News Category: General Spine

You’ve probably heard about the man who had the wrong leg amputated. Or the woman who went in for a gallbladder operation but had heart surgery instead. Avoiding mistakes like this is the goal of every hospital, doctor, and patient.

The North American Spine Society (NASS) has suggested using a systems-based approach to avoid these mistakes when treating spine surgery patients. Medical care and especially surgery is complex. More than one step is needed to prevent mistakes.

The SMaX system and the Universal Protocol are two methods used to reduce medical errors. Three steps are included: 1) Review the record (make sure it’s the correct patient), 2) Mark the side or level to be operated on, and 3) Recheck before starting the operation. A checklist of steps to ensure patient safety is used. Relying on memory is just another way to miss a step resulting in an error.

Many medical errors are preventable. A systems review is advised. This is much like the preflight checklist used by pilots before flying an airplane. It gives the surgeon an organized way to review important information about the patient, site, and surgery. The result is a safe and successful operation.

Ankylosing spondylitis (AS) and rheumatoid arthritis (RA) are two forms of arthritis that can affect the spine. In this review article, Dr. Borenstein from the George Washington University Medical Center explains how these two conditions are different. Major improvements in treatment are discussed for each form of arthritis.

Both AS and RA are inflammatory forms of arthritis. Both affect the spine although RA is more likely to cause problems in the cervical spine (neck). AS affects the spine from the neck all the way down to the sacroiliac joints and sacrum.

The inflammatory process is similar but the effects are very different. AS affects the entheses, the place where tendons and muscles attach to the bone. Inflammation leads to calcification and stiffening of the soft tissues. The bones start to fuse together. Pain and limited motion are the result.

RA affects the synovial and cartilage linings of the joint including the top layer of bone. The joints become weak and unstable. They can even sublux or partially dislocate. Patients with RA of the cervical spine are at risk for damage to the spinal cord or pressure on the nerve roots.

Treatment for both conditions has improved with the discovery of disease modifying drugs. These medications called tumor necrosis factor (TNF) inhibitors stop the soft tissue changes and joint destruction. Pain can be controlled. Patients are able to maintain function. Details of what these drugs are and how they work are presented.

Surgical treatment is an option for patients with severe deformities or who don’t get better with medical treatment. Spinal surgery to correct deformities and/or spinal fusion are possible for patients with AS. Patients who have RA and develop vertebral subluxations may need a fusion to stabilize the spine and prevent neurologic problems.

Across the United States there’s a wide range in the use of spine surgery. One thing’s for sure: the use of surgery for back problems is on the rise. Researchers for the Center for Cost and Outcomes Research at the University of Washington in Seattle summarize trends in care for back pain patients.

They looked at Medicare, Worker’s Compensation, and hospital data across the U.S. They found that the rate of spine surgery has gone up and up. The number of spine fusions increased 100 percent in the last 20 years. And they noticed a wide range of differences from region to region.

Other trends they noticed included:

Any time tissue is removed from the body it’s sent to the lab and examined. There’s been some question about this practice for disc material taken out of the spine. Should lab work be done every time? In this study scientists from Germany report on the pathology results of over 2,000 degenerative discs removed.

The discs had the usual tears, dead cells called necrosis, and scar formation expected in aging, damaged discs. In a small number of cases infection and malignancy were also found. These conditions were unknown to the patient or doctor.

In one case a 76-year old man with low back pain going down the leg had cancer that had spread or metastasized from the prostate to the spine. In a second case a 30-year old man presented with low back pain that also went down his leg. Disc material removed showed malignant lymphoma. The cancer had spread through the lymph nodes to the spleen, liver, and spine.

The authors say the unexpected but important findings from examination of tissue specimens shows that routine pathology testing of disc material is needed. Early detection of cancer and treatment right away can result in a better outcome for the patient.

The low cost of the pathology report far outweighs the savings in the quantity and quality of life for these patients.

In this report doctors review new filler materials used for bone fractures of the spine. Vertebrae of the spine weakened by osteoporosis or cancer can break called vertebral compression fractures. Cement can be used to repair the fracture or fill in the bone.

