News Category: General Spine

Back pain and spine problems are common in young people. Research has been done to try to determine whether carrying heavy backpacks for school has anything to do with the problem. These authors looked through the literature and summed up current thinking on the issue.

The research makes it clear that a backpack or book bag weighing more than 15 to 20 percent of a child’s weight is related to back pain. Wearing or loading the backpacks or bags incorrectly only adds to the problem. And it is known that kids with back pain are more likely to have back pain as adults.

Here are some highlights the authors found in the research:

After 20 years, researchers are still trying to find surgical cement that can be easily injected into the spine to fuse it. The cement must be able to fuse the bones together, keep the spine aligned properly, and hold up against twisting and shearing forces.

Currently, spine fusion is done with pieces of bone or bone dust called a bone graft. There are many problems with bone grafts, especially when the bone is grafted from the patient’s own body (an autograft). Scientists are looking for cement that will substitute for bone to avoid these problems.

In Germany, an injectable calcium phosphate cement (CPC) was used in sheep models. The size and shape of sheep and human spines are similar, making comparisons possible. The fusion was done using a method called transpedicular lumbar interbody fusion (TLIF).

TLIF requires making a hole through the pedicle bone. The pedicle is part of the bony ring that circles the spinal cord. The disc is removed from between the vertebral bones. Then, the cement is injected into the disc (interbody) space through the hole in the pedicle. The cement sets up between the two vertebral bones, allowing them to grow, or fuse, together.

Two groups of sheep were studied. One group received a bone graft or bone chips to fuse the spine. CPC was used with the second group. In almost all cases, the cement cracked and broke into pieces. The cement and nearby bone was absorbed, and inflammation occurred in that area. The spine was unable to withstand the force of movements such as twisting or bending.

No problems occurred in the bone graft group and fusion took place. The authors of this study conclude that no cement exists yet that will fuse the spine using the TLIF method and hold up against shear forces. Fusion with bone graft is still the preferred method. More research is needed in animal models before clinical trials for humans can be done.

Total disc replacement (TDR) continues to be a heated topic. But after 15 years, there’s still no evidence that disc replacement is reliable over a long period of time. These authors report that TDR should be considered an experimental operation until proven safe.

There are two parts to the natural disc: the central part called the nucleus and the outer layer, the annulus. Both parts are replaced in TDR. An implant of this type is referred to as an artificial joint or disc arthroplasty.

There are still many questions about the use of these devices. For example:

Worldwide research continues to understand disc herniation. The disc is the soft but firm material between vertebrae in the spine. When aging or injury breaks a disc down, problems can occur.

The effects seem to depend on whether the disc merely bulges outward or if the center of the disc, called the nucleus, actually squeezes out of its space. When the nucleus pushes out of its normal space, it is called a herniation. A herniated nucleus may put pressure on the nearby spinal nerve.

Disc problems can cause pain. Additional problems can happen if pressure is placed on the spinal nerve. In these cases, weakness and changes in sensation occur in the areas where the nerve travels.

New research shows that a disc herniation adds a new dimension. The chemicals within the herniated nucleus create additional problems when they come in contact with the nerve.

This study looked at what happens with a disc bulge, a bulge that puts pressure on a nerve, and a herniation in which the nucleus contacts the nerve or actually presses on the nerve.

No major changes were noted at first. But after one week, the nerve cells started showing differences. Herniations showed the biggest changes, whether the nucleus pressed against the nerve or simply contacted the nerve. However, the damage was much worse when the herniated nucleus pressed on the spinal nerve. The changes were less dramatic when a disc only bulged or when the bulge pressed on the nerve.

These findings could help direct treatment. The amount of chemical irritation around the nerve and actual pressure on the nerve can be measured before and after each treatment. This may help to show which treatment works best for each type of disc problem.

Osteoporosis is the loss of bone mineral density (BMD) that tends to occur with aging. It is especially common in women who are past menopause. Osteoarthritis (OA) of the spine is another condition that affects the bones. These two conditions are known to be different diseases with different causes.

Since osteoporosis and spine OA both happen with aging, it seems like they would both be seen in older patients. But that is not the case. In fact, this study agrees with past research showing that patients with spine OA actually have greater BMD in the spine.

These researchers wanted to get an accurate measure of the relationship between osteoporosis and spine OA. They used sophisticated X-rays to measure BMD in the spine and the hip of postmenopausal women. They found that patients with spine OA did indeed show higher BMD in the spine. This “inverse relationship” suggests that the presence of spine OA means there’s less possibility of also having low BMD (osteoporosis). Notably, the patients with spine OA also tended to have higher BMD in their hipbones.

