News Category: General Spine

Back pain. Who’s at risk? Is it a physical or psychologic problem? That’s the focus of this study from Stanford Medical School in California. Doctors know the biggest risk factor for chronic low back pain (LBP) is a previous bout of LBP. Is this because the spine is degenerating in these adults? Or are psychosocial factors such as depression more important?

One-hundred (100) adults with known mild back pain were studied. No one was disabled by pain. Everyone was contacted every six months for five years. The goal was to find risk factors that predict who will get back pain again.

The condition of the spine was monitored using a physical exam, MRIs, and studies of the lumbar discs. Questions were asked about number of days missed at work, pain levels, and number of medical visits.

The authors report that structural changes in the spine did not increase risk of future back problems. Psychosocial factors were strongly linked to both short-term and long-term disability. Worker’s compensation claims, heavy work, and fear of injury were most closely linked with future back pain.

The results of this study support psychosocial variables as a better predictor of who will need future medical care for episodes of back pain.

Successful spinal fusion doesn’t always mean the patient gets better. These are the results of a study from Duke University after following 56 patients with an interbody cage lumbar fusion (ICLF) for 2.6 years.

ICLF is one method to treat chronic low back pain. The surgeon uses a special X-ray machine called fluoroscopy to perform the operation. The damaged disc is removed and a special device called a cage is inserted in its place. In fact two fusion cages are put in side by side. Then the cages are filled with bits and pieces of bone.

In this study most of the patients (84 percent) had a solid fusion. Even so half were unhappy with their function and quality of life. More than one-third were worse off and totally disabled. Factors such as age at the time of surgery, use of tobacco, depression, and legal status were examined.

The authors report that tobacco use, depression, and litigation were the best predictors of poor patient outcomes. For example patients were nine times more likely to be disabled when a lawyer was involved. The odds of being disabled were 7.7 times greater when the patient was depressed.

The authors conclude results of spinal fusion using ICLF might improve with better patient selection. Patients who smoke or who are depressed before surgery could get treatment first and then have the fusion for a better final outcome.

Narrowing of the spinal canal called spinal stenosis causing back and leg pain is a common problem in adults 65 and older. Pain can disable older adults and greatly reduce quality of life (QOL). Conservative treatment often doesn’t help.

Surgery to remove bone pressing on the spinal nerves may be an effective option. This operation is called a laminectomy. But is it safe and effective for older adults? That’s the question this study takes a look at.

Twenty-three (23) patients over the age of 80 were included in this study. All patients had at least one other health problem. Many patients had several other diseases or illnesses.

Success of the laminectomy was measured using pain levels, number of pain relievers, and QOL. Before the operation all patients were taking pain relievers every day. After the operation, 63 percent were drug-free. Only a small number remained regular users of analgesics for pain relief.

Everyone had relief from leg pain while walking. Some patients still had some back and leg pain, but most reported good pain relief. All patients were followed for at least two years. Improvements in pain, function, and QOL stayed the same during this time.

The authors conclude that laminectomy is safe and effective in adults aged 80 and older. Patients with stenosis at more than one level don’t have as good of results. Future improvements in surgery may make it possible to treat all levels at the same time with good outcomes.

In this study scientists at the University of Ulm (Germany) compare EMG
(electromyographic) studies of low back muscles. They compared the patterns of muscle fatigue in two groups. One group (31 patients) had chronic low back pain. The second(control) group (31 subjects) was healthy and didn’t have back pain.

The two groups were matched by age, gender, and amount of body fat. These three factors affect EMG outcomes. All the back pain patients reported pain for more than two years of moderate intensity. MRIs showed the pain was caused by disc problems.

The electrical activity of four groups of back muscles was measured. Maximum strength was recorded after 3 trials. The results showed the patient group only had 60 percent of the flexion strength of the control group. Ninety percent (90 percent) of the control group also had stronger muscles in extension (pushing back). The group with back pain had less fatigue but this may be caused by pain and moving in a way to avoid pain.

The authors conclude that back muscles do play a role in back pain. Lower strength and less electric activity of the muscles in the patient group helps prove this. Having matched pairs in this study reduced any differences there might be in the two groups. The results of this study will help researchers find better ways to treat back pain.