But there are some problems with the current filler cements. They can’t remodel or reform the bone. High heat is needed to inject the cement. The heat may damage the blood vessels in the bone. And while the cement is stiff and that’s needed for the fracture, sometimes it’s too stiff and doesn’t allow motion where it’s needed.

Scientists are trying to make new materials that can be absorbed by the bone and help form new bone. These synthetic bone substitutes have been tested in animals such as dogs and sheep. None are ready for use in the human spine yet. Some just cost too much. Others are absorbed quickly but take too long to set up.

The authors report two other important features of bone fillers. They must be seen on X-rays to help guide the surgeon during the operation. The cement must flow through a small needle to inject it into the vertebral body. The cement can’t act too quickly or the needle can get stuck in the bone.

From the review of all studies the conclusion is that the current cement called polymethylmethacrylate (PMMR) really works the best. Better filler materials may be ready in the future. They must be affordable and have better features than the PMMR.

Millions of people use the Internet every year to get medical information. Doctors at the SUNY Health Science Center in New York checked information about scoliosis posted on the Internet.

Three board-certified orthopedic surgeons reviewed the information for accuracy. All doctors were spine experts with at least eight years of practice. They present the results in this report.

Five search engines were used. A total of 50 web sites were reviewed. The web sites were divided into five different kinds. The groups included academic, commercial, physician, nonphysician health professional, and unidentified (for example, message boards).

The results of this study showed that most of the websites scored poorly for content and accuracy of materials. This was true even for academic sites.

The authors are concerned about the accuracy of medical information on the Internet. They suggest doctors welcome patients who are interested in their own health. Doctors should remain the main source of information for patients on topics like scoliosis. Physicians should be aware of what’s on the web. Any websites posted by physicians should be reviewed and updated regularly.

There’s a lot of talk about “core stability” but what is it? And what does it have to do with the legs and injuries? That’s the topic of this article by a group of physical therapists.

Core stability is defined differently by various groups. There’s agreement that the lumbar spine, pelvis, and hip joints are the center of the “core.” This area is called the lumbopelvic-hip complex.

Stability in any part of the body means all the structures hold steady and don’t buckle under force or pressure. Core stability in the human body refers to the ability of the structures to keep the spine firmly in place.

The spine stays steady as the human body changes postures. It withstands all kinds of loads so that the spine acts as a stable base for movement of the arms and legs.

The authors take a look at studies linking lower extremity injuries with core function. They found that leg injuries decrease core stability and vice versa. Core weakness may lead to lower extremity injury. These researchers think that lower extremity injuries may be prevented in athletes with core training.

Given a choice between standard medical care or alternative care for back pain, which would you choose? Patients in the state of Washington who had insurance coverage for both went 50-50.

In this study insurance claims data from two large companies in Washington state were studied. The goal was to find patterns of use and cost between conventional care and complementary and alternative medicine (CAM). All patients in the study were treated for back pain. All had insurance coverage for both types of care.

Of the 104,358 adults treated for back pain 43 percent used only complementary and alternative medicine (CAM). CAM was provided by chiropractors, massage therapists, acupuncturists, and naturopathic physicians.

About 45 percent received conventional care. Conventional medical care was given by doctors, physical therapists, nurse practitioners, and physician assistants. A small number (12 percent) saw both types of providers at least once each.

The authors also reported the number of visits to a CAM provider was double that of conventional care. Men were more likely to see a chiropractor. CAM users were usually younger patients. They had fewer other health problems.

The cost of CAM care was less but so was the amount covered. Most of the extra expense with conventional care was due to X-rays, MRIs, and other imaging tests.

If most people who have back pain get better without treatment, then why bother spending money on medical care or therapy? In this study, researchers discovered that patients in group therapy went back to work a full week sooner. The cost savings and financial benefit may be worth the cost of a “Back to Fitness” program.