No one knows yet what to make of the relationship between osteoporosis and spine OA. Perhaps the presence of spine OA increases hormones that help to counteract osteoporosis.

Research like this is laying the foundation for doctors to understand what happens in the bones as they age. The authors recommend further study on genetic factors related to these diseases.

Many studies show that people with ankylosing spondylitis (AS) are helped by regular exercise. AS is a type of arthritis that causes the bones of the pelvis and spine to fuse together. Exercise can help patients with AS gain improved movement, posture, and fitness.

Doctors often advise a lifetime of daily exercise. But how many patients actually heed this advice? This study surveyed 1500 patients with AS to find out about exercise patterns. The author expressed disappointment about the findings. Patients who are more disabled reported exercising more often. Younger patients with AS who are less disabled were generally less willing to exercise.

Knowing the benefits of exercise is one thing. Finding ways to motivate AS patients to do the exercises is another. The unfortunate motivator found in this study was a greater amount of disability from the disease. Those with more severe disability were more likely to exercise consistently.

Exercise is key to a healthy future when AS is a part of that patient’s life. Regular exercise starting early in this disease shows a link to better future health. In the past, the question has been which exercises are best for AS. The main concern now is how to get patients with fewer problems and less disability to exercise at all.

Exercises need to be effective in keeping the patient flexible and with good upright posture. There also needs to be a way to make the exercises attractive enough to keep the patient interested over a lifetime.

Joints in the body can tell what position they are in. Joint position sense is called proprioception. When a joint is injured, proprioception can be damaged. Scientists are studying this special joint function. If we can understand how joint sense works, there’s a chance to help repair it after injury.

There are joints in the spine, too. Back pain can alter joint sense in the back. Researchers are in the early stages of studying how this works. One area of interest is the accuracy of joint positioning. This looks at how well a person can return to a position after moving out of it.

Some studies have only used one test position (standing). Physical therapists and other movement experts at McGill University in Canada are studying spine position sense in other positions, too.

Recently, they tested a group of 70 men between the ages of 20 and 51. No one had back pain and all were manual laborers. The three positions used were standing, sitting, and on hands and knees called four-point kneeling (FPK). The men were tested with their eyes open and also blind folded.

The men assumed each position, then moved out of the position, and returned to the same position as closely as possible. Measurements were taken of how well they returned to the original positions. As reported in other studies, the men were best able to return to the same standing position. The most difficult position to resume was FPK.

Lumbar (low back) spine position seems to go from best to worst when comparing positions of standing and FPK. Researchers reported this was true with and without vision. The authors think this has something to do with the affects of gravity, the position of the hips and knees, and the way muscles contract in different positions.

Position sense in the spine must be taken into consideration during rehabilitation for back pain. The results of this study show that exercises to train proprioception should include more than one position.

Soccer is one of the most popular sports in the world. It’s an intense sport with bursts of sudden speed. Players must also be able to stop suddenly, jump, twist, turn, and kick the ball while on the run.

Injuries are common among soccer players. Most of these occur in the legs with at least one-fourth affecting the thigh and groin. Efforts to reduce injuries are being made by coaches, players, and team trainers and physical therapists. In Belgium, a study to find risk factors for injuries was done.

Physical therapists measured leg flexibility in 146 professional soccer players before the season. The flexibility of four muscles was measured. These included the hamstrings (behind the thigh), the quadriceps (front of thigh), adductors (inner thigh), and calf muscles.

For each muscle, the players were divided into two groups. One group had no injuries, the other were injured during play. An injury was defined as any tissue damage that kept the player from practicing or playing soccer.

The researchers found that decreased flexibility of some muscles is a risk factor for injury. The injured group had less flexibility in the hamstrings and quadriceps muscles. Injuries to the muscle or tendinitis of the knee are common problems when these muscles are tight.

The authors of this study suggest preseason flexibility screening for soccer players. Finding players at risk for hamstring or quadriceps injury may help reduce these problems. Stretching may be the first step. Other studies are needed to prove that stretching prevents injuries.

Many things about back pain remain a mystery. Nerves have been found in and around the spine in the joints, the ligaments, and the outer covering of the disc. Until recently, nerves to the bones of the spine (the vertebrae) had not been identified.

Over the years, researchers have found nerves inside the bone marrow in the human spine. Animal studies showed nerve tissue in the vertebral bones of rats. It wasn’t until 1998 that this same discovery was made in the human vertebrae.

Since then, a group of researchers have been able to remove nerve tissue in the human vertebrae, cut it into sections, and stain it. The stain makes it possible to see the tissue under a microscope. Once nerve cells are found, these are stained again to show substance P.

