News Category: Lumbar Spine

Sciatica or a radiating leg pain from low back issues is a common and uncomfortable physical problem. Studies indicate it can happen in up to 34 percent of adults each year. The good news is that it usually improves with time. Unfortunately, sciatic back pain has significant negative medical, financial, social, and work-related impacts. This type of injury tends to take longer to get better and is often more disabling as it hurts to move. Recent reviews of the research state that there is not enough evidence to make a recommendation for or against using Physical Therapy (PT) or a structured exercise program for people with this back and leg pain condition.

This study aimed to investigate whether patients with kinesiophobia (fear of movement) improved any more with PT and general practitioner advice (intervention group) compared to receiving care from their general practitioner (control group) on returning to normal movement and medication alone.

135 patients with acute sciatic qualified for this study and were randomly assigned to either the control or intervention group. These groups were again divided into high or low kinesiophobia groups based on surveys and their exam results. Each group was assessed at three months and one year following their treatments.

The results found that patients with high levels of initial fear of movement due to their radiating leg / sciatic back pain benefited more from PT considering their significantly improved measures of reduced leg pain one year following their treatment. At three months after the start of their pain episode, 68 percent of the patients reported improvements in recovery from their sciatic condition (73 percent of which were in the intervention group and 63 percent were in the control group).

One year after the start of their pain episode, 73 percent of the patients reported significant improvements towards complete recovery (82 percent of which were in the intervention group and 63 percent were in the control group).

Researchers in this study were surprised that patients randomly assigned to the PT intervention group did not show more improvements at the three month follow up, as this is when they were getting their most intensive treatments. This study concluded that in this rather small sample population of persons with sciatica, there is good evidence to support that the higher the level of kinesiophobia and pain initially, the better the chance they will benefit from decreased leg pain intensity after their Physical Therapy and general practitioner intervention at the one year follow up.

Failed back surgery syndrome (FBSS) is a problematic source of chronic low back pain. This syndrome is estimated to effect between five and forty percent of all patients who have had surgery for low back pain. This chronic pain can often result in long term disability and contributes large costs to the health care system. Even with the rising frequency of spinal surgery, there is no agreed upon best management for FBSS. This article by Shivanand et al seeks to determine if the use of spinal cord stimulation (SCS) can help to control costs and provide pain relief for this syndrome.

Patients with FBSS are typically treated with conventional medical management (CMM) which mostly includes medicines for pain and depression, physical therapy, and psychosocial therapy. Other treatments may include epidural injections, nerve blocks, and home based portable electrical stimulation units (TENS). If these usual courses of treatment continue to fail, the last options are either to perform another back surgery or to implant a spinal cord simulator. Repeat back surgery has poor outcomes ranging from only twenty-two to forty percent success rate. Repeat surgery also increases the risk for complications and is very expensive. Several randomized controlled trials have shown SCS to have superior outcomes for pain relief over CMM and repeat surgery. This article examines the complications and long-term health care costs of SCS compared to repeat surgery in order to increase the body of knowledge to help decide on the most economic and effective treatment for FBSS.

Spinal cord stimulation is the use an electrode implanted into the spinal cord which provides stimulation to the nerves that come from the source of the pain. This electricity changes the impulses of both the excitatory and inhibitory neurotransmitters to effectively block the sensation of pain. Since its inception in the 1960s many innovations such as smaller and more effective electrodes, and better surgical techniques have made SCS an increasingly viable option for treating chronic back pain.

In this study Shivanand et al looked at the MarketScan commercial Claims and Encounters, Medicare Supplemental and Medicare database records from the year 2000 through 2009. These databases contain patient specific information about usage and costs from claims of employers, health plans, government and public organizations. They searched for all cases with a lumbar surgery or an implantation of SCS which was performed for FBSS or postlaminectomy pain syndrome. They found 16,455 patients who fit this criteria, and among this group there were 6,497 patients who had at least two years of continuous records following this procedure. Only a little over two percent of this group underwent the SCS surgery (395 patients) and the remaining patients, over ninety seven percent, had spinal reoperation (16,060 patients).

Some of the interesting data that they found was that the proportion of females undergoing SCS was higher than those that underwent lumbar surgery. Patients who had SCS also had more comorbidites. Patients with Commercial and Medicare insurance were more likely to have a reoperation, but Medicaid patients were more likely to have the SCS. Complications following the procedure were significantly higher for lumbar reoperations at almost twelve per cent versus only five per cent for SCS. Even at the ninety day follow up the reoperation group was two times more likely to be experiencing complications than the SCS group.

Total costs on the health care system were also investigated by this study. They found that lumbar reoperation patients had a longer initial hospital stay, four days versus two days on average for SCS patients, however this increased stay did not result in significant difference in cost of the initial hospital stay. They also found no significant difference in total costs within the two year follow up timeframe. There was no significant difference in the use of prescription medications in either group either.

In conclusion this study has shown that in a large national group of patients there were fewer complications, shorter initial hospital stay, but similar costs in the first two years for SCS compared to reoperation for FBSS. This study was unable to directly monitor outcomes, but it did see that there was no difference in opioid medication use in either group. Considering this positive information the authors suggest that, at a rate of only two and half per cent utilization, SCS is an underused option of treatment for the increasing number of patients with FBSS.

Low back pain (LBP) is a big problem, with approximately eighty percent of people reporting back pain at some point in their life. This pain can be the cause of much stress, lost function, lost productivity and financial expense. Exercises have been shown in many research articles to be effective for LBP, but it is not clear as to the parameters. This study by Aleksiev looks into some specific exercises to see which are most helpful over a ten-year period, including frequency, intensity and duration. They looked at the long term effect of strengthening versus flexibility as well as the additional effect of abdominal bracing for everyday activities.

This study included six hundred patients with non-specific low back pain randomized into four treatment groups, each with one hundred and fifty participants. One group performed strengthening exercises alone, one group performed flexibility exercises alone, the third group performed strengthening exercises and did abdominal bracing for everyday activities, and the last group did flexibility and abdominal bracing for everyday activities. All the participants were followed for ten years, and were interviewed on a yearly basis about their symptoms. The participants were asked about maximal pain intensity and duration in days during the latest recurrence of pain as well as the number of episodes of pain during the year. They were also asked to report the number of exercises per day, minutes per session and intensity of the exercise sessions.