Back to Fitness consisted of information, advice, and a simple back program with group exercise therapy. Results for patients in this group were compared to a group of patients who got a booklet on back care, one session of advice, and regular care by their doctor.

Patients in the group therapy exercised three times a week for an hour in a gym. Back and abdominal muscle exercises were done along with a set of spine stabilizing exercises. Everyone went for two weeks unless they went back to work first.

The goal of a Back to Fitness program is to help patients help themselves. The program is simple and easy to follow. Early pain relief allows patients to move on to a fitness program. This study showed such a program results in a speedier return to work.

Researchers in England say spinal shrinkage may be linked to low back pain from disc problems. Discs are largely made up of fluid. When fluid is pushed out of the disc there is a decrease in height and loss of stature called spinal shrinkage.

Less disc height puts more force and pressure on the lumbar spine. The paraspinal muscles along the spine try to help by contracting to support the spine. When this happens stature recovery is delayed and back pain is worse.

These conclusions were made from a study comparing two groups of 20 people each. The first group had a history of chronic low back pain (CLBP). The second group was normal adults of similar ages and gender without CLBP.

A special device called a stadiometer was used to measure height while in a relaxed standing posture. Everyone was measured in the morning while discs are at their fullest height. Electrical activity of the paraspinal muscles was measured. Then each person walked on a treadmill at his or her own pace while wearing a weighted vest. The goal was to compress the spine.

Measurements were repeated after the treadmill walking and again after a period of rest. Stature loss, stature recovery, and paraspinal muscle activity were compared between the two groups before and after spinal loading.

Results showed increase muscle activity after exercise in the CLBP group. There was a slower recovery of spinal height. This put increased pressure on the spine. The CLBP group reported more pain and discomfort in the low back after walking. The authors say increased spinal loading of this type may cause more damage in the long term.

It’s not clear that changing paraspinal muscle activity will improve stature recovery and reduce back pain. More study is needed to find the links between these factors.

Kyphoplasty is a safe and effective way to treat vertebral compression fractures (VCF) of the spine. It can reduce the fracture and restore spine alignment. It can also restore some of the height lost in the spine from the collapse that occurs with VCF.

These are the results of a study from a group of spine surgeons who did 254 kyphoplasty operations at their spine center. Kyphoplasty involves inserting a long, thin needle into the vertebral body. A small balloon is inflated inside the fractured, collapsed bone. The balloon makes a cavity inside the vertebral body. Cement is injected into the cavity to repair the damage.

Almost everyone had pain relief right away. Those who still had pain often had a second or third bone fracture in the spine. Another measure of success was restored height of the vertebral bone. Using X-rays, the researchers were able to show up to a 50 percent increase in height after kyphoplasty.

The authors say that kyphoplasty can even be used on old fractures. Patients in their study who had pain for months from VCFs improved after kyphoplasty. The low rate of complications from this operation makes it a good option for VCFs.

Which is better for treating low back pain (LBP) in the long-run? Manipulative therapy and exercise along with your doctor’s advice or just the doctor’s information and counsel? This is the question addressed in this study reported by scientists in Finland. They also looked at which program cost more money.

Patients with LBP lasting more than four months were included. Group one was the “combined group.” They received treatment from a physical therapist once a week for four weeks. Treatment included manipulation and stabilizing exercises. They also received a booklet explaining the possible causes of back pain.

The second group received the same instruction. They were encouraged to stay active instead of having passive treatment. All patients in both groups were followed for a full two years.

The authors report good results in both groups. The combined group had higher patient satisfaction compared to the consultation group. Although the consultation group was slower to get better, in the end, participants reducedtheir use of health care services. They also used less sick leave.

The authors conclude that most patients with LBP do well with their doctor’s advice. It costs less and its effects last a long time.

This study looks at what happens to the spine when there’s a spondylolysis on one side. Spondylolysis is a stress reaction or fracture of the pars interarticularis, a thin section in the back of the vertebral bone.

The defect is thought to be a fatigue fracture. Repeated loading and unloading of this region from physical activity may cause it. Anyone with a pars defect on both sides can progress to spondylolisthesis, a slippage of the vertebral body forward over the vertebrae below it.