When anything new comes out it makes sense to step back and take a look at the big picture. That’s what these two doctors do in this review article about artificial disc replacements. Long-term results aren’t available but the reasons for its use and short-term results are presented.

Those in favor of using disc implants say this device gives patients normal spine motion and disc height. A disc replacement helps prevent damage at the level above and below the replaced disc. The operation is shorter and has fewer problems than spinal fusion. Best of all the patient gets pain relief and returns to normal activities quickly.

Disc replacement for the cervical spine (neck) and lumbar spine (low back) must be studied separately. Range of motion and loads put on the spine with daily activities are different for these two segments of the spine. Typical loads for the lumbar spine are much higher than for the cervical spine.

Different implant designs, safety, wear testing, and results are also reviewed by these authors. Scientists are trying out different materials to see which one holds up while giving the patient normal movement. Not enough is known yet about each type to say which one is best.

Very few failures of disc implants have been reported. Likewise complication rates after surgery are low–much lower than after spinal fusion. The authors remind us that anyone thinking about a disc replacement must keep in mind it’s still an experimental form of treatment. Long-term results are unknown.

The FDA approved the use of an artificial disc replacement (ADR) in October 2004. In this report orthopedic surgeons review when and why to use the ADR. Early results and complications with the ADR are presented.

A large number of adults suffer painful symptoms from damage to the discs as a result of the aging process. Most are treated successfully with physical therapy, pain medications, and anti-inflammatory drugs. Weight loss is also advised.

Spinal fusion is often the last treatment offered. Fusions result in lost motion and breakdown of the discs next to the fusion. The ADR is used in the small number of patients who still have low back pain after conservative care has failed but before fusion.

Patient selection and surgical technique are described in this article. The surgeon’s skill implanting the ADR is important to a successful outcome. Doctors Shuff and An explain why. Damage to any of the nearby blood vessels can lead to failure. Other possible problems with the ADR are also discussed.

The authors conclude that the success of ADR today depends on the strength of the bone, spinal alignment, and patient motivation. In time the ADR will be improved so that fewer problems occur. More people will be able to take advantage of this new treatment for chronic disc-related low back pain.

Things are changing in the operating room when it comes to spine surgeries. The new minimally invasive surgery (MIS) makes it possible to avoid opening up the spine. A small incision is used instead. The surgeon uses new (smaller) tools and special imaging to see inside the spine.

Spinal fusion can be done from the front or the back of the body. In either operation, pedicle screws are inserted into the bone from the back. The screws help hold the spine together until the fusion is complete. But there are problems using the pedicle screws. Can these problems be solved by using MIS to insert the pedicle screws?

In this study, doctors compared two groups of spinal fusion patients to answer this and other questions. One group had the standard open pedicle screw fixation. The second group had a MIS called percutaneous pedicle fixation (PPF). Percutaneous means “through the skin.”

To compare results two measures were used: size and strength of the multifidus muscle. The multifidus is a deep spinal muscle that attaches to the vertebrae. With the PPF operation, the multifidus doesn’t have to be cut and stripped away from the bone. As shown in this study, there is less bleeding and less damage to the muscle.

There wasn’t much difference in pain levels between the two methods of screw insertion. The PPF group used fewer drugs for pain relief. In addition to these benefits, the authors also report shorter operation time with PPF.

You’ve probably seen people at the gym using the large Swiss ball to do their exercises. The idea is to train the core muscles of the back and abdomen. But is there any real benefit of doing these exercises on the ball? Do you get the same effect without the ball? Those are the questions asked in this study.

Eight healthy adults did four exercises on and off a Swiss ball. They rated the level of difficulty for each exercise on a scale from ‘very easy’ to ‘very hard.’ The researchers used electromyography to measure activity of five muscles of the abdomen and back.

The authors explain that normal core muscle activity is based on a ratio. It’s not just how much each muscle contracts but the level of muscle activity compared to other muscles. This study reports ratios for the muscles in each activity on and off the ball.