The exercises for the strength group were a held crunch movement and a back extension with legs and hands behind head, like superman. Each exercise was to be performed at fifty percent of maximum effort and held for three seconds, they were instructed to perform three sets of ten repetitions. The flexibility exercises included flexion stretch for the back muscles and an extension stretch for the abdominals. The stretches were held for ten to twenty seconds, three to five times. For groups who performed the abdominal brace they were all instructed to incorporate bracing into the regular activities. They were instructed to “brace and breathe,” and to initiate this before any whole-body movement or exercise as often as possible. Bracing intensity and duration were self selected.

This research found that both strength and flexibility exercises were equally effective if done daily to decrease pain. In fact, the more frequent the exercises the better the pain relief. Frequency was more important than intensity or length of time exercising. If abdominal bracing was done for daily activities this also significantly decreased the pain reported over the ten-year study, over one and a half times compared to the groups without abdominal bracing. The largest improvement occurred over the first two years and then the pain reducing effect slowly lessened.

The author hypothesizes that the bracing was more beneficial because it automatically increased the frequency of abdominal and back muscle contraction, therefore increasing strength. The groups doing the abdominal bracing also had increased frequency of exercise, possibly due to the fact that doing the abdominal set reminded them that they should do their exercises, which also increased strength gains.

In conclusion, this study presents abdominal bracing as the most effective method when combined with regular exercise to decrease nonspecific LBP for the long term.

Cauda Equina Syndrome (CES) is a resulting cluster of issues a person experiences following damage to their nerves that exit the base of the spine in the shape of horse’s tail, hence the latin anatomical name of “cauda equina”. This important bundle of nerves gives sensation and motor supply to the pelvic organs and lower limbs. In addition, the cauda equina extends parasympathetic nerve supply to the bladder. When injured, persons with CES experience many functional problems with their bladder and/or bowels, decreased sensation in their crotch area, or sexual dysfunction.

Dr. Kim and his research collaborators in Cheonan, South Korea at the Department of Rehabilitation Medicine at Dankook University College of Medicine set forth to find what causes bladder dysfunction in persons with CES or lower spinal cord peripheral nerve injuries.

It is well recognized in the medical community that persons with CES will have bladder problems due to the injury to parasympathetic nerve supply to their bladder. This injury creates a subset of problems called “neurogenic bladder” making it difficult or impossible to urinate, or the opposite end of the urination spectrum making the bladder overactive. Dr. Kim’s team was specifically interested in delving into the cause of this hyperactive bladder or detrusor (muscle) overactivity (DOA).

The hyperactive bladder is problematic in 15-31 per cent of persons with cauda equine syndrome, but the mechanism that causes it cannot be explained solely by the level of the injured spinal nerve. The root causes of the variations in neurogenic bladder issues was the basis for this study. They aimed to further the science using clinical tests (think sophisticated measurements on urine output), radiological (like MRI images), and electrophysiology (like a nerve conduction test) on a group of 61 participants with CES and a hyperactive bladder. Discerning the highest level of spinal cord injury on each person was important finding the injury’s specific neurological impacts down the chain of innervated muscles and organs. Then they took it one more step to differentiate an overactive bladder muscle’s (DOA) dysfunctional performance from its inverse-yet-more-commonly-found bladder muscle dysfunction of detrusor underactivity (DUA).

Dr. Kim and his team found that a third of the study subjects had overactive bladders and within that group most (85 per cent) had their highest level of spinal cord injury at or above the 2nd lumbar spine level. The remaining two-thirds of the study subjects had underactive bladders and most (91 per cent) had their highest level of spinal cord injury at or below the 3rd lumbar spine level. Another interesting finding on subjects with overactive bladders was they often had a higher injury at the lowest section of the spinal cord (conus medullaris) a along with the cauda equine injury.

Posterior lumbar fusion is a relatively common surgical procedure for pain in the low back. In this surgery two or more levels of vertebra are stabilized with bone grafts, or bone graft substitute. Then movement at those levels is limited to encourage the natural processes to grow bone in the space between the vertebra and subsequently stop all movement at this level. There are many options when planning for such a procedure and there is some debate over the best techniques. This article is a review of some of the more recent research and longer term studies in this area.

In 1991 there was a landmark study by Herkowitz and Kurz which showed that patients with degenerative spondylolisthesis had a better outcome with the combination of a fusion and a laminectomy than with the laminectomy alone. In this research it was noted that some successful outcomes were had even with pseudarthrosis, which means that the fusion was not complete and still allowed slight movement. Due to this study, for several years it was felt that full fusion was not necessary for successful outcome. In 2004 Kornblum et al detailed the long-term results of this same group of patients and found that for long term positive results (five to 14 years follow up) a solid union was more effective. Kornblum showed that the clinical outcome for those with a solid fusion was excellent in eighty-six per cent of patients compared with only fifty-six per cent excellent outcome with a pseudoarthrosis. The evidence presented in this longer term study suggests that gaining a complete fusion improves the clinical outcome for the patients in the long term.

The considerations are many when planning a surgery for a lumbar fusion. The first is whether to use instrumentation, additional hardware such as screws and rods, or not. Some surgeons argue that for older adults non instrumented fusion decreases time of procedure and loss of blood which may be preferable. However, in 1999 a Cochrane review by Gibson et al found that there was strong support in the research for better fusions when instrumentation was used. Newer studies have shown very slight benefits including decreased use of pain medication, and cost versus quality of life measures with instrumented fusions. In this authors opinion a solid fusion from instrumentation is the best choice for the positive long-term outcomes.

Some techniques also use more bone placed between the vertebral endplates, also called inter body fusion, to increase chance of a solid fusion. This technique has been shown by Ito et al to have a fusion rate as high as ninety eight per cent. However a recent systematic review by Lee et al of randomized trials using the Cochrane system of standards found that there is moderate evidence that there is no difference in complete fusion rates between posterior inter body fusions and posterior lateral fusion.

Often a bone graft is also used to improve likelihood of a solid fusion. Currently the gold standard is the use of an iliac crest bone graft (ICBG) due to evidence of between forty per cent and eighty nine per cent successful fusion rates. However with ICBG there is increased blood lost from a second surgical site as well as increased operating time and increased hospitalization time.

