News Category: Lumbar Spine

Tumors of the sacrum are rare but can create serious problems. They can be benign or malignant. They may be primary, which means they develop first right in the sacrum. Or they can be the result of local invasion or metastases. Local invasion means they start in a nearby area (like the pelvis or rectum) and spread to surrounding tissues. Metastases refers to the fact that the cancer cells spread from someplace else farther away — most often the lung, breast, prostate, kidney, gastrointestinal tract, or thyroid.

In this review article, neurosurgeons from Johns Hopkins University bring us up-to-date on the various types of sacral tumors, how to diagnose them, and how to treat them. Tumors anywhere in the body can be classified in different ways. Sacral tumors are put into one of four main groups. Those groups are congenital (present at birth), metastatic (malignant cancer spread from somewhere else in the body), primary osseous (forms first in the bone), or primary neurogenic (forms first in the nerve tissue of the sacrum).

Most of the time, sacral tumors are the result of cancer someplace else in the body. Regardless of where the tumor arises (in the sacrum first or metastasized from elsewhere), the diagnosis is difficult to make and can often be delayed significantly. Symptoms develop slowly.

The patient may experience back and/or buttock pain that seems to get better or worse with certain movements. This type of back pain is referred to as mechanical low back pain. Often the symptoms mimic other less serious back problems. The patient may be treated conservatively with pain relievers. If symptoms persist, they may be referred to a physical therapist. All of this can delay an accurate diagnosis for months to years.

It isn’t until the tumor grows large enough to cause additional symptoms such as loss of bowel and/or bladder control or change in deep tendon reflexes that the true nature of the problem is discovered. In other cases, severe, chronic and painful constipation or sexual dysfunction are the first clues to tip the doctor to look more closely at the problem. Sometimes pressure on the nerves in the sacral area causes severe enough pain that the diagnosis is finally made.

Additional diagnostic studies may include X-rays or more advanced imaging such as CT scans, MRIs, and/or bone scans. X-rays are very unreliable for these kinds of tumors. The tumor may not show up — or other structures in the area can block a clear view of the tumor. That’s unfortunate because it can mean the diagnosis is delayed again.

CT scans may be more helpful. Certain features of the tumors may be seen more clearly with this type of imaging because it is more detailed and more sensitive. CT scans are also used to guide needle biopsy, which is used to detect sacral tumors with greater accuracy. The authors discuss when to use needle biopsy and what kinds of risks there are with this type of diagnostic testing. If the results of needle biopsy are unclear, then open biopsy may still be required.

Bone scans are able to show where lesions are present, but they don’t answer the question of what are those lesions? A more advanced form of bone scan called SPECT can help tell the difference between benign and metastatic lesions. Some experts advise ordering SPECT scans for anyone suspected of having cancer in the lumbar spine, sacrum, or pelvic areas.

Once the diagnosis has been made, then a plan of care is established. Pain control is the first priority. These tumors can be very large and press on many structures creating intense pain. The location so close to nerves (called the lumbosacral plexus) in the lumbar and sacral areas creates severe nerve pain in the majority of patients.

Pain relievers such as mild analgesics may not be enough. Some patients require opioid therapy (narcotic drugs). Other medications used to control cancer pain include corticosteroids, antidepressants, anticonvulsants, and even indwelling (continuous) nerve blocks.

Surgery to remove the tumor isn’t always possible right away. The tumor can be too large or too enmeshed with other structures to remove it easily. Radiation may be used first to shrink as much of the tumor as possible. But even radiotherapy has its limits because the area involved can be large, complex, and difficult to reach.

Newer technology with stereotactic radiosurgery focuses several cross-fired beams of radiation to a single point or smaller area at a time. This helps reduce damage to the surrounding tissue that doesn’t need radiation. Computer-controlled robotic spinal radiosurgery is now available. You may have heard of this as it is referred to as CyberKnife treatment. It’s not available everywhere, and studies are ongoing but early results are very favorable.

And finally, there’s surgery. Tumors that are advanced by the time they are diagnosed make surgery difficult and complex. Removing the tumor, a procedure called resection, isn’t always a straightforward process. The anatomy of the pelvic and sacral areas is a challenge. Bowel, bladder, and sexual function are easily disrupted by any changes in this area. The patient’s preoperative health can also make a difference (e.g., diabetes, high blood pressure, heart disease).

Some patients just won’t be able to have surgery to remove the tumor. For example, this may be the case if the tumor has invaded the spinal cord, nearby organs, or major blood vessels and can’t be cut out easily. Or there may be so much bone involved that it’s impossible to amputate enough soft tissue and bone to get it all without major disfigurement or loss of function.

Even for those for whom surgery is an option, multiple procedures may be needed to reconstruct vital bowel and bladder structures. Removal of the entire sacrum (called sacrectomy) can be a major undertaking, especially if the sacroiliac joints are compromised by the tumor. This anatomical area provides support, stability, and biomechanical function for the entire lower body.

Some patients will need additional radiotherapy after surgery. Patients who have surgery combined with follow-up radiotherapy have the best outcomes when compared with surgery alone or radiotherapy alone. Measures of outcome are reported in terms of pain levels and ability to walk again. For example, in one study, 84 per cent of the patient who had surgery followed by radiotherapy were able to walk again. Many of those patients were unable to walk before the surgery. This was compared to only 57 per cent who were able to walk having only received radiotherapy.

Great improvements have been made even in the last 10 years in surgical techniques for these kinds of problems. Many patients are able to regain motor function and walk again. Prognosis is good for pain reduction. Disease-free survival is possible but the rates vary with each tumor type. Recurrence can occur, but the incidence of such was not reported in this article.

