was stimulated (the transverse abdominis, or TrA). The TrA goes across the belly, rather than up and down. By contracting and applying downward pressure, the TrA helps us force air out of the lungs, pass stool, and vomit. The muscles were tested in three ways: (1) both sides of the diaphragm contracting at one time, (2) both sides of the TrA at the same time, and (3) just one side of the TrA at a time (left, then right).

First the researchers measured how much movement occurs between the third and fourth lumbar vertebrae (L3 and L4) when there are no muscles contracting. They compared this control value to what they found with each of the three tests. The results show that contracting the diaphragm or the TrA does indeed reduce motion between L3 and L4. This increases the stiffness (and thus the stability) of the spine.

Increasing spine stiffness relies on three things. The muscles must be attached to the spine properly. The muscles must contract normally. And there must be an increase in IAP. These findings are important because other studies show TrA contraction may be delayed in people with chronic low back pain.

The authors suggest weakness of the transverse abdominal muscle may lead to decreased spinal stability. At the same time, when breathing is increased and the diaphragm is weak, the lumbar spine is affected. This information is helpful for physical therapists working with back pain patients. A program of strengthening exercises for the diaphragm and the TrA may be needed to improve spinal stability.

You may have heard the term matrix in a math class. Or perhaps you’ve watched the popular movie series by the same name. Matrix is a structure or base from which something else can grow. In the body, the matrix is a scaffold that allows cells to fill in and form tissue, such as cartilage.

Chondrocytes are cells in cartilage that help make the matrix in discs between the vertebrae. They can even build the matrix when they are damaged or removed from the body. Perhaps there’s a way to use chondrocytes in the discs to help repair damaged discs. That’s the focus of this study in dogs.

The researchers removed disc chondrocytes from 18 dogs. The chondrocytes were used to grow more cells for the matrix. These cells were then reinserted into the same dogs. The lab-grown chondrocytes were returned to the same disc 12 weeks later. The disc tissue was analyzed at three, six, nine, and 12 months after the cell transplantation.

The researchers measured many parts of the bone, discs, and matrix. They looked at changes in disc height, density of the matrix, color of the bone and marrow, and presence of fluid or swelling. They found that the longer the cells were present, the more changes could be seen.

For example, it wasn’t until 12 months later that an increase in disc height was observed. New growth in the disc was seen by six months and continued to increase after that time. The scientists wondered if these changes were from the transplanted chondrocytes or just the result of the normal healing process. They were able to find proof that the transplanted chondrocytes formed the new matrix.

The authors conclude that removing chondrocytes from discs (even damaged ones) may be a new treatment for disc problems. The cells grow in number in a lab and are later reinserted into the patient’s own discs. A new matrix forms similar to normal disc material. This method may be able to keep discs from breaking down and to treat discs already damaged in adults.

Only 48 cases of traumatic L5/S1 spondylolisthesis have ever been reported. A traumatic fracture in the last vertebra in the low back is rare. Spondylolisthesis is the slippage of one bone over another in the spine. After the lumbar bone breaks, it slides forward over the bone below it.

This type of spinal fracture and dislocation must be treated right away. As the L5 vertebra slips forward over the S1 segment, the end of the spinal canal narrows. This puts pressure on the nerves in the spinal canal. This condition is called cauda equina. Permanent nerve damage can result.

What’s the best way to treat this problem? Open surgery to realign the bones and fuse the spine is advised. How do we know this? We learn from case reports like this one. When only a small number of cases exist, doctors rely on reports from other physicians who have treated similar patients.

In this case report, a 21-year old man was thrown from a car and had a L5/S1 fracture- dislocation. X-rays, CT scans, and MRIs were all used to find the problem. These imaging studies helped the doctors see bone fractures, bone slippage, disc rupture, and damage to the ligaments. With this information, the doctors could plan the best operation for the problems present.

The operation was a success, and the patient recovered with only slight and occasional low back pain. There was also an area of numbness on the right foot. Reporting these findings is important for future cases of traumatic L5/S1 spondylolisthesis. Previous cases treated in different ways haven’t always done so well.

The authors conclude that case reports and modern imaging studies make it possible to successfully treat rare traumatic injuries. In this case, quickly removing bone and fragments took pressure off the nerves. The severe damage was minimized, and the patient had a good final result.

Many studies have shown that back pain is a common problem among adults. Very little is known about back pain in adults over 75. This study presents information on back pain in Danish twins aged 70 to 102 years old.

The researchers report that back pain is common in old age. It’s often part of general poor health and linked with other diseases. Migraines, lung disease, heart disease, and stomach ulcers are all linked with back pain. So are joint problems, osteoporosis, and bone fractures. Women are more likely to have worse back pain than men. It’s not known if this is because they have worse general health or because of some other factor. Living alone is linked with back pain for men.

According to this study, years of education aren’t always associated with back pain for men or women. Other studies have linked lower levels of education with back pain. The authors aren’t sure if the age of the subjects in this study cancels out the effect of education. Maybe back pain from physically demanding jobs isn’t reported because of retirement.

There are two major findings of this study: (1) Back pain occurs just as often in the older adult as in the younger population. (2) Back pain in old age occurs along with many other health problems. Preventing and treating back pain in seniors is complicated because of its link to other health problems. Doctors will face this challenge more and more as the number of people over 75 increases.

In Benjamin Franklin’s day, nothing was certain but “death and taxes.” Today we can add one more thing to that list: back pain! Research shows that back pain is one of the biggest health problems in the United States. The older we get, the more likely it is that we will have back problems.