Each alternative has some advantages and disadvantages and these must be considered on an individual basis. When a decompression is performed in conjunction with the fusion, this removed bone from the lamina is routinely used with good results in the literature. The drawbacks may include a minimal amount of bone available, and often surgeons elect to increase the amount of bone by adding bone marrow aspirate (BMA) or ICBG. Another option is an allograft which is tissue from a different individual, however there is lots of variability in the research with this technique.

Another substance that has been hypothesized to improve fusion is the presence of bone morphogenetic proteins (BMP). In 2012 Kang et al found eighty six per cent fusion rate with use of BPM from demineralized bone matrix plus laminectomy bone compared to ninety two percent fusion rates for ICBG plus laminectomy bone. In yet another study by Schizas et al these two same procedures showed equivalent fusion rates. There are some recent studies which are shining some problems on BMP, and are focused on the safety of this substance. There has been some concern with increased rates of retrograde ejaculation in men and a recent association with recombinant human bone morphogenetic protein-2 and an increased risk for cancer.

There has been further research in the area of ceramics, platelet gels, and electrical stimulation to aid in fusion surgeries. In animal studies it has been shown that ceramic substrates can have osteopromotive (meaning they attract bone growth) properties and be a substitute for autograft in posterior lumbar fusions. In clinical studies ceramic materials have successfully been used as a bone graft extender with ICBG and fusion rates range from eighty two per cent to ninety six per cent over several different studies. However, it is interesting to note that some of these fusions were assessed with CT scan, and bone and ceramic material have the same density as viewed in a CT scan, so there may be some argument about whether a true fusion is the outcome vs unfused ceramic material. As a bone graft substitute ceramics have mixed results including longer time to achieve radiographic fusion and needing a larger area of bony surface to achieve fusion. There has been some promising animal research with platelet gels, however they have not translated into effective clinical adjuncts for fusion with two studies showing a decrease in fusion rates greater than nineteen per cent compared to fusion without platelet gel. Electrical stimulation is an adjunct to enhance fusion rates and in the research the results tend toward small percentages of benefit or no change.

There are some circumstances which put patients at risk for non union, or pseudarthrosis and they include smoking and increased motion during the healing phases. It is due to these findings that patients are counseled to cease smoking prior to a fusion procedure. A clinical study of two level fusions with laminectomy showed that there was a forty per cent pseudarthrosis rate in smokers compared to eight per cent in non-smokers.

The author of this review study makes the conclusion that the iliac crest autograft remains the best option for gaining a solid fusion, but it’s use can be reserved for long multilevel fusions. There is good evidence that for shorter fusions use of autograft of laminectomy bone in adjunct with cancellous allograft chips and simple BMA is effective without the sequela of a second surgical site. The author feels that there is not sufficient evidence to utilize foreign or man-made proteins or manufactured ceramics due to concerns of complications of unexpected immune reactions. Lastly this author recommends use of electrical stimulation be reserved for problematic cases as a safe and effective adjunct to increase likelihood of a solid fusion.

For the past few decades different surgical techniques including spinal
decompression and spinal fusion have been used to successfully treat lumbar
spine conditions. Typically benefits of these surgeries are measured in pain
relief, low rate of complications and return of function. But there is new
emphasis placed on quantifying the value of surgery in terms of cost to
patients and society. Unfortunately, as recent systematic review
demonstrated, there is limited evidence available in examining cost-
effectiveness.

Lumbar stenosis (narrowing of the spinal canal) and
spondylolisthesis (forward displacement of a vertebra) are two common degenerative spine conditions. In addition to non-operative strategies, surgical decompression and arthrodesis (fusion) are accepted options for these conditions. The aforementioned systemic review was performed to examine the cost-effectiveness of these procedures. The review ran into
several limitations including scarce literature available, the inconsistency
and variability present in what literature was present and that many of the data was based on mathematical modeling algorithms versus actual patient data.

In terms of operative treatment versus non-operative treatment, it is expected that surgical techniques will have a higher upfront cost secondary to the possible hospitalization, anesthesia and invasive nature of the procedure itself. Some may argue that if there is permanent removal of the neural compression through a surgical technique the upfront costs should
dissipate over time by allowing the patient prolonged relief of symptoms and return of function and contribution to society. At this time, due to the
limited amounts of literature, there are too many limitations to support this argument one way or the other. The systemic review brought up the concept of delayed gratification being very important to analyze in a procedure that may have a prolonged course of action. There are differing opinions on when in the process this analysis should be made. A two-year time window was used by several of the studies used in the review but it was stated that this may not be a long enough period to see an effect thus reinforces the difficulty in drawing definitive conclusions on the cost-effectiveness of surgical
techniques versus non-operative treatment.

A recent review article has been published looking at active rehabilitation as a tool to improve postoperative results from lumbar spinal stenosis surgery. Spinal stenosis is the narrowing of the spinal canal which can lead to pressure on the spinal cord or nerve roots, resulting in pain in the back and legs. This condition is usually caused by changes related to aging in the disc, lumbar vertebra, and supporting structures. Surgery to relieve this pressure accesses the spine through the back and then the excesses bone, thickened ligaments and degenerative disc tissue is removed to create space. This procedure has been increasingly common due to rising older population and over the age of sixty five spinal stenosis is the most common indication for spinal surgery. In the US Medicare system more than 37,000 decompression procedures were reported for 2007.

Although this surgery is becoming more common, there is quite a bit of variability reported in the outcomes, and many people do not regain good function following this procedure. Studies report functional improvements between fifty-eight and sixty-nine percent, and participant satisfaction ranges greatly from fifteen to eighty-one percent. Due to these suboptimal outcomes there is need for more research about how to improve upon the success rates. This review was undertaken to determine whether active rehabilitation; including education, exercise, behavioral training, neuromuscular training and stabilization training improved outcomes compared to “usual postoperative care.”

Several common databases were searched for randomized controlled trials that compared the effectiveness of active rehabilitation to that of usual care for adults who have undergone primary spinal decompression surgery. The searches resulted in three studies which fit all the criteria for this review. Usual care included limited advice about being active postoperatively to a brief routine of exercises focused primarily on prevention of deep vein thrombosis. Active rehabilitation included group or therapist led exercise programs focused on restoring or improving function. These programs included exercises for stabilization, muscle strengthening and flexibility as well as education about staying active. Success was measured with a disease-specific measures of functional or disability status (such as the Oswestry Disability Index), measures of global health (36-item Short Form Health Survey), and pain severity.