Substance P is a messenger in the nervous system. It sends pain signals. In this study, scientists found substance P in every sample of nerve tissue removed from the vertebral bones. This means that the bones of the spine can send pain messages.

The authors conclude that some patients may have back pain caused by the bone itself. How much back pain is caused by nerve tissue inside the bones is still unknown. Finding out more about these nerves may lead to new and better ways to treat back pain.

Many studies report that women suffer more back pain than men. No one is exactly sure why. Pregnancy, hormones, natural bone loss before menopause, and different lifestyle and work environments have all been suggested as possible factors.

Because back pain is such a major cause of absence from work, it is important to understand more about why women seem to be more affected than men. This study outlined the effects of pregnancy on the statistics for back pain. The researchers looked at records for missed work days over the course of one year for all insured workers in a city in Sweden. All of the workers were between the ages of 16 and 44.

Women did have a higher rate of missing work for back pain than the men. However, when men were compared to non-pregnant women, the numbers were about the same. Pregnant women accounted for 37 percent of women who missed days of work because of back pain.

In other words, the small number of pregnant women badly skewed the statistics for all women. The authors stress that pregnancy must be taken into account when looking at the data about back pain in women.

The pelvis connects to the spine at the sacrum. (The sacrum is the triangular bone in the lower spine that fits between the bones of the pelvis.) This connection is called the sacroiliac joint (SIJ). The SIJ may not move much, but it can still cause a lot of pain if it isn’t functioning well.

SIJ problems can be a source of chronic pain. The pain often radiates to the groin, buttocks, thigh, and even to the foot or abdomen on the same side as the painful joint. SIJ pain can happen after surgery to fuse vertebrae of the lumbar spine and the sacrum. Doctors think this is because the fusion shifts force onto the SIJ.

The problem with pain caused by SIJ is that it is hard to diagnose. Several other problems can cause similar symptoms. Physical exams, X-rays, and other types of scans may help rule out some of these other problems, but they do not positively identify a painful SIJ. The only way to tell seems to be to inject a local anesthetic into the SIJ and see if the patient feels pain relief.

These authors looked at records for 34 patients in their spine clinic who needed an SIJ injection after having fusion of the low back vertebrae to the sacrum. Over half of the patients had greater than 75 percent relief of their pain 45 minutes after the SIJ injection. Another 18 percent got some pain relief. But 24 percent had no pain relief from the injection.

Bone graft material used to fuse vertebrae is sometimes taken from the top of the pelvis bone. The authors found no relation between SIJ pain and whether bone graft was taken from the pelvis. Only 25 percent of the patients in this study had bone taken from the pelvis. In these patients, there was no relationship between the side of the SIJ pain and the side where surgeons had gotten the bone graft.

Based on these results, the authors concluded that the pain in about one-third of the patients definitely came from the SIJ. The pain was “possibly” caused by the SIJ in another 29 percent of the patients. The authors suggest further research to better understand SIJ pain after lumbar fusion surgery.

Spinal fusion is a treatment used for a variety of back problems. Two or more spine bones (vertebrae) are generally fused together using bone graft. The graft eventually heals to the bone above and below, forming one solid section of bone. One method of spine fusion involves using screws to hold the spine steady while the graft heals.

Fusion may be used for spine problems arising from cancer to the bone, trauma, disc disease, or scoliosis (a sideways curve of the spine). In these cases, the fusion is used to restrict extra movement in the problem area of the spine.

Successful fusion is thought to depend on the disease present and the number of vertebrae that need to be fused together. The rate of good fusion differs from disease to disease.

Doctors at Emory University in Georgia studied success rates for spinal fusion. They observed 457 patients during a seven-year period, one of the largest series of patients studied in one center. This gave the doctors a baseline to compare against newer methods in the future.

In all cases, screws were used to help with the fusion. The screws were placed in the pedicles of the vertebra. The pedicle bones connect to the back of each vertebrae, giving bony protection to the nerve tissues inside the spinal canal.

Pedicle screws have been used for spinal fusion since the 1980s. This study with its large number of patients and variety of diseases gives doctors a benchmark of data. As new ways to fuse the spine are found, doctors can check the results against today’s standard method using pedicle screws.

Fusion of the neck is an ever-changing process. Since the late 1950s, doctors have been able to operate on the neck and perform fusions using an anterior approach. This means the surgeon opens the neck (cervical spine) from the front (throat side) rather than the back of the neck.