Painful leg cramps during the day or at night can be very disturbing — both to daily activities and to sleep. And many aging adults complain of this problem, so it has caught the interest of doctors and scientists around the world.

So far, scientists still don’t know exactly what causes leg cramps to start. They have identified various other health conditions that may be linked with leg cramps but don’t know the mechanism that leads to this symptom. It may be a problem at the motor unit of the muscle. There are some studies showing that older adults start to lose motor groups with age.

But this wouldn’t necessarily explain what happens in other cases such as women who are pregnant, people with diabetes, or anyone taking certain medications that seem to be linked with leg cramps. Some of those medications include diuretics (water pills), statins to lower cholesterol, beta-blockers for heart disease, steroids and antidepressants.

In this study from Japan, researchers from Keio University School of Medicine in Tokyo report on leg cramps in patients with lumbar spinal stenosis compared to older adults without spinal stenosis. Stenosis is a narrowing of the spinal canal around the spinal cord This type of narrowing can also affect the foraminal spaces (holes) where the spinal nerves pass through the vertebral bone in order to travel down to the legs.

Stenosis is a common finding in older adults. And leg cramps are common in both stenosis and older adults. But as mentioned, leg cramps also occur in pregnant women, people with diabetes, as a result of taking some medications, and may be a hereditary disorder in some people.

So the question is: if stenosis causes leg cramps, would decompressive surgery relieve those symptoms? Decompression surgery removes bone from around the spinal nerve roots. When the spinal nerve roots are being compressed, back and leg pain with leg cramps can occur. Removing bone from around the nerves gives them more space and removes the pressure. The hoped for result is reduced pain (or in this case, leg cramps).

They sent a survey of questions about leg cramps to two groups of people. The first group had decompression surgery at one or two lumbar levels for back and leg pain associated with lumbar spinal stenosis. The second (control) group was from the general population. They didn’t have any back pain or back surgery. They came to the clinic for a general health checkup and agreed to participate in the study.

The survey asked questions to identify who had leg cramps, how often they occurred, if they affected both legs and where the symptoms were located (foot, calf, shin, thigh). The participants also answered questions about time of day/night the symptoms came on, if they could walk (and how far), and if there were other symptoms present such as numbness, cold sensation, or a restless sensation.

For the patients who had surgery, they asked if the leg cramps had changed from before to after surgery and if they were satisfied with the results. They also answered questions about any treatment they may have had for leg cramps (e.g., medications, massage, acupuncture, physical therapy). The presence of any sciatica (shooting pain or numbness down the leg) was reported by the surgical group. Both groups were asked if (and how) the leg cramps affected their daily activities.

Here’s what they found:

If we could find a way to prevent back pain, it would save many people the pain of the condition as well as the expense of treatment. Many studies have been done trying to find a successful answer to back pain prevention. In this study, researchers from the Department of Orthopedic Surgery at the University of Washington in Seattle took the time to review high-quality studies to see what might be working.

They looked for controlled trials, which means one group of patients receives the treatment. Then the results are compared with a second (control) group who do not receive the treatment. They found 185 possible studies. But when they looked a little closer, only 20 were acceptable. And even within those 20 studies, the patient populations were so heterogenous they couldn’t do a systematic review.

What do all these research terms mean? Heterogenous refers to the fact that the patients from study to study were different enough that it was like comparing apples to oranges. Various factors in the studies were also too different to make comparisons. Experts say for better (more high-quality) research, the patients in each group should be more homogenous (alike) than different.

The bottom-line was that this group of authors could not use the combined results of all the studies together to perform a systematic review. Systematic reviews can be helpful when studies are too small to really give significant results. Adding them all together creates a bigger pot from which to draw conclusions. But again, if the pot is too full of different ways to approach the problem, then this type of review can’t be done.

Having said all that, what kind of studies were included and what did they find? First, only adult patients (ages 18 to 65) with similar types of back pain were included. Anyone with a medical cause of back pain such as a tumor, infection, or fracture was not included. That helped create a group of homogenous patients. The follow-up period was at least six months. And statistical analysis was done properly.

Types of prevention techniques included patient education, exercise, braces, and orthotics (shoe inserts). Changes in work policies and activity modification (work and recreation) were also included. A final category included ergonomic equipment. This would include anything that helped people reduce the workload or reduce stress on the back.

In order to compare results of studies, the outcome measures have to be reported in similar ways from group to group. Types of outcome measures allowed in this study were objective (e.g., number of sick days due to back pain, medical costs, work injury claims) and subjective. The subjective measures were geared around what the patients could remember about their back pain (e.g., how often symptoms occurred, how intense was the pain, type of limitations or disability experienced).

The authors carefully explain how they conducted their literature search, how they evaluated the studies they found, and how they rated the strength of the evidence they reviewed. They provided the reader with extensive and detailed tables summarizing the results of each treatment approach. In the end, what they found was that exercise was the most effective in preventing low back pain.

Things like back supports, shoe inserts, stress management, and back education had no effect on reducing or preventing the incidence of back pain in working adults. Reduced lifting programs had no effect either. So, what kind of exercise is best?

Most of the studies focused on abdominal and back extensor muscle strength, power, and flexibility. The most successful exercise programs were supervised, consisted of 45 to 60 minute sessions, and took place twice a week. The length of time patients met ranged from three months to a full year. The patients in the exercise groups had stronger abdominal and back muscle strength. They also had much lower work absence (28 days) compared with control groups (155 days) over the same period of time (13 months).