The evidence coming from these three studies indicates that there is moderate evidence to support that active rehabilitation is more effective than usual care. This is true for both short term and long term function and for low back pain. There is also moderate evidence at twelve months post operation that active rehab is more effective than usual care for improving leg pain. This particular study also mentions a few other studies which, although they did not fit the criteria to be included in these results, have also corroborated these findings, indicating that more research is needed in order to find out the timing and content of the rehab for the best outcomes. Some of these other studies also included pre-operative therapy, cognitive-behavioral therapy, and a back-cafe model (guided group exercise, education and support sessions), indicating that further research needs to be done on a more holistic approach including education and finding patient preferences to help improve outcomes for this increasingly common surgical procedure.

The incidence of “slipping a disc” in your low back or herniating an intervertebral lumbar disc, in the medical vernacular, while attempting to move that heavy filing cabinet is not all to uncommon. The ensuing low back pain and often accompanying radiating leg or buttock pain from a bulging disc putting pressure on your spinal nerves is also unfortunately, quite common. Dr. Jon Lurie and a collaborative team of researchers based out of Dartmouth’s Department of Medicine, Orthopedics, Health Policy and Clinical Practice set forth to assess the data of eight years of outcome research from operative versus non-operative treatment for this debilitating back issue.

Decompression surgery to relieve disc-related spine pain is a well-researched and a highly-accepted indication for spine surgery. While in the throws of an episode of raging low back pain, the quick fix of going under the knife seems like a logical decision, but spine surgery comes with plenty of costs and risks. The questions Dr. Lurie’s team set to answer was: why does the rate of surgery vary so greatly geographically in the U.S, if the surgical option is more effective and faster to provide relief? They also aimed to add to the body of knowledge of high-quality, multiple-testing sites, with randomized controlled trials of prospective surgical (or conservatively managed) effects on patients over the long term.

This study was considered a ‘concurrent prospective randomized and observational cohort study’, as each of the 1,991 eligible participants chose either a route into randomized study (surgery vs. nonsurgery) at one of 13 spine clinics participating in this Spine Patient Outcomes Research Trial (SPORT) or the observational group. The observational group got to choose their not-so-random, treatment route of surgery vs. nonsurgery. There was plenty of lenience in the eight-year study for either group to opt in or crossover to the other group as their back issue and provider deemed necessary. The nonoperative group was tracked over the course of the study and received the “usual care” recommendations. These treatments were customized to the individual and included at least: physical therapy, back pain education and counseling, and medication management.

All of the enrolled participants received thorough screenings and imaging tests for eligibility (such as >6 weeks of radiating low back pain with a confirmatory MRI), outcome measures and assessments on a regular basis (six weeks, three months, and six months, and annually thereafter). Most surgical participants had the standard bulge trimming or ‘open discectomy’ and exam of their pinched nerve root. The study gets highly complicated statistically, as the analyses were multifactorial and convoluted to best capture the longitudinal comparisons of the randomized and observational groups. Lurie et al. provided plentiful and excellent flow diagrams cited in the original paper for those that want to peruse the detailed statistical intricacies behind such analyses as “intent-to-treat” versus “as-treated” groupings.

The results reiterated the hypothesis that usually, effective and selective surgery relieves radiating low back pain. Over the course of this 8-year study, more measurable improvements were “clinically significant” in all of the main outcome measures (ie. bodily pain, physical function, perceived disability) for the surgical group than those who remained nonoperative. However, both groups experienced heavy amounts of statistically challenging “crossover”, as humans tend to change their mind on the question of: Should I Get My Sciatica Relieved Surgically, Or Should I Wait? The common exception for both groups was neither returned to prior work status. Or once you ‘blow a disc’ hoisting that filing cabinet up the stairwell, you’re less likely to return to moving heavy office equipment regardless of choosing surgery or conservative care for your back. The study goes on to throw the conclusive bone to those deliberating this costly surgery, that “even among patients with strong surgical indications, many (34 per cent) remained in the nonoperative group out to eight years”. Take comfort in conservative rehabilitative care and do your core stabilization exercises and spine stretches if surgery doesn’t sound like your calling, as improvements in “sciatica bothersomeness” happened in both groups.

The United States has the greatest number of spinal surgeries performed per year even when compared to other countries with the same amount of people with spinal stenosis.  Because of the high cost, need for more surgeries and complications associated with fusions, authors of a recent study recommend a decompression surgery to address spinal stenosis.  If a fusion is required, they suggest that a noninstrumented fusion is performed.

Spinal stenosis is a narrowing of the space surrounding the spinal cord.  It naturally occurs as we age, however it can become bothersome if the narrowing starts to pinch on nerves that exit the spine.  Often it can be managed with changing movement patterns, but sometimes surgery is warranted.  While there are several options for surgery, the optimal technique is still being determined. A decompression surgery removes bone that is encroaching on these nerves and is named for the piece of bone that is removed.  For example, a laminectomy removes a piece of vertebrae adjacent to the spinous process (or pokey part of your back). A fusion is another type of surgery in which hardware or bony tissue is placed to prevent the spine from moving and encroaching on nerves.  An instrumented fusion utilizes actual metal hardware, like screws and rods, to stabilize the spine.  A non-instrumented fusion relies on bone tissue harvested from elsewhere in the body, which is then transplanted to stabilize the spine.  Sometimes surgical treatment includes a combination of the two and both a fusion and decompression surgery are performed.

Authors of this study tapped into a large database and analyzed patients who had treatment for spinal stenosis from 2002 to 2009.  The number of people in the database with a spinal stenosis diagnosis was 12,657.  Of those, 2,385 people had a decompression surgery and 620 patients had a fusion along with data that followed up longer than five years.  They were interested in the surgical complications, (such as infection or failure of the surgery to provide relief) the need for another surgery, and the overall cost effectiveness of the surgery, which they gauged by looking at how many resources, like cost of initial surgery, emergency room visits and medication charges, occurred after the surgery.