The authors say that exercising on the Swiss ball does increase activity of certain muscles more than doing the exercises without a ball. Different exercises activate muscles in various ratios.

They conclude that core-training programs should use a wide range of exercises. Knowing which muscles are activated in each position can help direct the training program.

This is the first study to report the long-term results of artificial disc replacement(ADR). The Prodisc implant was used in each case. Sixty-four patients were followed between seven and eleven years after ADR implantation. Patients included men and women ages 25 to 65. The longest study to report results up until now has been 4.3 years.

Measures of success included pain level, X-ray findings, need for pain relievers, and disability (mental or physical). Patient satisfaction with results was also measured. The researchers looked at the effect of age, gender, and how many discs were replaced on the results.

They found older patients had less pain and better function after surgery. Older was defined as 45 years old and older. Men and women had equal results although women saw themselves as more disabled before surgery than men did. Single and multiple level disc replacements had equal results.

The authors say more time is really needed to see the long-term results of ADR. A study is needed comparing patients with ADR versus patients with spinal fusion. For now they know the Prodisc device can apparently be used at multiple levels with just as good of results as a single level implant.

Back pain is common even among athletes. Alpine ski instructors are no exception. But how often does it happen? That’s the subject of this research study. In fact it’s the first time this information has ever been collected and reported.

Physical therapists sent out surveys to 500 members of the Professional Ski Instructors of America asking questions about back pain. They found out 75 percent of those who replied had a history of low back pain (LBP). This was about the same as for the general adult population. It’s higher than for most other sports athletes. About 30 percent had back pain at the time of the survey. Many LBP injuries reported by the ski instructors weren’t caused by skiing activities.

The therapists who conducted this study mention the high cost of LBP for this group. A ski instructor can make up to $400.00 in a single day. Sick leave is costly to both the employee and the employer. Better equipment and preventive training may be the answer.

Training programs to prevent knee injuries in ski instructors work well. Maybe a similar program for the spine would be a good idea.

It makes sense that repeated loads on the spine put the back at risk for injury. Many studies show the risk of back stress or strain increases when the same movement is repeated over and over.

But how many repetitions are needed before this happens? And how much rest is needed to restore overused tissues? Doctors and engineers tested the limits in cats.

The animals were put in three different grous. Each group had the lumbar spine flexed over and over for 10 minutes followed by 10 minutes of rest. This cycle was repeated in group one three times. Group two had six cycles of movement and rest. Group three had nine cycles of movement and rest.

The researchers found that the number of repetitions on the lumbar spine does make a difference. With repeated motions the muscles contract and increase the stiffness of the joints. This is one way the body tries to prevent or limit damage to the soft tissues. The more a motion is done over and over, the stronger and longer the muscle contractions become.

At the same time the ligaments, joint capsules, and fascia lose their elasticity. The ability of these tissues to stretch and loosen up is called creep. Repeated motions reduce the creep of soft tissues.

Even after rest, the tissues are unable to recover fully. The worker exposed to repetitive motions starts the next work day with less creep than the day before. Tissues that aren’t allowed to heal with limited creep are at risk for chronic inflammation and disability.

According to these authors seven hours wasn’t enough to restore creep in cats. More studies are needed to find out just how many repetitions it takes to cause a cumulative trauma disorder of the human spine. How many hours of rest is needed to restore creep each day is also being studied.

Are you training your core muscles and yet still have back pain? Many people work on strengthening their core muscles, which include the abdominal and deep low back muscles. The idea is to reduce back pain by using the core muscles to stabilize the spine. Researchers in the field of physical therapy may have a recommendation.

The results of this study show there may be another muscle involved. The psoas muscle (a hip flexor) may be just as important. When the size of the psoas muscle was measured from side to side, there was a decrease in the number of muscle fibers on the painful side.

Fifty patients between the ages of 18 and 65 years of age were included in this study. Everyone had back pain on one side (unilateral pain) lasting at least 12 weeks. MRI was used to measure the shape and size of two muscles: the psoas muscles and the multifidus muscles. (The multifidus muscles run along the back of the spinal column). Muscles on each side of the spine were compared.

A link was found between the amount of a patient’s pain and the size of the muscles at the same spinal level. The researchers also found smaller muscle size at the levels above and below the painful area.

The authors conclude that the psoas muscle provides stability to the spine. When there’s back pain on one side, the muscles on that side lose size and strength. The psoas muscle is sensitive to changes and should be trained along with the other core muscles.

Compression fractures of the spine from osteoporosis are often very painful. A newer treatment called percutaneous vertebroplasty is becoming more popular because it gives fast pain relief. But do the good results last and for how long? That’s the focus of this study.

In a percutaneous vertebroplasty the surgeon injects a medical-grade cement through a needle into a painful fractured vertebral body. This holds the fracture together and stabilizes the bone.

Patients at the Center for Bone Diseases in Marshfield, Wisconsin, took part in this six month long study. Forty-six patients with severe pain and difficulty with daily activities were included. All had failed to get better with conservative care.

Pain level and quality of life were the main measures of success. Everyone was tested in these areas before the operation, at two weeks, at two months, and six months after theoperation.

The authors found good results with fast pain relief (within one day) that lasted. No bone fractures occur as a result of the treatment. Quality of life improved and stayed improved through the six months marker. They conclude that percutaneous vertebroplasty can be used safely in frail, elderly patients.

Nurses are at high risk for low back disorders because of handling patients. What happens when a nurse or nurse’s assistant has to respond to a sudden load shift like a falling patient? Do the abdominal muscles all contract together at the same time? Ten well-trained judo and jujitsu fighters were put to the test to find out.

When the abdominal muscles contract, there is an increase in the pressure inside the abdomen. This is called intra-abdominal pressure (IAP). IAP helps stabilize the spine. It’s an important part of protecting the spine when lifting or responding to sudden, heavy loads.

The 10 subjects were given various lifting trials with a healthy male acting as a patient. A device inside the abdomen recorded IAP during each movement. Muscle activity was measured on the outside using electromyography (EMG). A special computer program calculated the twisting (torque) and compression forces in the low back.

The results support the idea that IAP helps unload the spine by using an extensor torque. This is possible because one of the abdominal muscles, the rectus abdominis (RA), doesn’t contract. The RA flexes the spine. If it contracted, it would be more difficult to handle a falling patient or heavy load.

The authors found that well-trained men and women don’t make full use of the IAP when the trunk is exposed to sudden loads. Women have to use a higher IAP to handle the same load compared to men.

Back pain is a common problem in adults around the world. Researchers in Sweden are conducting a series of long-term studies on back pain patients. This study looks at a group of adults from 18 to 60 years old. All had been treated by a physical therapist or a chiropractor.

The goal of the study was to find groups of patients who don’t do well after treatment. This group was compared to groups of patients who got better. The idea was to look for ways to direct patients towards a treatment program that works for them.

Two groups emerged from this study. One group had constant back pain, or the pain came back after a pain-free period. The second group was pain-free for at least six months and didn’t seek treatment or health care during that time.

All patients were followed for five years. Results after one year were compared to results after five years for both groups. The authors report the following findings for working-age adults with back pain of unknown cause:

What can be done about back pain that doesn’t respond to treatment and doesn’t go away on its own? Prolotherapy may be the answer, especially when combined with other treatments. Prolotherapy is a way to inject agents into the ligaments and tendons of the spine. The soft tissues are built back up after an injury or trauma. The patient gets relief from pain and increased function.

It sounds good, but does it work? Researchers from the University of Queensland in Australia decided to check it out. They reviewed studies already done on the topic. They found four good studies with a total of 344 patients. Pain and disability were measured before and six months after treatment. Some patients had other treatments at the same time.

The results of this review show that prolotherapy injections as a single treatment for chronic low back pain don’t work any better than no treatment at all. Patients get better pain relief when prolotherapy is added to another treatment. More studies are needed to find out what treatment works best when combined with prolotherapy.

What is soft, elastic, and has superb mechanical strength and endurance? It can also bend, extend, rotate, and twist, holding up for 20 years or more. The answer is the artificial disc. But can artificial discs really live up to the hype? Researchers from around the United States studied 304 patients to answer this question.