Over the past few decades, employers, individuals, and communities have spent large amounts of time and money in an effort to prevent back pain in working adults. And they have continued to do so without any real proof that what they were doing was working. This is the first study to step back and take a look at high-quality research studies and report on their findings.

It appears that exercise programs of all kinds work best. There seems to be a general benefit to exercise that results in reduced episodes of low back pain and fewer days lost at work when back pain does occur. What’s the explanation for this? It’s not clear yet if there is a simple answer.

There may be ways in which exercise affects the body that go beyond the biology. Maybe people feel more confident after exercising. The results are reflected in their general health including reducing incidents of back pain. Maybe they are less fearful of injury and somehow this lends to lower episodes of such injuries.

What the authors know for sure from this systematic literature review is that well-designed, quality trials are needed to continue testing out new ways to prevent low back pain. Using work absence and function seems to be a good way to sort out what works and what doesn’t.

It’s possible that combining two or more prevention techniques would have even better results than exercise alone. There’s no proof for this at the present time. Further studies are needed to sort out where our resources should go to prevent low back pain in different homogenous groups of people.

Exercise is the most powerful wonder drug in America. In fact, the American College of Sports Medicine (ACSM) has launched a program called Exercise is Medicine with the sole purpose of getting Americans to incorporate physical activity and exercise into their daily routine, especially those people with health problems.

Exercise therapy has been shown effective with chronic low back pain (LBP). But physical therapists and other researchers are still grappling with what kind of exercise is best? Lately, there’s been a trend to use stabilizing exercises during the early phases of recovery. This type of exercise program focuses on specific muscles of the abdomen and trunk. It helps reduce pain and improve function by controlling spinal segmental motion.

Studying exercise and back pain is a challenge. The patients are heterogenous (very different). So it’s difficult to find a homogenous group to compare treatments with. Homogenous means they are more alike than different.

There are also many ways to study exercise. Should it be combined with other treatments such as manipulation or general exercises? Should patients receive additional information to help them understand back pain? Will adding this type of patient education improve the results of an exercise program or have any effect at all?

What about dividing patients up based on whether they work or not? Would that affect the results of an exercise program? There are many possible factors to consider in sorting out what type of exercise(s) work and with which patients.

In this study, working adults with recurrent nonspecific low back pain were placed in one of two treatment groups. By choosing patients who were still working, the authors created a more homogeneous group to study. Nonspecific means there was no medical cause for the back pain. It wasn’t something serious like a tumor, fracture, or infection. With nonspecific low back pain, symptoms typically occur with active movement.

The patients were randomly placed in either a graded exercise program (the exercise group) or in a daily walking program (the reference group). A physical therapist supervised both groups for eight weeks. The graded exercise program focused on spinal stabilization. Graded means the exercises could be increased in number or difficulty when the patients’ pain level decreased and when movement improved.

Each subject was given a specific program teaching them how to contract and hold stabilizing muscles. The exercises were done during daily activities and in a variety of different positions (sitting, standing, moving). Patients were taught how to activate the stabilizing muscles whenever they were in situations that might cause pain. Positions known to cause pain were avoided. Patients were encouraged to breathe correctly and avoid increasing abdominal pressure with breath holding.

The walking (reference) group was told about the benefits of daily walks. They were advised to walk as fast as was comfortably possible without setting off their pain for a total of 30-minutes every day. If pain developed or increased, they were to slow down. The 30-minute walk could be done in two sessions of 15 minutes each.

Results of the two programs were compared using several different measures. The main measures of outcome were pain and perceived disability (measured by a self-reported survey filled out by each patient). The secondary measures included general physical health, ratings of self-efficacy (confidence to move and participate in activities), and fear-avoidance behaviors (FAB). Fear avoidance refers to patients avoiding movements or activities because these might increase their pain.

Everyone was followed for a total of three years with individual follow-up measurements taken at six-months, 12-months, and 36-months. At the end of the first year, half of the graded exercise group had more than a 50 per cent reduction in their pain. This was compared with only one-fourth of the walking (reference) group experiencing an equal amount of pain relief.

Both groups reported decreased disability, but there were more patients in the graded exercise group than in the walking group to report this result. Likewise, patients in both groups experienced improved general health. Only the exercise group reported a decrease in fear-avoidance and improved self-efficacy (confidence) behaviors.

More people in the graded exercise group stuck with the program (96 per cent) compared with the walking group (71 per cent). Fewer patients in the exercise group had a bout of recurrent low back pain during the first 12 months. But over the entire three-year period, recurrence of back pain was equal between the two groups.

The authors concluded that the graded exercise program had some benefits not seen with a simple walking program. The exercise group had a self-management strategy to use for pain and they were much more satisfied with the results. Patients in both groups did benefit — just in different ways. It would be interesting to see if these two programs combined together would yield even better results than either group alone.

The authors suggest further studies are needed to continue looking for ways to reduce pain and disability in back pain patients. Finding a way to prevent back pain recurrence is one important goal. Preventing back pain from ever developing is another equally important goal. Pain and perceived disability are only two ways to measure the results of treatment. In a working group of adults, general health, freedom from fear to move, and confidence to do their job tasks are also very important.

It used to be that a bulging disc, herniated disc, or degenerating disc was very bad news. Surgery was often done and in many cases with less than satisfactory results. But much more is known about disc disease now. Better technology allows for earlier diagnosis and successful treatment without surgery. The authors of this review article bring us up to date on what’s the latest with lumbar degenerative disc disease (DDD).