The study found that surgical complications were significantly higher for patients who had both a laminectomy and a fusion than for patients who just had a laminectomy immediately after surgery and at a 90-day check up.  Both of these patient populations however did not have a difference in the re-surgery rate, even five years after the first surgery.  Authors also discovered that by the five-year mark the total costs of treatment were similar between the patients who had decompression surgery and those who had a fusion.  The two types of fusions (instrumented and noninstrumented) cost-wise had a slight difference (~$7,000) with noninstrumented fusion being the cheaper of the two at around $100,471 in total care cost at a five year follow up.  

Any surgery has the chance for mess-ups.  Some of these mistakes can be more detrimental than others. A “sentinel event” is the worst kind of mistake– mistakes that could be avoided that result in death, the risk of death, physical or psychological injury.  A recent study took a closer look at the prevalence, type of surgery error, and the overall results of these sentinel events in regards to lumbar spinal surgery.  

Researchers tapped into a national database that approximately represents 20 per cent of all patients sent home from U.S. hospitals.  It looked at a window from 2002 to 2011 and identified all patients who had a lumbar spine surgery, eliminating patients younger than 18 and only using data of patients who were admitted for degenerative conditions, with a total of 543,146 lumbar spine surgeries identified. They then flagged sentinel events occurring in this population, totaling 414.  Of these, 30 were bowel or peritoneal injuries (i.e. puncture), 82 were vascular injuries (i.e. cutting a vein or artery), 108 were nerve injuries, 54 were foreign objects left inside, and 142 were wrong-sided surgeries.

Some specific surgeries were found more likely to have errors associated with them. With a posterior (back) approach the risk for wrong-sided surgery increased and with an anterior (front) approach the risk for peritoneal, vascular or bowel injuries increased. The chance of death in correlation to a sentinel event for this population was found to be 20 times greater than in patients not having a sentinel event and the possibility of a further post surgical complication like a blood clot or heart problems significantly increased.  

Authors concluded that patients who had a sentinel event had longer hospital stays and incurred more costs and have overall poorer outcomes following a lumbar spinal surgery.  Sentinel events are avoidable and if they do occur procedures should immediately be mitigated to prevent future occurrence.

Low back pain costs the U.S. about $100 billion dollars per year.  While there are numerous causes of back pain, “discogenic,” or pain caused by a disc, makes up about 39 per cent of all low back pain cases.  Diagnosis of the disc as the cause of pain is challenging as the gold standard diagnostic, “provocative discography,” is known to frequently misdiagnose disc pain. Additionally, discogenic back pain is difficult to treat due to psychological and emotional factors affecting the perception of the pain and often surgery does not alleviate symptoms.

If surgery is not the most effective treatment for discogenic pain, then what is? Researchers recently had this question and combed the research to find evidence to back up available treatment options.  They found 11 quality studies investigating traction therapy, ablative techniques (either via methylene blue injections to deaden nerve endings or by heating them to destroy them) and injections.

Lidocaine injections were found to be just as effective as steroid injections in six of the studies. There was also no difference in reported pain with traction therapy versus placebo traction.  Methylene blue injections proved effective in one study for two years after the procedure. (This was the only quality study that the authors could find on the topic, however, so more research is needed to see if the same results are obtained.)  Nerve ablative therapies, with either radio frequencies or electricity, was found to not be effective for the general population because of the coinciding disability that comes with it.  There also still remains a debate over which portion of the nerves to destroy for greatest benefit.  

Overall, the two take-home points from the evidence review are that methylene blue injections are showing promise but there is more research needed and that there are no notable differences between steroid and lidocaine injections with pain relief. Discogenic pain remains allusive both diagnostically and with treatment, but hopefully with further research future treatments can be more specific and effective.

Low back pain affects 60 per cent to 80 per cent of people worldwide. One of the sources of back pain can be the facet joints of the spine. They have been implicated in up to 15 per cent to 45 per cent of back pain cases. Facet joint-related symptoms could be presented with lumbar pain radiating down toward the buttock and posterior thigh.

FJRD (Facet joint radiofrequency denervation) for the treatment of facet joint related pain was first described in 1975 and has been used in as a minimally invasive procedure for pain relief. Radiofrequency denervation for the treating facet joints uses energy in the radiofrequency range to kill off specific nerves that innervate the facet joint, blocking the transmission of pain. The purpose of FJRD is for pain relief and decrease the possibility of recurrence. This study was a systematic review, meaning that it examined past studies done on radiofrequency denervation for facet joint pain. The systematic review assessed the treatment effects of FJRD for patients with facet joint related chronic LBP. Pain, quality of life, cost-effectiveness and complications were some of the outcomes examined. Studies are searched based on certain criteria and then narrowed down to the most applicable. The initial search found 329 studies and through the filtering process nine were considered to be acceptable studies to review.

Findings:
Pain reduction was demonstrated with most studies assessed in this review. Meta-analysis also suggested that there was a benefit in pain control with FJRD up to one year after the intervention.

Results for functional status improvement favored FJRD against placebo. Only one study suggested that better results were obtained for radiofrequency then for a steroid injection but the study did not use a measurement device that had been validated. There was no significant difference for quality of life through the studies examined.

There were no comparisons for cost-effectiveness of FJRD against physical therapy or steroid injection.

Conclusions:
The available evidence reviewed in this study should be read with caution. Most studies complied for this review had low to moderate methodological quality, only a few evaluated functional status, quality of life with validated scales and none controlled for other health factors. Findings indicated that FJRD is more effective then placebo in pain control and functional improvement. Comparing FJRD to steroid injections was inconclusive and it is possible that FJRD is more effective the steroid injections for pain control. Complications and adverse effects were not reported sufficiently to accurately compare. Cost-effectiveness was not examined in any studies, so no evidence is available.

There is no arguing that low back pain is an illness that burdens a large percentage of Americans. Sadly, centuries of folk cures and decades of research have fallen short predict reduce the prevalence of low back pain. Modern medicine has dramatically improved the health and livelihood in many arenas, but back pain remains an age-old, expensive, debilitating and frustrating… pain.

The average person with back pain and the American health care reform analyst are equally interested in sorting the worthwhile from the worthless treatments for reducing the duration and frequency of back pain episodes. Comparative effectiveness research hopes to shed light on what services should be recommended and reimbursed by insurance carriers. For example, the Cochrane Collaboration, another meta-analysis think tank, in 2010 looked at fifty studies on chiropractic treatments on low back pain and found muddled results across years of research.