In this article, Dr. Mark Melhorn from the University of Kansas School of Medicine gives us his opinion about work-related back pain. In particular he focuses on occupational spine care. Several questions are asked and then answered. The questions include:

Doctors know that epidural injections help some patients with mild to moderate sciatica pain. The cause of the pain is usually from a herniated disc. Medicine is injected into the epidural space within the spinal column, around the spinal cord. It would be helpful to know which patients will get relief of pain with this treatment. Are results based on age? Gender? Lifting? Pain medications? Social Security disability? workers’ compensation? These are some of the factors researchers at the University of Michigan Spine Program looked at as predictors of results.

They reviewed the charts of 76 patients. All patients had studies done to show that a disc pressing on a spinal nerve root was the cause of their pain. Imaging studies pinpointed the location of the problem so that an injection could be given at that site.

Patients were rated as better, same, or worse in terms of pain and function. Age, height, weight, and gender didn’t seem to make any difference in results. The two major predictors of outcomes were heavy lifting and getting Social Security Disability Insurance (SSDI) or workers’ compensation (WC). In this study, patients with heavy lifting, SSDI, or WC didn’t get better after getting an injection. They had just as much pain and needed just as much medication. Patients who were working when they first came for treatment tended to have a better result. Injections also seemed to have better results when it was clear that there was pressure on the spinal nerve.

The authors report that this is the first study to link physical demands of the job with poor results after injection for sciatica. They suggest using injections for patients who don’t have SSDI or WC and who don’t have a job that requires heavy lifting. An epidural injection for these patients may have a better chance of lessening pain and reducing the need for drugs.

The authors conclude these are just two factors to use when deciding treatment for sciatica. More studies are needed to narrow down who can and can’t benefit from epidural injections. Patients who aren’t likely to get better with injections can avoid the risks that come with this form of treatment.

Are patients happy with the results of degenerative spinal surgery in the back? Is their satisfaction based on symptoms or ability to walk after the operation? Doctors in Japan are following a group of 83 patients to find out. Doctors used to ask patients to rank the results after surgery by using a scale from poor to excellent. As medical costs continue to go up, more questions are being asked about the results of treatment. Patient satisfaction has become an important measure of health-care quality.

Degenerative spinal stenosis (DSS) refers to a narrowing of the spinal canal. The spinal canal surrounds the spinal cord. Degenerative means that the condition gets worse over time. DSS occurs as part of the aging process for many patients. Changes in the joints, ligaments, bones, or discs can cause DSS.

In this study all patients had surgery to remove a piece of vertebral bone, ligament, or joint. The purpose of the operation is to take pressure off the nerves inside the spinal canal in the low back. After the operation the doctors asked patients about back and leg pain and numbness or tingling in the legs. Symptoms were compared at rest and during walking. Walking time was also measured (how long the patient could walk without stopping).

The doctors also asked each patient, “How satisfied are you with the results of surgery?” The authors report that patients were affected most by how severe the pain was after the operation. The more pain relief they had, the happier they were with the results. Walking ability was important, but not as much as the intensity of pain.

Anytime you have major surgery, your doctor has help. There are nurses, anesthetists, and surgical assistants. Other doctors are involved, too. In the case of spinal surgery, the extra doctor may be a general surgeon. A specialist in the heart and blood vessels called a vascular surgeon may be on hand.

Who does a better job? The orthopedic spine surgeon or the doctor who is assisted by another specialist? This is the focus of a study from a United States spine surgeon. Only one type of operation was reviewed: anterior spinal surgery. In these surgeries, the body is opened from the front. The reason for the surgery varied among the 450 patients enrolled. Some had spinal deformities. Others had fractures, tumors, infection, or disc disease.

The researchers compared complications due to the method used to open the body. Problems included amount of blood loss, length of surgery time, number of deaths, and number of blood vessels damaged. The researchers found a big decrease in problems among patients treated only by an orthopedic surgeon. Problems in the group operated on by an orthopedic surgeon along with another surgeon were much higher.

The authors conclude that orthopedic surgeons should be able to operate on the spine using an anterior approach without the assistance of another surgeon. In many places orthopedic surgeons aren’t allowed to do this without special training. Some centers don’t allow it even when the doctor is qualified.

This report supports the idea that training should be changed to include this method of spine surgery. The researchers think this training should be offered to any orthopedic surgeon who wants to get approval for these techniques.

Surgery to fuse the lumbar spine doesn’t always work. Research shows it’s getting better, with 80 percent success in the short run. This is up from the previously reported 50 percent. But there are still problems with pain from the bone graft, bracing, and unwanted motion at the fusion site.

If fusion is the last step in treatment, what can be done next? Try total disc replacement (TDR). The TDR implant preserves motion and normal spinal alignment. This prevents more damage in the spine. With a spinal fusion, the loss of motion at the fused area transfers the force and load to the level above or below it. The result is degeneration of these segments.

This is the longest study so far showing the results of TDR. Forty-two patients received a special replacement disc called a Prodisc prosthesis. They were followed for an average of eight years. Range of motion at the level of the disc replacement and damage at the levels above and below were measured.

The researchers report at least two-thirds of the patients kept their forward and backward motion in the low back area with a TDR. This is important. Without the motion, there’s no difference between a TDR and a fusion. They found that women are less likely to have as much motion as men. The reasons for this are unclear.

The authors report that there are still a lot of unknowns in this area of research. How much motion is needed to avoid problems? Why do women tend to have less motion after TDR compared with men? How does the Prodisc model compare to others now on the market? How does TDR compare to fusion 10 or even 20 years later? More research is planned by these scientists to find some answers.