Two or more bones of the cervical spine are fused together using pieces of bone shaved from another site. The graft may come from a donor or directly from the patient. Sometimes problems occur with this operation. The problems can be caused by the operation, the graft process, or from the fusion material.

The goal in all methods is to hold the cervical spine in place while saving the natural alignment. This is hard to do when there are problems such as fractures, infection, graft collapse, or graft rejection. For this reason, scientists are trying to find a good substitute to replace the bone graft.

Scientists in Japan are using a man-made ceramic material instead of actual bone. They used dogs in the first study. Two levels of vertebrae were fused together. The first used the bone graft method usually done in humans. The second used the ceramic substitute. In all cases, dogs were the patients.

The fusion material was put in a “fusion cage.” These cages are tiny containers and are commonly made of titanium. The cages are packed with bone graft material and placed between the two vertebral bodies. The fusion cage was invented in the 1980s. The cage is designed to prevent collapse of the bone graft during the natural healing process.

Researchers found that there was no difference in the results using bone graft or a ceramic substitute. The authors conclude that there’s no need to harvest bone from the patient or donor. The cage filled with ceramic fusion material increases the bone strength needed to get the problem vertebrae to fuse together. By using this bone fusion material as a replacement for actual bone grafts, it reduces problems that can come from grafting bone.

There have been many changes in the past 20 years in surgery to correct the sideways curvature of the spine called scoliosis. The standard operation up until the early 1980s used upright bars called Harrington rods. A rod was placed on both sides of the spine. Hooks were used to secure the rods to the bones.

Screws were later used in place of hooks in the low back to get better correction of lumbar curves. Recently some doctors in Germany found that screws can be used in the thoracic spine with good results. The thoracic spine is the middle portion of the spine from the base of the neck to the bottom of the rib cage.

Not only do the screws give a straighter spine, but they also hold the curve in place with less loss of correction. There are two possible reasons for this. One is that the screws give greater resistance to the force of tension on the spine. The second is that the screws are positioned in a different place than the hooks. This is thought to give them better leverage.

There are other reasons to use screws instead of hooks in scoliosis surgery for the thoracic spine. A shorter amount of the spine needs to be fused when using screws. There is generally also less blood loss during this surgery, and there are fewer problems after the operation.

Doctors have been using screws, pins, wires, and plates to hold bones together for a long time. In the spine, these implants are used most often when bone has been grafted to hold two or more vertebrae. The “hardware” is used to hold the grafts and bones in place until fusion takes place.

Metal implants of this type can have some problems. The implant may move away from its intended spot. It may simply not work as designed. Metal of any kind makes it more difficult to use X-rays to “see” what’s going on in the bone underneath. Sometimes, if there are problems, a second surgery may be needed to remove the hardware.

Researchers have been looking for ways to improve implants. Newer implants are bioabsorbable. This means they don’t have to be removed once the job’s done. The body will send enzymes to break down the material and absorb it into the body.

Bioabsorbable materials must be strong enough to hold the bones in place. They should be translucent, which means X-rays will not be blocked by their presence. The material must be something the body can break down and sweep away without disrupting normal cell life.

Many studies are underway to develop bioabsorbable materials that can do all these things. Doctors are looking for ways to improve the rates of successful spinal fusion. These new implants may be that answer.

Bone grafts are used in spinal fusion surgery. The graft material grows into the surrounding bone, essentially “healing” two or more vertebrae together. The faster the graft grows, the better. Problems usually arise if the bones do not heal together, so doctors have tried different ways to improve the rate of healing. Over the past 25 years, surgeons have used electrical currents to promote faster growth of the bone graft.

Electrical stimulation in spinal fusion is an evolving technology. There are several ways to apply electrical stimulation. The different methods are based on different theories of why and how electrical stimulation works. The main three methods of electrical stimulation are direct current, pulsed electromagnetic fields, and capacitative coupling.

It is not always clear which type of stimulation will work best. The technology is still too new, and not all spinal fusion surgeries are alike. Spinal fusion is done for a number of different spine problems. There are also several different surgical techniques that can be used.

These authors sorted through the existing research on electrical stimulation. Their review suggests that electrical stimulation can improve the success rate of spinal fusion. They found that direct current seemed to work better than the pulsed electromagnetic fields. Capacitative coupling is too new to know for sure, but it also seems to be more promising than pulsed fields. The authors expect increased use of electrical stimulation in future spinal fusion surgeries.

Many pregnant women suffer from pelvic pain. For some of them, the pain lasts even after the baby is born. Doctors don’t understand exactly what causes it or how best to treat it. This is one of many studies that try to make some headway in understanding pregnancy-related pelvic pain (PRPP).