… there is … no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in
… low back pain. … Future research is very likely to change the estimate of (the) effect and our confidence in the results.

Double doctor, J. Michael Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, found very little supportive evidence in his meta-analyses on comparative effectiveness of various manual therapies in his review of the existing literature. A comparative effectiveness meta-analysis” was performed to compare the relative effectiveness of various spinal manipulation treatments (from the ancient bonesetter to the modern back cracker), medical management (READ: drugs, injections, etc), physical therapy, and exercise for acute (less than a month) and chronic (more than three months) nonsurgical management of low back pain.

The good news is most pain originating from the muscles and joint in the human body is self-limiting, meaning slowing down, protecting your injury, and letting the body heal will often suffice. Research supports
the notion that 60 to 70 percent of acute low back pain settles in six weeks without any medical treatment. Chronic low back pain sufferers get better in a year without treatment 40 to 70 per cent of the time.
Pain whether short-term or long-term is indubitably unpleasant, so why suffer any longer than you have to if effective treatment is available.

This study looked at 56 spinal manipulation studies published between 1974 and 2010 and classified them into six different treatment categories. The categories included: 95 spinal manipulation studies, 31 exercise studies, 51 physical therapy/physiotherapy modalities (for example, ultrasound, electrical stimulation, and hot packs) studies, 40 usual medical care studies, and 40 control group studies of subjects that received no treatment.

The results found a 96 per cent relative improvement in the first 6 weeks across acute back pain studies was unrelated to treatment. Thus the “carry on with your life” control group and the various treatment groups were
nearly equal in settling their acute pain. The chronic pain comparison analyses found that 32 per cent of the various treatment studies could claim improved outcomes. The balance of the percentage of claimed improvement in the chronic pain comparison analyses can be attributed to everything else (letting the injury run its course). Looking at the printed boxplots of the six treatment categories effect sizes attributable to the passage of time alone, the three largest effect sizes were in the exercise group, then the spinal manipulation group, then the modality group.

This study also examined which spinal manipulation treatment provider did the best job for improving chronic back pain. It was determined in the comparison that getting your spine manipulated in the first six weeks has little influence on the outcome of shortening the duration of your acute pain. Five types of spinal manipulation providers (osteopaths, physical therapists, chiropractors, allopathic medical physicians, and bonesetters) were compared. Spinal manipulation by a physical therapist was found to be most effective, and most variable, in treating both acute and chronic back pain.

In the 36 years and 8,400 patients subjected to comparative spinal manipulation studies research cost from $32 to $80 million. Menke’s comparative analysis makes the bold assertion that ‘equivocal outcomes are unacceptable for this investment’, and funding more research on the topic should be stopped. It stands to reason, that inadequate analytics and methodology throughout the studies could be part of the problem. The take home message was that all of the compared treatments for acute and chronic low back pain are hard to quantify when looking at their relative effectiveness versus letting the injury run its course.

It seems to be accepted conventional wisdom that gravity has many harsh effects on the human body as we age. Dr. Videman, MD and PhD out of the University of Alberta and his team of researchers attempt to dispel the myth that spine compression causes the shortening of the human stature. Prior research has long focused on either the flattening disc as a culprit in back pain problems, or the deteriorating vertebral body, but very few studies have examined both structures and their relationship. In other words, is it the shock absorber-like cartilage disc getting squished between our spine’s vertebrae or the crumbling spinal tower theory that can explain why we seem to be shrinking in height after retirement.

Subjects in this study were selected from a 232 Finnish identical twins initially recruited in a Twin Spine Study in the late 50’s. Twin populations are particularly interesting, as they tend to tell us a lot about human similarities and differences in the context of aging and genetics. Apparently, this group of men was also highly representative of the average Finnish population and thus an applicable sample population of the typical European descendant’s spine. These selected gents were at an average age of 63 years (ranging between 50 and 79) at the time of the final follow-up, thus putting them at in their late 40’s/early 50’s on the initial measures. Videman’s team took particular interest in the low back or lumbar spine, focusing in on the MRI’s over the years. They tried to precisely measure the consistent changes in structure and form of the discs and vertebrae during five, 10, and 15-year follow-up studies.

The disc height comparisons concluded that we are indeed getting shorter gradually with a flattening of the disc at five years out by approximately three per cent. The 15-year follow-up found a continued slow compression by 8 per cent in the upper discs to 11 per cent in lower discs of the low back. Measurements of the low back’s bony vertebra at five years out could not find signs of any height changes. However, looking at the 15-year follow-up MRI’s, they found significant vertebra height growth by an average of three per cent in the upper vertebrae levels and by five per cent in the lower back vertebrae after 15 years. Thus, our discs do flatten slowly, but the spinal vertebrae keep pace in remodeling or growing taller (as well as wider) with age. Looking more closely at what exactly happens to the disc and vertebrae at their interface, this article found that the once clearly defined junction appeared to have more or less “melted” into one another. This merging of bone and cartilage results in the appearance of taller spinal vertebra and a narrowed or flattened disc. We are getting shorter, but by only .13 millimeters per year on an annual average after middle age. This not-so-incredibly shrinking average man was in line with the average decrease in our standing height by three millimeters from their baseline measured height to their re-measured height at the 15-year follow-up.

It can be confirmed that we gradually lose somewhere between 9 to 13 per cent of our lumbar disc height in a 15-year period around middle-aged, but why? Videman’s team found a lot of variations within the sample population of researched subjects. Some subjects had no measurable loss of disc height, whereas others had significant disc height flattening, due to degeneration. The exact process of degenerating discs and additional vertebral bone growth is speculated in this paper based on other spine-related research. Two proposed explanations include a cumulative micro-trauma theory at the disc-vertebra interface that creates an inflammation process and merging of the cartilage and bone. The second theory suggests a gradual tensioning of the disc pulling on the vertebra that eventually triggers a process of converting the cartilage to bone. Either way, this was a strong paper with a fairly large population size, precise MRI measurements and a 15 years of follow-up research. There was good evidence in this paper that we are losing disc height and gaining vertebral height at a nearly equal rate. Further research was suggested to explore the exact mechanism causing gain in vertebral height.