But what happens when the defect is only on one side? According to researchers at the Spine Research Center (University of Toledo, Ohio), one-sided (unilateral) spondylolysis can lead to a fracture on the other side. Increased stress in the area may be the cause.

The scientists used a computer model to analyze CT scans. Thirteen young athletes with unilateral spondylolysis were included. The results showed the stress reaction increased on the opposite side of the spondylolysis. The stress increased with all lumbar motions, especially spinal rotation.

Changes were seen in more than half of the cases. This took place slowly as the defect got worse. The authors warn surgeons of these possible changes and the increased risk of fracture in active athletes. Young patients with unilateral spondylolysis should be watched very carefully.

When children and adolescents have a spinal fusion special rods, screws, and hooks may be used. These implants hold the spine in place until the bone graft grows enough to fuse the spine. This study looks at the blood levels of metals such as nickel and chromium used in the implants.

Metal implants do breakdown. They can release metal ions into the body. Long-term exposure to these metals may be toxic. A few studies have shown a link between leukemia and lymphoma and metal hip joint replacements. These findings led researchers to wonder if children with implants are at risk. Their young age when the spinal implants are used may expose them to toxic metals for years.

To answer this question, blood levels of nickel and chromium were measured in 37 adults who had metal implants used in the spine when they were teenagers. They found elevated levels of both nickel and chromium. Levels were above normal right after surgery, two years later, and remained elevated four years or more after the operation.

The authors say that levels of chromium in this group were equal to blood levels seen in adults after a metal hip joint replacement. The long-term effects of elevated levels of metals in spinal fusion patients are unknown. For now it is news worthy that the levels are above normal. Problems related to toxicity may occur years after the fusion. More studies are needed in this area.

Is this your first time having low back pain? Wondering if you’ll get better?

This study followed first-time back pain sufferers for three months after going to their primary health care provider. They report 76 percent of the patients got better from their back pain. There was a quick decrease in pain and return to normal during the first four weeks.

Why didn’t the other 24 percent recover? That’s what the authors of this study from the University of Oslo in Norway report on. They included 123 patients ages between 18 and 60 years old with low back pain occurring within the last three weeks.

Everyone went to a doctor, chiropractor, or physical therapist for care during the first three weeks. For this study, they were examined by a physical therapist. Each patient also answered questions on a survey about pain, use of pain relievers, sleeping, working, and other functions.

Factors linked with nonrecovery included age (over 45 years old), work loss, and two or more neurologic signs. Psychosocial factors including distress and depression were also linked. Smoking, leg pain, gender, and education weren’t linked to nonrecovery.

The authors conclude that primary care providers need to think about psychologic factors in patients making their first visit for low back pain. Anyone who is distressed and depressed is more likely to have chronic back pain after the first episode of acute back pain.

The cause of most back pain remains a mystery. Equally mysterious is the best way to treat this problem. Physical therapists (PTs) in England compared two types of rehab programs for patients with back pain lsting three or more months. This study reports the results of these two PT interventions.

Both groups had eight treatments lasting one hour each over eight weeks. Group one worked directly with the PT one-on-one. They received 30 minutes of manual therapy with mobilizations to the spine. Mobilization is a hands-on joint treatment applied by the therapist. Each patient also did special exercises to stabilize the spine.

Group two worked in groups with up to 10 patients in each group. Three PTs led the groups in a series of exercises set up at 10 stations. The stations included manual therapy, aerobic exercise, and spinal stabilization exercises.

The bottom line was that both groups got better (less disability, more movement) but the group therapy cost less (40 percent less). The authors conclude more study is needed to find the best treatment for back pain patients. Group therapy would save money that could be used for other programs.

What happens to the lumbar spine after several hours of sitting at a desk? Is the low back at risk for injury from prolonged sitting? Do women respond differently to long periods of sitting compared with men? These are all questions answered in this study from
the University of Waterloo in Canada.