Hormonal changes during pregnancy loosens the pelvic joints in preparation for delivery. In earlier research, this team of authors found that PRPP seemed to be related to asymmetric laxity of the sacroiliac (SI) joints in the pelvis. The sacroiliac joints are where the blade of the pelvis meets the sacrum, near the bottom of the spine. Asymmetric laxity means that one SI joint was looser than the other.

In this study, 123 women were tested for PRPP. At 36 weeks into their pregnancies, SI joint laxity was measured using a special type of ultrasound called doppler imaging. The women also answered questions about pain and disability and were tested for PRPP. Their pain was rated as “none or mild” or “moderate to severe.”

The tests were then repeated eight weeks after giving birth. Most of the women with PRPP had gotten better by then. However, 65 percent of the women who had asymmetric laxity in the first test still had moderate to severe pain. Notably, of those with asymmetric laxity in the first test, only a mere five percent had mild to no pain.

This means there’s a definite link between asymmetric SI laxity and PRPP. The authors indicate that laxity of the SI joint during pregnancy makes it three times more likely that the new mother will have moderate to severe PRPP after delivery.

When it comes to lifting, women are not smaller versions of men. This is an important research finding as more and more women enter physically demanding jobs. It’s not uncommon to see women performing jobs that have always been done by men in the past.

Work demands aren’t usually adjusted for women. Does this put them at increased risk of injury? What are the actual differences between men and women when performing heavy lifting? These are the questions for which researchers at a biodynamics lab at Ohio State University are seeking answers.

Earlier studies have shown that there are differences in muscle anatomy between men and women. Men have more muscle fibers. Muscle fibers are laid down in different directions for women. Trunk proportions vary between the genders. Pelvic width is wider in women. It turns out that all of these factors make a difference when lifting heavy objects.

Women have less strength in the low back and tend to use their pelvis more when lifting. Men use a lifting style that relies more on trunk motion. Women use extra muscles in the trunk, back, and pelvis to complete lifts. Lifting in this way helps reduce the load on the spine. However, the spine in a woman can’t tolerate as much load as men can handle.

Women are injured more often than men when lifting similar heavy loads. This can be accounted for by differences in muscle anatomy, body proportions, and spine load tolerances.

Low back pain is a common problem with many possible causes. One possible cause is the facet joint. Each bone in the spine (each vertebra) has several joints. The facet joints line up on the back of the spine, connecting vertebrae to each other. The facet joints glide across one another as the spine moves.

Pain from an ailing lumbar facet joint is usually caused by the changes of aging. Like other joints in the body, facet joints can become arthritic. The lining of the joint can become thin and worn from past injury and daily activity. Pain can be extreme because of the rich supply of nerve endings to the joint.

Isolating the problem to the facet joint can be difficult. There isn’t one test that doctors can use to show that the problem is coming from the facet joint. The only way to know for sure is to block the nerve from sending and receiving signals to the joint. Blocking can be done using a local anesthetic injected into the nerve or joint.

Accurate injections are possible now with advanced imaging technology. The doctor can see to guide the needle to the exact spot. Patients can report results of the block before the doctor permanently destroys the nerve. If the pain is gone or reduced at least 50 percent, then the nerve to that joint is destroyed with a probe in a method called lumbar facet kryorhizotomy.

Kryorhizotomy is a new way to carefully destroy the precise nerve going to the facet joint. The first study from Switzerland has just been reported. This form of treatment is easy to use, safe, and can be done more than once if pain relief isn’t complete. It works best for patients who haven’t had a major back surgery in the past.

Say zygapophysial. Zyga what? Now say this: low back pain. Now that’s an all-too-familiar term. In many instances of low back pain, it’s actually the zygapophysial joints that are causing the pain. These spinal joints are also known as facet joints. These flat, smooth-surfaced joints make it possible for us to twist, turn, bend, and straighten.

Researchers gathered available information on treating problem facet joints. They reviewed all of the articles on the topic. Their goal was to find out the best way to treat this condition and who gets the best results. They found studies focused on two areas of treatment: injections into the facet joint and radiofrequency (RF) to cut the nerve that goes to the problem joint.

The authors report that injections are good to help find the problem, but they don’t usually work to solve the problem. Treatment with RF was more favorable. Each study reported a positive response to this form of treatment. Patients got pain relief that lasted. Cutting the nerve involved less time and cost than other treatments for painful facet joints. Even patients who had pain for five years or more got relief.

Not all the studies agreed. The researchers think that more (and better) studies are needed to sort out the best ways of treating painful facet joints.