Chronic lower back pain ( lower back pain lasting for more than 12 weeks) is a serious health concern that affects 70 per cent to 85 per cent of people at some point of their life. In Australia where this study was done chronic low back pain cost $9.17 billion (yes, billion) dollars annually. The cost accounts for treatment related expenses and missed work. Obesity is also a serious health concern and it is common among people who experience low back pain. This study wanted to examine if there was a link between changes in body mass index (BMI) which is weight divided by height squared (kg/m2) {m is squared}. BMI is classified as follows: 18.5 kg/m2= underweight; 18.5 to 24.9 kg/m2= normal weight; 25 to 29.9kg/m2= overweight; 30 kg/m2 or more obese. BMI has been critizied because of its inability to discern between muscle mass and fat differences in the body.

Research on the relationship between BMI and chronic low back pain has not yielded consistent results. Studies have had inconsistent findings but these two issues present commonly enough that there relationship should be explored. Exercise is a common intervention for both health conditions and known to be helpful in controlling low back pain. Recent findings suggest that exercise may moderate the relationship between obesity and chronic low back pain. This study investivgated the relationship between BMI and exercise-related changes in pain and disability in patients with chronic lower back pain.

The study used 128 people from 18 to 55 years old that had low back pain for 12 weeks minimum. BMI was calculated for each person, a pain scale was used where particpants put a line an 100mm bar; from “no pain” to “worst pain imaginable” and a self-reported disability questionarie. In the study there were no correlations seen between initial BMI and initial pain reports or initial disability questionarie. In the group 77 per cent of the patients were classified as overweight or obese, yet there was no baseline relationship between BMI and pain or disability.

The study lasted eight weeks and each patient went through exercises after there baseline assessment. However, the type of exercises differed among patients, meaning that some used an indoor cycle, some did core stability exercises. Exercise sessions were three to five, one hour sessions with at least one being supervised.

In conclusion, the study considers that the criticism of BMI might be valid. Other measures might be more beneficial is studying the link between obesity and chronic low back pain. An example would to be measure the amount of fat tissue, as that has been linked to chronic low back pain. The study did not report on changes the exercise impact on individual markers of pain or disability. BMI changes are not related to pain or disability changes after exercise in this study.

Obesity and LBP combined make up for about 30 per cent of U.S. health care costs. More evidence is supporting an association between obesity and low back pain (LBP) but, not much is known about the relationship between the two. Obesity is listed as a impacting factor in LBP mostly described through the body mass index (BMI). Body mass index is categorized as: normal weight <25, overweight 25-30, obese 31-35, and ultraobese 36+. Physical activity is a logical suspect to connect obestiy and lower back pain, but no study has demonstrated the role of physical activity. Exercise and weight loss is know to benefit some with back pain, yet the role that physical activity plays is unclear. This study looked into the relationships between LBP, obesity and physical activity.

To collect data on the relationships between obesity, LBP and physical activity information was obtained through participant surveys, physical examinations, and for 7 days the participants wore accelerometers. (Accelerometers can measure in real-time, duration and intensity of motion). Participants wore the accelerometer while they were awake and every minute of that time was used to calculate activity level.

Once the data was collected the findings were very interesting. First, the baseline risk of LBP increased with increased BMI. Smoking was consistently a strong predictor of LBP across any BMI level. WIth overweight subjects it was found that time spent doing sustained activity in a moderate range reduced the odds of having LBP and was even protective from getting LBP. For the average overweight American increasing time doing moderate activity by 17.6 minutes a day, decreases the risk of getting LBP by 32 per cent! In obese subjects, time spent in sedentary activity states had positive relationship with increased LBP. In the morbidly obese category more time spent in moderate activity reduced odds of getting LBP. A small increase in moderate activity level for the morbidly obese by 2.1 minutes reduces back pain risk by 38 per cent!

This study shows that there is a relationship for increased BMI being a risk factor for LBP. Reduced physical activity is also a risk factor for getting LBP, lots of sedentary time and reduced moderate activity have a greater impact on increased LBP risk in overweight Americans. In the overweight population physical activity can be a dimishing factor in lower back risk and it does not take great increases in physical activity to for exercise to have a protective effects.

It is widely accepted that low back pain is one of the most common orthopedic pains we will experience in a given year. It is also a highly scrutinized and researched health condition, as it is a very costly public health problem that affects a third of all adults. Treatments for low back pain range from medication, to surgery, to therapist-delivered care. Recently, Dipesh Mistry and a team of health scientists from the UK’s Warwick Medical School, performed a systematic review of the research on the quality and effectiveness of low back pain treatments performed by therapists. Acceptable therapies for low back pain included a lot of treatments from psychological interventions to intensive rehabilitation programs, from laser acupuncture in Australia to high velocity thrust manipulation in Sweden. The targeted types of low back pain were classified as ‘nonspecific’, meaning they do not come from a likely cause such as a fracture, tumor, infection or inflammatory disease. Nonspecific back pain is generally known as the common back ache or strain.

Mistry’s team combed through the research to select only high-quality, randomized controlled trial-based articles on subjects older than 18 with a history of nonspecific low back pain. Their results largely followed the prior literature reviews consensus small, rather than the conventionally-accepted moderate positive effective gains from therapeutic treatments. They were able to use a total of 39 articles from various search engines (i.e., Medline and Cochrane Controlled Trial Register) completed between the years of 1948 to 2013. They divided the articles into two sub-classifications as either a confirmatory finding or an exploratory finding. Confirmatory are more rigorous, follow-up research that strides to confirm or test the hypothesis. Exploratory are more preliminary research that aims to generate future hypotheses or build a base for future research. Of the accepted, high-quality studies, only three studies (8 per cent) tested hypotheses and were classified as confirmatory. Eighteen studies (46 per cent) were classified as exploratory findings. The remaining 18 (46 per cent), fell short of a substantive conclusion and were given the ‘insufficient findings’ status. The researchers further tweezed each articles’ respective study methods for appropriate statistical testing for each interaction between studied variables. Fortunately, appropriate stats were employed in 27 of the 39 of the articles. The remaining articles had sub-classification reporting deficiencies or other areas deemed too weak to qualify for this paper’s systematic review.