Six men and six women with no prior back pain or problems were part of this study. All were university students who sat on an office chair doing deskwork for two hours. Lumbar range of motion was measured before sitting, after one hour of sitting, and after two hours of sitting.

The researchers found men and women respond differently to long periods of sitting. Men had more low back stiffness after one hour of sitting compared to women. Low back stiffness varied among the women over the two-hour trial. Men seemed to reverse the stiffness by sitting up straighter during the second hour.

The authors suggested the following ideas from their results:

Spinal fusion for chronic disc-related low back pain is usually done at one to two levels. Does fusion of a longer segment cause more problems than fusion at a short segment? Researchers in this study compared two groups of patients with lumbar spinal fusion to find out.

The first group had a short fusion (one or two levels). The second group had a long fusion (three to five levels). Patients in both groups were evenly matched in terms of age, gender, and smoking and work status. Measures included pain and levels of function
(physical and social). Both groups were followed for two years.

The results showed no difference betwee the long and short group when measures of pain and function were compared. In other words quality of life (QOL) was rated the same in both groups. Differences were seen in the fusion rate. The rate of successful fusion was
much higher in the short fusion group. Patients in the long fusion group had more failed fusions and second surgeries.

The authors suggest that patients in the long fusion group did as well (QOL) as the short fusion group for two reasons. First, patients were chosen carefully based on age, type of disc problem, and symptoms. Second, each patient joined an exercise group before the surgery to improve strength and general health. Patients willing to complete the pre-
operative exercise program may be more likely to be committed to their own recovery.

When the disc material between the vertebrae protrudes and gets pinched off, it forms a free-floating body inside the spinal canal. There’s danger of pressure on the nearby spinal nerves. Surgery is commonly done to remove the entire disc. The idea is to prevent
another herniation. But what if the disc is left alone and just the fragment(s) is removed? That’s the focus of this study from Germany.

Surgeons know that removing the entire disc causes a decrease in the height of the disc space. The ligaments and capsule around the disc get loose and become unstable. The patient can end up with more back pain. Why not leave the healthy disc tissue in place?

In this study two groups of patients with herniated lumbar discs were compared. The first group had the entire disc removed. The operation is called a discectomy. The second group had a sequestrectomy, which is just the removal of the herniated fragments.

Using leg and back pain as a measure, patients in both groups were followed for 12 months. Both groups had much less back and leg pain. Most numbness and tingling were reduced, too. Patient satisfaction was much higher in the sequestrectomy group. Only half as many patients in the sequestrectomy group had a second herniation compared to the
discectomy group.

The authors conclude that sequestrectomy may be all that’s needed after disc herniation. This is especially true in cases where there has been some healing or scarring where the disc pushed through its outer covering. With a sequestrectomy, there’s no need to reopen the healed disc.

In this study the results of 16 patients’ treatment for leg pain from disc problems was reported. All were treated with a procedure called nucleoplasty. Some also had intradiscal electrothermal therapy (IDET) at the same time.

Nucleoplasty is a way to remove the center of the disc (nucleus) without opening the spine to do major surgery. A long, thin needle is inserted through a very small cut in the skin. Radiowaves are sent through the needle to the nucleus. The disc collapses slightly taking pressure off the nearby spinal nerve.

IDET is a form of heat that is used to seal small tears in the outer covering of the disc. This was done in some of the patients just before nucleoplasty. Success in all cases was measured by a 50 percent reduction in the patient’s pain level. They were also asked about use of pain relievers and return to work.

Before the operation more than half the patients were using drugs daily to control their pain. After the operation only one patient reported pain relief of 50 percent or more. The rest either stayed the same or increased their drug use because of increased pain.

Most of the patients said that given the chance to do it over, they wouldn’t have this treatment. The authors say the poor results of this study may have to do with patient selection. Other studies show that nucleoplasty works best in patients with small tears of the outer disc. Patients with more leg than back pain seem to have better results, too.

The authors don’t think the use of nucleoplasty should be abandoned. Finding the right patients who respond to the treatment is the next goal of research.