Two-thirds of the patients were in a group that received a special disc replacement called the Charité intervertebral disc. One-third (the control group) had a spinal fusion with insertion of a special cage filled with bone chips. The cage was put in place of the vertebral body. Results were compared up to two years later.

The authors give a detailed review of artificial discs. They present pros and cons of their use. They also offer a description of each kind on the market. Sizes, angles, and function are discussed. The Charité disc used in this study restores disc height and motion as closely to normal as possible.

In this study, the Charité artificial disc was as safe and effective as fusion. This study limited use of the disc to one level in the low back area. All patients had degenerative disc disease. The number of neurological problems after each type of surgery was the same.

The authors suggest three factors needed for the best results:

This report reviews the physical therapy (PT) treatment received by a patient with whiplash injury. The patient was a 32-year-old woman who had been in a car accident. PT was started two weeks after the accident. At that time, she couldn’t sit for more than 10 minutes. She was unable to do her job as a postal worker because of neck and upper back pain.

Early PT treatment consisted of manual therapy such as soft tissue and joint mobilization. The therapist focused on the upper back area from T1 through T6. These vertebrae form the upper thoracic spine. Problems in this area can cause neck pain and loss of neck motion. The authors provide a detailed description of the treatment used.

After two treatments the patient was able to drive and sit without any pain during the day. Neck motion was better but not normal. Joint manipulation and exercises were added to the patient’s PT program with good results. One week later the patient was able to return to work.

Her remaining symptoms were relieved when the therapist treated the neck area. The authors give a step-by-step description of the treatment used. By the end of the fourth treatment session two weeks later, the patient was pain free. She was also back to her full activities at work and at home.

The authors suggest this case shows how symptoms after a whiplash injury may be coming from the thoracic spine, not just the neck. Manual therapy and exercises returned the patient back to normal in four treatment sessions. This was much faster than results reported in other studies using medications, rest, neck collars, and other forms of treatment.

Disc problems continue to plague adults of all ages. Spinal research is being done to try to find out how to keep discs healthy into old age. Testing the load applied to the disc is the focus of this study. Pigs were used since it’s difficult to insert sensors into healthy human disc material.

A special needle was put through the outer part of the disc (the annulus) into the center (the nucleus pulposus). Different loads were applied to the disc for 30 seconds. The pressure inside the disc was then measured.

The authors report that pressure inside the disc goes up as the load increases. The disc starts to flatten or collapse during constant loads. The disc is also under more pressure in certain positions. For example, in this study, standing appeared to put more pressure on the disc than sitting.

Studies of this kind can help identify factors that start the process of disc degeneration and herniation. Understanding the effects of different types of load and changes in body position on the disc may help us find ways to prevent disc problems. Rehab programs and advice for workers in the workplace may be redesigned as more information is found.

Doctors at the Sports Medicine Center in Akron, Ohio, have shown the need for early diagnosis in young athletes with spondylolysis. This condition affects the low back. It involves a fracture in the bone structure in a small area in the spinal column.

Finding the problem early gives the patient a better chance for bone healing. Older lesions and fractures on both sides of the spine are less likely to heal completely. Bone scans and special CT scans called SPECT (single photon emission computed tomography) find problems X-rays don’t show.

In this study, 40 young athletes between the ages of 12 and 20 with spondylolysis were followed for up to 11 years. The subjects were divided into three groups right after diagnosis. Group A showed no sign of new bone or healing. Group B was in the process of healing. Group C had some bone bridging the fracture, indicating a later stage of healing.

Each patient was contacted by phone seven to 11 years after being diagnosed with this problem. They were asked questions about function and the need for surgery. They were asked to judge the effect of spondylolysis on their everyday activities.

The researchers found that all patients were still active in some kind of sport. Only two reported their choice of work or job was made based on their back problems.

Defects on one side only of the spinal column healed fully. Defects on both sides shows signs of breaking down. Overall most adolescent athletes recovered from spondylolysis with conservative treatment. Early diagnosis is important to complete recovery. A bone scan appears to be better than an X-ray to find early defects.