They concluded that the sub-classified (either the confirmatory or exploratory findings) therapies for treating nonspecific low back pain have been ‘severely underpowered’ in their analysis. In other words, over the past 65 years, the 39 acceptable high-quality articles were only able to provide exploratory class research with insufficient evidence to boot. Moreover, they had poor quality data in their reported findings. Misty’s team also generalized that if we hope to better identify which form of low back pain treatment will be the most economical and effective, then we need to better classify which subgroup of persons with back pain are appropriate for each treatment. Future research was suggested here to develop new methods to effectively identify subgroups in back pain research. Furthermore, they recommended that the low back pain research community needs to collectively revise their current approach to subgrouping the back pain studies. Continued perpetuations of exploratory class research won’t help improve the care for our substantial population of persons with back aches looking for effective therapies.

Despite spending more than 86 billion dollars a year on treatment for back pain in the United States, Americans continue to struggle with this problem. It has become a national epidemic. Twenty-five years ago, prominent medical doctors called for new ways to diagnose back pain and measure outcomes of treatment. Today, very little has changed. In fact, there is evidence to suggest that Americans with spine problems are worse than ever before.

What have we learned from these last 25 years of scientific inquiry and study? In this editorial, Dr. R. G. Hazard from the Department of Orthopaedics at Dartmouth Geisel School of Medicine offers some perspective on this question.

First, it should be noted that in 1987, randomized controlled trials were started. These studies used scientifically validated measures of low back pain and subsequent disability. And second, the focus shifted from looking for a specific pathologic reason for the back pain to an understanding of the biopsychosocial factors accompanying back pain.

Stress at home and at work, feelings of being out of control of life situations, and self-perceptions were some of the biopsychosocial aspects mentioned at that time. Along with these two new approaches came awareness that treatment at that time was driven by patient complaints, distress, and behavior.

On the medical side of things, it is clear that finding a clear and accurate diagnosis to label each patient is often impossible. Imaging studies with X-rays, CT scans, and/or MRIs are often “negative” (no findings of anything “wrong” in the bones or soft tissues). Even knowing this, physicians continued to use steroid injections, narcotic medications, and surgical procedures to address the problem of back pain.

Not only that, but when clear-cut diagnoses could be made (e.g., lumbar disc herniation), patients with this diagnosis responded differently to treatment. Finding one single approach that worked for everyone just didn’t happen. Some experts even recommended providing patients with amenu of (treatment) options and letting them pick their treatment of choice. This idea was labeled a shared decision-making model. However, results so far have not been any better than with physician-prescribed treatment.

So, where are we today? There is a shift toward emphasizing ability (function) rather than disability (limitations). Instead of focusing treatment on pain relief, rehab programs aim to improve flexibility, endurance, and strength in the presence of ongoing pain. If pain is relieved, well then, so much the better. But pain relief is no longer the main treatment objective.

Recovering function (daily activities) and the ability to return to work are the main goals of today’s treatment for chronic low back pain. This approach is referred to as the Goal Achievement Model for the treatment of low back pain. Efforts to reduce disability from back pain based on patient goals is a new way of thinking about the problem of back pain.

Concepts such as setting “acceptable targets” and forming “patient-based action plans” are the new words attached to current treatment ideas about chronic low back pain. Health care providers can still use the biopsychosocial model (working with patient values, attitudes, and beliefs) while the patient gets the results he or she is after. This approach has worked quite well with other health problems (mental health and chronic diseases that lead to severe disability).

Where will we be at the end of the next 25 years? Hopefully, clinical and research efforts will solve the dilemma of chronic low back pain. Whether it is with a goal-oriented program that takes into consideration physical, emotional, psychologic, social, and spiritual or some other approach remains to be seen. Lowering costs, preventing low back pain, meeting patient expectations, and providing successful outcomes and patient satisfaction are all important but complex factors that must be taken into consideration.

Back pain with leg pain caused by disc herniation is a complex problem and not one that is easy to diagnose. Physicians rely on the patient’s history, physical examination (including specific neurologic tests), and imaging studies such as X-rays, MRIs, and CT scans. Accurately identifying the problem is one step. Determining the spinal level where the disc is pressing on the spinal nerve is a separate diagnostic step.

It would be helpful for examiners evaluating patients with back and leg pain if they knew which clinical tests are the most accurate and reliable. This is especially true if it turned out that one neurologic testing procedure could provide good overall diagnostic accuracy.

According to this study from New Zealand, current motor, sensory, and reflex testing used to diagnose disc herniation and specific level of pathology are not accurate. In fact, after pooling all the data together and analyzing the studies published so far, it looks like the accuracy value of the tests is poor at best.

After searching six of the most relevant electronic databases, they found 14 studies that matched their inclusion criteria. Their search history, search strategy, and algorithm (flow chart) for the studies was presented as an easily readable diagram. Study characteristics (e.g., author names, tests reported, type of physician examiner, herniation type and level) were presented in an easy-to-read table.

An in-depth description of the problems encountered with each study was provided. This helps explain why the neurologic testing to detect lumbar disc herniation and spinal nerve root involvement is not reliable enough to become a standardized test. Here’s a quick summary:

Today’s physicians depend on evidence from clinical studies and what are considered “best practice” approaches by experts whenever possible. When evaluating patients with degenerative lumbar spinal stenosis (DLSS or sometimes referred to as just LSS), the clinical practice guidelines of 2006 have been the “go to” document for guidance. This saves physicians from sorting through the hundreds of studies published each year in many different journals.

But now, the 2006 guidelines have been reviewed (based on published studies up to and including July 2010) and revised. In this document, members from the Degenerative Lumbar Spinal Stenosis Work Group of the North American Spine Society (NASS) provide a summary of the new guidelines. This update is now considered the most recent evidence-based clinical practice guideline (CPG) on LSS.

Sixteen questions were posed and answered in the 2006 Clinical Practice Guidelines. The questions covered topics ranging from natural history of LSS to diagnosis and treatment of this condition. All questions were reviewed and responses provided in this 2013 update. The levels of evidence were indicated for each response using grades labeled A (recommended), B (suggested), C (an option), and I (insufficient evidence to recommend for or against).

The working group also provided a consensus statement when there wasn’t enough reliable evidence to provide a guideline. This consensus statement is the opinion of the group based on all currently available evidence and expert opinion. Here is a sampling of the questions and some of the updated responses: