Slipping Back in Time to Keep Spines from Slipping Forward

Spondylolisthesis is a medical term used to describe a vertebral body that slips forward on the one below. The problem is associated with hyperextension of the spine, as often happens in sports like gymnastics and football. This extreme backward bend in the spine focuses stress on a section of the bony ring around the spinal column. In some cases, this can cause the bony ring to fracture, allowing the vertebra to slip forward on the one below.

People with spondylolisthesis may find relief from a combination of treatments like medication and physical therapy. However, if the pain continues, nerve problems start. If the vertebra has slipped too far, surgery might be needed.
Various surgical procedures have been used over the years to help people with spondylolisthesis. History is a wonderful teacher, especially when it comes to finding out which surgical procedures seem to work the best. Unfortunately, there isn’t a lot of information that shows how people are faring many years after surgery for spondylolisthesis. The researchers for this study went back through history to see the long-term benefits of two different types of surgery.

This follow-up study reviewed 22 patients who had lumbar surgery for spondylolisthesis between 1968 and 1999. Ten patients had fusion surgery. Twelve patients underwent fusion with metal hardware, known as Harrington instrumentation. On average the patients were 17.9 years old when they had the surgery. As part of the follow-up, the authors had each patient examined an average of 15 years after the surgery. Participants also filled out two separate surveys about their back health. The authors also gave the surveys to a group of people who never had back pain. This allowed researchers to compare the surgery patients and the general population.

Most of the surgical patients showed similar results on the surveys. Their results were even comparable to people who had never experienced back pain. However, this was not true when surgical patients were known to have had a large amount of slippage before surgery. The authors believe these results support the use of surgery in patients with spondylolisthesis.

In the past, some surgeons reasoned that attaching hardware onto the bones of the spine would hold the spine in better alignment, make the fusion more solid, and keep the spine from slipping in the future. They expected people with Harrington implants to fare better over the years. Not so in this case. At the follow-up, complications were much higher among those with the implants.

The authors acknowledge that newer types of hardware are being used with improved success these days. However, their results lead them to conclude that fusion alone gives similar long-term benefits without risking the complications of Harrington implants.

Quitters Never Win–Except for Smokers Who Need Spine Fusion Surgery

Cigarette smoking is a well-known risk factor for low back pain. Cigarette smoking also has a negative impact on how well smokers do after spine fusion surgery. It’s a fact: nonsmokers fare better after spine fusion surgery than people who smoke. However, this study is the first of its kind to compare whether quitting smoking could make a difference for those needing spine fusion surgery.

The authors checked the medical records of 188 cigarette smokers and 169 nonsmokers who had spine fusion surgery between 1992 and 1996. All patients were surveyed by telephone at least two years after their surgery date. Smokers were asked questions about how much they smoked before surgery and whether they had stopped smoking before or after surgery. The amount of time they were tobacco-free was also recorded. All respondents were asked whether they’d gone back to work and how satisfied they were with the results of their surgery.

People who smoked the most before surgery had the hardest time quitting. Nearly 80% of quitters who had smoked less than a pack a day before surgery were still not smoking one month after surgery. This compared to only about 40% of people who had been smoking more than two packs per day.

Those who hadn’t quit before having surgery were least likely to quit after their surgery. People who quit before surgery were more likely to be tobacco-free up to six months after surgery. This group also stayed tobacco-free for a longer period of time than those who hadn’t quit before surgery.

A key marker of surgery success is whether the bone graft becomes solidly fused. When the bone graft doesn’t fuse, the complication is called non-union. Nonsmokers had the fewest instances of the bones non-union. Smokers had significantly more problems with non-union than nonsmokers. And there was a trend showing that people who stayed tobacco-free the longest after surgery had better fusion results than those who hadn’t quit.

Going back to work is another way to measure success after surgery. Nonsmokers were more likely to return to work than smokers. However, people who quit smoking for at least six months after surgery showed nearly the same rate of returning to work as nonsmokers. Of people who hadn’t quit smoking, just over half were able to return to work; the other half remained disabled.

People who smoked were generally less satisfied with their results than were nonsmokers. Satisfaction scores among smokers were lowest in those who smoked the most before surgery, and satisfaction improved with the amount of time quitters stayed tobacco-free after surgery.

In view of these results, the authors encourage doctors to make every effort to have their patients stop smoking both before and after surgery. “This effort,” they conclude, “is justified by the expectation for improvement in fusion rate and the likelihood of return to work, as well as an increase in overall patient satisfaction.”

Spines at Risk: Snowboarders Versus Skiers

When heading out to the slopes to snowboard or ski, it’s nice to know the risks that lie ahead. Both sports carry a high risk of injury. But according to this recent study, snowboarders have four times the risk of having a serious spine injury.

According to the authors, the goal of their study was to pull together information that could improve injury prevention programs for skiers and snowboarders. Specifically, they wanted to find out how often people doing these sports injure their spines, and they wanted to find out which types of spine injuries happen the most.
The authors tallied the number of skiers and snowboarders frequenting two ski areas in Canada between 1994 and 1996. The bar codes on the lift tickets ensured an accurate count of the number and ages of people using the lifts at these two resorts. Snowboarders accounted for 15% of the people on the slopes, indicating that its popularity is on the rise.

A total of 56 people had serious spine injuries during the study period. This included 34 skiers and 22 snowboarders. Ten of the skiers were women. All of the injured snowboarders were men. The average age of the skiers was 34.5 years. Snowboarders were generally younger, averaging 22.4 years old.

Skiers were most commonly injured from a fall. Jumping was the main culprit for snowboarders, accounting for 77% of the injuries in this group. Age and sex did not seem to have affect how people were injured. Whether girl or guy, young or old, skiing and, especially, snowboarding are high-risk sports when it comes to spinal injuries.

The authors realize that jumping is a big part of snowboarding and that telling people to avoid jumps isn’t the solution. They do feel, however, that instruction and training on the risks of jumping could be a step in that direction. “Until research defines effective injury-prevention strategies,” they conclude, “knowledge of the risk of snowboarding should be disseminated and techniques for safe jumping should be taught.”

Back Surgery, the Movie–Coming Soon to a Surgeon’s Office Near You

Back surgery is usually optional. Most of the time, patients weigh the pros and cons and decide whether it will work for them. Down the road, research shows that a group of people who had back surgery fared no better–and no worse–than people who did not.

Patients need to know this kind of information when they are considering back surgery. If patients were well informed about their options, it might affect whether or not they chose surgery. What are the best ways to teach people about the pros and cons of back surgery?

This study was designed to answer those questions. It involved 100 patients who were candidates for a first back surgery. Most of them had a herniated disc. The next most common problems were spinal stenosis and sciatica. Researchers divided the patients into two groups. The control group only received a booklet with back surgery information. The second group received the same booklet plus they had access to an interactive video. The video included a touch-screen so people could pick topics of interest. It also showed interviews with patients who had undergone back surgery, with both good and bad results.

The patients were tested before and after going through their information. In both groups, patients who scored high on the pretest  did equally well after getting more information. However, the patients who scored lowest on the pretest had much better scores after watching the video. The low-scoring group was generally older than the group average and included fewer high school graduates.

Patients reported they liked the video better than the booklet. And overall, the video group did slightly better on the test than the control group. The biggest difference was in patients’ choices. Patients who watched the video were much less likely to choose surgery. Only 23% of those who watched the video chose surgery, compared to 42% of the group who only got a booklet.

The researchers concluded that the video format was the best educational tool. Patients liked it better and got better test scores after watching the video. But the researchers also acknowledged how giving patients a simple booklet was helpful, even though the booklet might be considered “low-tech.”

New Thoughts to Keep Back Problems from Becoming Chronic

When back pain or injury becomes chronic, health-care costs escalate dramatically. By offering effective treatment right away, chronic problems might be avoided and costs reduced.  But which treatments work best to keep back problems from becoming chronic?

The way people think about their back problem affects how well they recuperate, which may explain why new types of treatment that help people change their thoughts and behaviors about back pain are showing good results in preventing chronic problems. 

One idea is to help back patients learn to overcome their fears about doing activities. Another school of thought is the cognitive-behavior approach, which gives people ways to cope with their situation in order to counteract chronic problems.

Researchers tested how well the cognitive behavior model compared to simply giving patients information about their problem. The patients in this new model took part in six group sessions led by a behavioral therapist. They learned and practiced ways to solve problems that might happen to people with pain. Other patients only received information. Some got a pamphlet about back pain. The rest received a packet each week for six weeks showing how to keep their backs safe and healthy.

Major benchmarks of how well patients did included the amount of time people were out of work and how often they needed to see their doctor or physical therapist. Levels of pain and ability to do activity were also measured. The authors also kept track of whether fear kept people from doing activities and how patients though about their back problem. 

The results show that the new model can really help, especially when it is used when people first start having back problems. Patients receiving the behavior treatment were nine times less likely to develop chronic problems. They also had fewer visits to their doctor and physical therapist.

The chance of helping people avoid chronic problems improves when a program like this is started soon after back pain or injury. “These findings,” say the authors, “underscore the significance of early interventions that specifically aim to prevent chronic problems.”

Making Butts about Smoking Improves the Chance Smokers Will Quit

Stop! That one word is likely the most helpful advice health practitioners can give to their spine patients who smoke. Many times, patients will quit the habit when they are treated by a health professional who takes the time and effort to help. Too often, however, medical professionals don’t bring up the issue with their patients.

Many smokers responded dramatically when their health provider makes the effort to help them quit. Researchers tracked a group of 3041 spine patients who smoked. Patients got either “usual” or “aggressive” assistance for quitting by their practitioner. The first group got a handout, and their provider occasionally mentioned the patients’ habit. Providers for the other group members brought up the subject and recorded smoking status at each visit. They also gave their patients handouts and educated them about the negative impact smoking could have on their spine condition. 

Over 35% of the patients getting aggressive help quit smoking, compared to 19.5% in the other group. And more patients at least cut down on their habit when they got aggressive help (67% vs. 38%). Merely asking about a patient’s habit had a drastic impact on cigarette usage.

Perhaps health providers don’t bring up the issue because they fear they’ll lose business. This did not happen in the research study. An equal number of patients from both groups returned for ongoing treatment.

Some patients had an easier time quitting. Quitters typically had smoked fewer packs per day and hadn’t smoked for as many years. Older patients also tended to quit easier than younger smokers. The decision to quit usually happened within the first four months of treatment.

The authors conclude that health providers need to be educated on ways they can help their patients who smoke kick the habit. They believe smokers will be more successful at quitting if at each visit their habit is addressed and their smoking status is tracked. Providers need to be a source of support and encouragement for their patients. Surprisingly, using this approach to help patients quit doesn’t cost a lot of money, yet the results can be dramatic.

“It is clear,” conclude the authors, “that the more the health care practitioner shows an interest, the more likely the patient will stop smoking.”