Degenerative disc disease is a problem usually linked with aging. Disc degeneration follows a predictable pattern. First, the nucleus in the center of the disc begins to lose its ability to absorb water. The disc becomes dehydrated. Then the nucleus becomes thick and fibrous, so that it looks much the same as the annulus (fibrous outer covering of the disc).

As a result, the nucleus isn’t able to absorb shock as well. Routine stress and strain begin to take a toll on the structures of the spine. Tears form around the annulus. The disc weakens. It starts to collapse, and the bones of the spine compress. It’s the compression of the soft tissues that probably causes painful symptoms.

What does the doctor look for to identify degenerative disc problems? Low back pain, of course. And pain that travels into the buttock, sacroiliac area, and/or down the leg. Symptoms might be worse first in the morning and with any kind of forward bending movement of the spine. But this isn’t standard and there can be a wide range of symptoms.

Without a specific set of identifying symptoms, surgeons often say that it’s easier to rule out other possible causes of back pain than it is to rule in disc disease. That makes degenerative disc disease a diagnosis of exclusion.

What can the patient with low back pain expect at the surgeon’s office? The physician starts with a detailed history and careful physical exam. Imaging studies such as X-rays and MRIs all contribute to the diagnostic process.

X-rays help show fractures, bony alignment, disc space narrowing, and bone spurs. MRIs give a detailed view of the discs themselves. If the disc looks normal on an MRI, the physician looks elsewhere for the cause of the painful symptoms. But even with abnormal findings, it isn’t certain that the disc is the problem.

Studies show that one-third up to one-half of all patients with disc degeneration have no pain or other apparent distress from these changes. To help doctors understand what findings on MRIs are helpful, the authors provide images and a detailed description of types and locations of signal intensity changes that point to painful internal disc disruptions as a possible cause of low back pain.

It is also possible to test the disc directly using discography. The disc is injected with a dye. The extra fluid in the disc increases pressure and causes pain if that’s the painful area. If there’s a tear in the covering around the disc (called the annulus), the dye will leak out.

The disadvantages of this test may outweigh the benefits, so it’s not used routinely. Besides being painful, it can create new pain in discs that were previously fine. And for patients who have other chronic pain patterns (e.g., neck, arm, general body pain), the risk of a false-positive result is much higher. Surgery isn’t always helpful even when the discography is positive, so the value of the test is limited.

Most of the time, patients with degenerative disc disease improve with conservative (nonoperative) treatment. In fact, up to 90 per cent of all patients with low back pain of some kind get better without any treatment at all. For that reason, immediate treatment isn’t advised unless there are significant neurologic symptoms suggesting an emergency situation.

Medications such as antiinflammatories and antidepressants have been found helpful with certain patient population groups. Physical therapy is often the first-line of hands-on treatment. Core training of the trunk (abdomen and back) muscles is used to stabilize the spine. Patients are taught correct posture, lifting techniques, the importance of movement, and other specific exercises that are appropriate for each individual.

When there is acute (recent) low back pain, spinal manipulation by a physical therapist or chiropractor has been shown to be effective. Chronic low back pain requires a different approach altogether with a multidisciplinary team of experts addressing physical, social, emotional, and psychologic issues.

When conservative care fails to reduce pain or restore movement or function, then more invasive treatment such as electrothermal therapy, steroid injection, or surgery may be considered. Intradiscal electrothermal therapy (IDET) is the use of heat to destroy damaged disc tissue. It has a very low complication rate but also mixed results, so it’s not widely used yet.

Steroid injections seem to provide short-term pain relief. In some patients, that may be all that’s needed to get them back on their feet and moving. More studies are needed to better understand this treatment approach. It may be possible to identify subgroups of patients who would benefit the most.

Spinal fusion is still done but it has come under question lately. The procedure is invasive, provides inconsistent results, and low overall long-term satisfaction. Some studies showed that doing nothing had as much effect as having a fusion.

Like all treatments for low back pain patients, it works for some, but not all, patients. Finding those patients for whom fusion would work best may help narrow down the field and produce better results.

For now we know that the predictive factors of a poor outcome include previous surgery for back pain, low income, tobacco use, depression, older age, and lawsuits. Current research is focusing on type of fusion and whether some types (e.g., posterolateral, anterior, interbody) have better outcomes than others.

As a result of these mixed reviews for fusion, surgeons have turned their focus in other directions looking for a better solution. The latest development has been what’s called motion-sparing technology. This refers to surgical procedures designed to preserve motion at the diseased level so that the adjacent segments don’t start to degenerate, too.

There are several types of motion-sparing procedures including supportive rods placed alongside the spine, polymers (manmade plastics and proteins) injected into the disc, and total disc arthroplasty (disc replacements).

Disc replacements are fairly new in the United States. Only a small number of patients qualify for this operation. They must have a stable spine and disc degeneration (not a herniated disc). There must be no stenosis (narrowing of the spinal canal), osteoporosis (low bone density or brittle bones), or obesity. Women who are pregnant and anyone with scoliosis, previous lumbar fusion, spinal infection, or vertebral fracture are also not good candidates for disc replacement at this time.

But data on the results of disc replacements is starting to be published. Most studies are small in number. There are complications such as failure of the implant, fractures of the vertebral bodies, and subsidence (sinking) or migration (movement) of the implant. Researchers are keeping an eye on adjacent disease and following patients to get long-term results.

The authors say that the big picture view of degenerative disc disease is that it can take a while to sort out all the possible causes of low back pain before determining the cause. Surgery is only done when the condition causes chronic pain and loss of function. Spinal fusion is still the most common surgical treatment. New evidence from studies on disc replacements may change that in the future, but for now, it’s a wait-and-see proposition.

The authors of this article investigated the frequency of lower back pain originating from the sacroiliac joint and the hip. By discovering this, doctors may be better able to develop alternative diagnosis and treatment, rather than just treating the back pain.

Researchers reviewed the records of patients who presented with back pain for the first time. They focused on 368 patients who were seen in one spinal surgeon’s clinic. Of these patients, 289 complained of lower back pain with or without leg pain, for the first time, the remaining 200 patients had undergone surgery for the lower back pain before.

To assess the patients, the researchers reviewed the history and examination findings, and any tests that were done, such as x-rays, computed tomography imaging (CT scans), and magnetic resonance imaging (MRIs). Patients had also had injections into the spine and area to help relieve pain. Some patients also underwent a test called a discography, sometimes called a discogram. To do this test, your doctor inserts a needle into the disc and injects a dye. This fluid increases the pressure in the disc, which can cause pain. The patient then rates the pain.

The patients’ hips were assessed by reports of where the pain was, such as in the groin area, when starting to walk, difficulty crossing legs, and increased pain of the hips were forced to move as the doctor checked for how much range of motion the hips had. Imaging tests may also have been done. If the patients had pain in the sacroiliac region, they were diagnosed as having SI problems and then were given injections into the joint or had physical therapy.

The findings of the study showed that 164, or 82 percent, of the patients had lower back pain, but only 130 of the patients, or 65 percent, experienced the pain directly because of the back. Thirty-five patients (17.5 percent) of the patients had pain caused by spine plus hip causes and/or because of the sacroiliac joint and the back. Sixteen patients (8 percent) had only hip or sacroiliac causes, not back. Cause of pain wasn’t pinned down in 20 patients (10 percent).

Interpreting the findings, the authors wrote that up to one quarter of patients who have lower back pain could have pain caused by something other than the back and up to 10 percent may not have any identifiable cause. This makes it important that the diagnosing doctor be aware of the alternative pain causes, testing for them before assuming that the injury is entirely back-related.

Chronic lower back pain, with its very high incidence across the country, is the subject of very many studies and different treatment trials. Many times, a treatment will seem like the perfect solution, only for patients and doctors to realize that the treatment isn’t as effective as they’d hoped or not as available, either cost-wise or practicality-wise.

The authors of this article wanted to see if one treatment that is gaining popularity to treat subacute or chronic low back pain, injections into the back, is helpful or not. The authors undertook to review studies that had been done and see what the general consensus was. The researchers did have to take into account that several of the studies have variations that could result in different findings, such as some studies looked at injections that went directly into the facet joints, others into the epidural space (space around the spinal cord), and yet others in different areas. There were also differences between the different medications used to inject: the corticosteroids tht would reduce inflammation or swelling, analgesics to numb the pain, and antibiotics to fight or reduce the risk of infection. Finally, a third difference is why the injections were done. Were they done for diagnosis or for treatment?

The researchers looked only at randomized, controlled trials. Patients ranged in age from 18 to 70 years and had to have had back pain for at least one month to be considered subacute and four months to be considered chronic back pain.The patients had all received injection therapy for their back pain, in the fact joint sites, epidural sites, and local sites (right where the pain was located). Pain was measured by pain scales, overall improvement, number of patients who were considered recovered, and patient reports of improvement in symptoms.

Eighteen trials were reviewed in all, with a total of 1179 patients. Ten of the trials were considered to be of high quality. Among studies that compared epidural corticosteroids with placebo injections, two studies compared the short-term effects and one of the studies as a high quality study, the second low quality. Both found there wasn’t any significant differences between the patients who received the corticosteroids and those who had placebos. There was a small difference in the corticosteroid group for better short-term movement and moderate evidence for pain relief.

Epidural injections were compared to other treatments for low back pain, such as using medications like NSAIDs (nonsteroidal anti-inflammatory drugs). Three studies looked at NSAIDs with the injections and none showed any increased benefit for either. In a high-quality study, morphine was compared with the injection but that study also didn’t find any significant differences.

Epidural injections with anesthetics were also compared with other treatments. There were no differences in either the low-quality or the moderate-quality studies. When facet joint injections with corticosteroids were compared with placebo injections, two studies (one high quality, one low) found no significant differences in how the patients reported their pain and any improvement when they were evaluated at one and three months after the injections, but at six months, those who had the corticosteroid injections did have better pain relief and function. Three other trials, considered moderate quality, didn’t find any differences in short-term relief and, in fact, two trials contradicted each other.

When the facet joint injections were compared with other treatments, the results were the same again: no significant differences. One small trial (only 84 patients) tried using a medication called sarapin along with the anesthetics and those researchers reported better pain relief, function, and return-to-work rates. Comparing fact joint injections with local anesthetics and other treatments, one high-quality study compared lidocaine with a placebo and the lidocaine group did do better with pain relief. A moderate-evidence trial also found a bit of improvement.

Local injections with corticosteroids compared with placebos, in high-quality and low-quality studies,found that there wasn’t much a difference after, although the high-quality study did report that more patients who had treatment reported improvements two weeks later. Local injections with anesthetics compared with placebos had similar results.

A low-quality study looked at injecting vitamin B12 into the muscles compared with placebo injections in treating the pain. The small study (60 patients) seemed to show that the patients receiving the vitamin did significantly better than those who didn’t, over the short term.

Overall, the evidence showed that there wasn’t a big difference – no increased relief from pain, no improvement in disability, no quicker or higher number of patients returning to work, and little improvement in self-reported pain – among any of the injection treatments.The authors of the article do, however, point out that even though there doesn’t seem to be any added benefit, that doesn’t necessarily mean that the treatment won’t work for individual patients.

Active people between the ages of 20 and 40 years can be susceptible to developing a back injury called a herniated disc (bulging disc, slipped disc). If nonsurgical treatments don’t work, then many undergo surgery to help relieve the pain and allow them to resume an active lifestyle. However, there are always some patients who either don’t respond well to surgery or they do well, but they herniate another disc later on.

The authors of this article worked on estimating the recurrence rate of lumbar (lower back) disc herniation after surgery in active young men. To do this, they reviewed the charts of 241 patients, all male police officers or soldiers, who had open discetomies, surgery to remove the injured disc. The researchers looked at the records and test results, and then had the patients respond to telephone surveys after to see if any new symptoms had developed.

The results of the stud showed that 17 patients had recurrent herniations. That leaves a rate of 91.5 percent of patients not having recurrence at 14 years after surgery. Fourteen of the recurrences (6.8 percent) occurred in patients between the ages of 20 to 29 years. The other three patients were between 30 and 39 years.

Sixty-five percent of the patients had their herniation at the L4 to L5 levels of the spine, which is the lowest part of the lower back before it becomes the sacrum, or the lowest part of the back. The herniation was between L5 and S1 (highest part of the sacrum) in 33.2 percent of the patients, and between L3 and L4 in 1.2 percent. The recurrences occurred in the L4 to L5 region in 8.2 percent of the patients and at L5 to S1 in 5 percent. The researchers also found that most of the recurrences happened in disc herniations that protruded.

The authors point out that their study did have limitations, such as their definition of recurrence was as seen by imaging and reports of pain. They didn’t include patients who had evidence of protrusion on the images but didn’t report any pain. The greatest limitation though, they write, is that the follow-up was that they lost quite a few patients to follow up and follow up time.

In conclusion, the authors write that the recurrence rate was significantly higher among patients who had protruding disc herniations.

According to this Japanese study, elite athletes who train for many years (from childhood on), are at risk for degenerative disc disease (DDD). Risk factors include participation in strenuous sports activities with specific postures and actions. A bout of severe low back pain during youth may also be a predictive factor of disc degeneration.

Repetitive physical loading of the lumbar spine varies with different competitive sports activities. Other studies have shown that the incidence of DDD is higher in elite gymnasts, weight lifters, soccer players, and high-load swimmers. Frequent trunk rotation, jumps, kick motions, and repetitive flexion and extension of the spine may account for the forces leading up to disc degeneration.

In this study, baseball players and swimmers with continuous, competitive participation had a higher incidence of DDD compared with the control group (nonathletic university students). The authors assessed each participant using MRIs and a self-report questionnaire about low back pain.

The survey included questions about past and recent episodes of low back pain. Severity of pain and location of pain were reported through the questionnaire. Other key points of information gathered included age, gender, height and weight to calculate body mass index (BMI), and number of years participating in sports.

Each individual was also examined by an orthopedic surgeon. Clinical tests included a neurologic exam, flexibility of the lumbar spine, and palpation of the low back area.

Data was analyzed and compared between the two groups (athletes and nonathletes). As mentioned, the baseball players and swimmers had the highest rate of DDD. All sports groups had higher rates of low back pain compared with the nonathletic group. Almost half of the group who reported low back pain also had degenerative disc disease. The more severe the back pain, the higher the likelihood of DDD.

Other studies in the past have reported that body mass index (BMI) isn’t linked with DDD. But the results of this study do not support that conclusion. They found a higher percentage of athletes with DDD who had higher height and weight measurements (resulting in a higher BMI) compared with the nonathletic group.

Frequent rotations do appear to be a contributing factor, even in well-trained athletes. Runners did not seem affected by degenerative disc disease. This finding supports the idea that specific postures and actions are important variables in the development of DDD. More study is needed in this area. The authors hope to be able to find ways to prevent degenerative disc disease and low back pain in athletes.

New information from this study suggests that spondylolysis occurs more often than was once thought. Past estimates of its incidence relied on X-rays, which may not always show the defect. Updated rates of prevalence using CT scans suggest almost double the number of cases in the general population compared to what was previously reported.

Spondylolysis happens when a crack or bone fracture forms in the bony ring on the back of the spinal column. Most commonly, this occurs in the low back. In this condition, the bone that protects the spinal cord fractures as a result of excessive or repeated strain. The area affected is called the pars interarticularis, so doctors sometimes refer to this condition as a pars defect.

Older children and teens whose bones are still growing are at greatest risk for this condition. Low back pain in athletes with spondylolysis may be more common in football players, gymnasts, wrestlers, weightlifters, and volleyball players.

But older adults can also develop a degenerative form of spondylolysis. Most of the time (in adults and children), the defect is present on both sides. In anyone with spondylolysis, the condition can progress to something else called spondylolisthesis.

With spondylolisthesis, the bone separates at the fracture site. The affected vertebra slips forward over the one below it. The result can be a narrowing of the spinal canal (opening where the spinal cord travels down the spine). As the spinal canal gets smaller, any pressure or pulling on the spinal cord or nerve roots can cause neurologic problems.

Recognizing spondylolysis early is helpful as it may be possible to prevent further worsening into spondylolisthesis. And now, with the information from this study, we know that the risk of degenerative spondylolisthesis increases with age. Men are more likely to be affected after age 40. Women have three times the chance of developing degenerative spondylolisthesis (compared to men) after age 50.

On the other hand, the incidence of spondylolysis in the younger years is greater among men by a 3:1 ratio (men to women). Spondylolisthesis in younger adults (less than 40 years old) occurs in men twice as often as women (2:1 ratio of men to women).

How did they come up with this new understanding of spondylolysis and spondylolisthesis? They used information gathered from a large group studied as part of the Framingham Heart Study. Adults from the town of Framingham, Massachusetts have been part of an ongoing study for generations now. The study started in 1948 and has continued through three generations.

Since data of all kinds are collected on these individuals, other researchers can use the information to investigate problems of interest outside of heart disease. And because CT scans were taken of the abdomen and chest to detect heart disease, the authors could use those same imaging studies to look for changes in the spine.

At the same time, information was collected on a variety of health-related topics. For example, patients were asked to report on any recent (last 12 months) episodes low back pain. Using this information, it was possible to check and see if patients with low back pain also showed evidence of spondylolysis and spondylolisthesis.

They could also compare how many people with these spinal defects complained of low back pain. The authors wanted to know if the two factors could be related or linked somehow. However, the results showed no significant association between spondylolysis, spondylolisthesis, and low back pain.

Other observations made in this study included the higher rate of spondylolysis in certain ethnic groups (e.g., Native Americans, Eskimos). Spondylolysis occurs in as many as 53 per cent of those groups. The reason for this was not known or explained.

The authors conclude that spondylolysis and spondylolisthesis are more common than we thought. These conditions do not seem to be linked with low back pain. This is an important finding as surgery is one possible treatment option for spondylolisthesis. But if spondylolisthesis is not the true cause of the back pain, then surgery may not be needed. Conservative (nonoperative) care may be all that’s needed.

When making the diagnosis, CT imaging is a better diagnostic tool (more accurate, more reliable) than X-rays. With these conditions, the fracture can be missed on X-rays depending on the patient’s position (standing up or lying down. The effects of gravity and postural muscles can really make a difference on X-ray results.

Physicians are encouraged to assess low back pain patients who have spondylolysis and spondylolisthesis carefully. Knowing that the pain may not be related to the spinal defect means that care must be taken not to automatically assume one goes with the other. The plan of care may depend on the physician’s understanding of this information.

Sometimes having low back pain can make even the simplest tasks difficult. Take for example, coming to a standing position from sitting. A loss of muscle power can make the sit-to-stand task much harder to accomplish. And that’s a problem because the sit-to-stand motion is incorporated into many of our daily activities. What can be done about this?

Well, before an exercise program can be determined and prescribed, it is important to figure out where’s the problem? Research has shown that low back pain alters the passive power flow in the lower quadrant. But is it a lack of power transfer from the spine to the pelvis or from the pelvis to the legs? What causes the change in power dynamics? What can be done about it? And for that matter, which came first: the low back pain or the change in power balance?

These questions were addressed in this study by a group of Australian physical therapists. They examined three-dimensional (3-D) movements of the spine-pelvis-thigh-leg segments of three groups. There was one group of normal, healthy adults without back pain, one group of low back pain sufferers without leg pain, and a third group of adults with back and leg pain. Pain shooting down the leg accompanied by back pain is called sciatica or radiculopathy.

Subjects were instructed to stand up from a sitting position while being monitored by force plates under the feet and sensors attached to the low back, pelvis, thigh, and foot. A computer program recorded the data, measured the power flow and velocity of the joints, and analyzed the flow of power from segment to segment. Patients reported if and when pain increased during the activity. This information was then compared to the timing of the movements.

There’s no doubt that low back pain limits lumbar spine motion, hip motion, and the coordination between the two. This has been proven in previous studies and confirmed by the results of this study. It may be a protective response to avoid loading spinal structures. But it definitely causes a change in how energy is transferred between bone and soft tissue in the spine, pelvis, and leg.

And that inefficient energy flow or transfer then places even more demand on the spine. A vicious cycle gets started of back pain-altered biomechanics-soft tissue injury-and more back pain. Without enough transfer of energy and muscle power, everyday activities such as standing up from a sitting position become difficult, if not impossible due to pain.

With the loss of power in the legs, the workload placed on the spine increases. Simple tasks become more energy-demanding and energy-consuming. Corrupted muscle coordination adds to the strain. Both groups with back pain (with or without leg pain) experienced the same phenomenon. There was no difference between the two groups. Patterns of power were the same whether or not the subjects with back pain also had leg pain. The control group (subjects without back pain) did not have any of these findings.

Now that we know there is a problem with transfer of energy in patients with low back pain that affects function, what’s next? The authors suggest several steps. First, find out was it the chicken or the egg? In other words, is back pain the cause of the abnormal power balance? Or does the compromised transfer or energy and power imbalance cause the back pain? We still don’t know this.

Next, find out what each group of trunk muscles contribute to power flow. These may be key in setting up a successful rehab program to address spine strengthening. When this is determined, then specific exercise programs can be established and the results measured to confirm the effectiveness of the program for low back pain patients.

Right now, it’s still not clear what the contribution of different trunk muscles is to power flow. And it’s not clear that just strengthening the muscles will do the trick. It may be necessary to restore normal joint reaction forces, speed of movement, and spinal joint proprioception (joint sense of position) before being able to end the cycle of back pain and altered power flow.

Since chronic lower back pain is one of the most common complaints of pain in the developed world, researchers are constantly looking for better ways to treat the pain and reduce its recurrence. The cost of back pain is high in terms of employer/employment cost, but also in life value.

Normally, adults with lower back pain are first treated with oral analgesics, pills or tablets to help relieve the inflammation and pain. They may also be given special exercises to strengthen their back. If these don’t work, then other treatments could involve alternative treatments, such as chiropractics, acupuncture, and others.

An important issue when dealing with chronic back pain is that patients can become used to having the pain and they need to learn other ways to remove the pain and make them get used to not having pain again. This is a goal in rehabilitation of back pain patients.

One type of treatment that is proving helpful for some with lower back pain is called percutaneous electrical nerve stimulation, or PENS. It’s like acupuncture with electrical impulses. Patients who have undergone PENS seem to have a quick reduction in pain, particularly in the younger patients. The authors of this article studied how effective the pain reduction lasted over three months in older adults with lower back pain.

Researchers evaluated 200 men and women who were 65 years old or older. They were divided into four groups: one group received PENS alone, the second received PENS and general conditioning and exercise, and the final two groups were control groups, one for the PENS group and the other did just conditioning and exercise. All patients were evaluated before participating in the study.

The PENS group received PENS for 30 minute sessions and the number of treatments were decided on by the acupuncturist in relation to how the patients reacted to the treatment. The control PENS group had acupuncture needles applied, but received only minimal stimulation to simulate receiving the treatment. The PENS and conditioning and exercise group received the PENS and participated in on-site conditioning with treadmill or stationary bicycle. At home, they performed flexibility exercises and a graded walking program.

The efficacy of the treatments on physical function was measured using the Functional Status Index and the Physical Activity Scale for the Elderly, and psychosocial function was measured using the Geriatric Depression Scale, the Chronic Pain Self-Efficacy Scale, the Catastrophizing Scale of the Cognitive Strategies Questionnaire, and the Fear Avoidance Beliefs Questionnaire. Quality of sleep was measured using the Pittsburgh Sleep Quality Index, and the health related quality of life was measured using the Medical Outcomes Study 36 Short Form Health Survey. Researchers also looked at physical function by asking the patients to walk, get in and out of a chair a certain number of times, and climbing stairs.

When the results were tabulated, the researchers found that all of the patients had some pain relief and improved disability, as well as speed of walking. The groups that participated in conditioning and exercise had fewer issues with avoiding pain. None of the groups had any side effects or complications from the treatments. Because both the PENS group and the control PENS group reported pain relief, the researchers weren’t able to tell what type of dosage was the most effective.

The authors concluded that PENS, twice a week for six weeks, for people over 65 years old, combined with conditioning and exercise was a safe and well-tolerated treatment and provided lasting effects after six months. PENS alone also provided the same relief. However, general conditioning and exercise, alone, did not reduce pain, nor did it improve function.

If you are over 40 years old and you’ve had X-rays of your spine, you might be convinced that any back pain you have is coming from those joints. That’s because as we age, signs of degeneration are abundant. Bone spurs grow around the joints, the joint cartilage thickens and reduces movement, and overgrowth of the joint margins blocks motion.

But the truth is, there are just as many people with degenerative changes seen on X-ray who don’t have any back pain. How is that possible? Scientists don’t really know. But they’ve been studying the relationship between low back pain and facet (spinal) joint degeneration for years.

There’s some evidence that lumbar facets could cause low back pain. The anatomical structures in that area have a lot of nerves that could get irritated and send painful messages up the spinal cord to the brain. Arthritic changes are most common in the lumbar spine, especially at the L4-L5 level.

But a study of 188 middle-aged (and older) adults didn’t show a statistically significant relationship between facet osteoarthritis and low back pain. The researchers compared self-reported back pain among this group with degenerative changes observed on multidetector CT scans of the low back.

They found an increasing incidence of facet joint changes as people got older. About one-quarter of the group who were 40 years old or younger had facet joint changes. This compared with two-thirds of the group 70 years old and older. But there were no degenerative or arthritic changes that predicted low back pain. And that is a major finding to support the idea that degenerative changes and arthritis of the facet joints are not responsible for low back pain.

The take home message for physicians looking at X-rays is: don’t assume that even the worst of degenerative changes observed on imaging studies has any clinical meaning. That patient’s back pain may not be coming from the facet joint(s) despite appearances otherwise.

The one sticking point to this message comes from the knowledge that some patients get relief from facet joint blocks. The surgeon injects a numbing agent and steroid into the facet joint area, providing pain relief for the patient. This treatment suggests some involvement at the facet joint. But whether that’s really a placebo (the patient expects the treatment to work, so it does) or some other factor remains to be proven.

Ongoing research is needed to end the debate and get down to the bottom of low back pain. The results of this study just adds one more piece to the puzzle.

Patients who have cauda equina syndrome usually have lower back pain, sciatica on one side or both, leg weakness, change in sensation in the “saddle” area, and possible loss of bowel or bladder. This is caused by pressure on the nerves.

The spine is made up of vertebrae (bones) that align one on top of the others to form the back. These vertebrae protect the nerves and other portions of the spine. The meninges, the membranes that surround the spine and brain, and the spinal fluid are also part of the protection of the spine. The outermost meninge is called the dura mater. Finally, the nerves that go down along the spine and branch off are called nerve roots. Near the bottom of the spine is an area that has a bundle of nerve roots and this is called the cauda equina.

As with any part of the spine, if a certain part is compressed, there can be pain, changes in sensation, weakness, and slowed reflexes. When this happens in the lower back and is severe, this is called cauda equina syndrome. Because of the severity of the problem, this is considered to be an emergency.

There are several issues that can cause cauda equina, including trauma and injury, tumors, build up of fluid that causes pressure, are a few.

To diagnose cauda equina syndrome, doctors need to do a thorough physical exam including x-rays to rule out other problems and to find at what level the nerves are being pressed. Sometimes, it is possible to confuse a bulging or herniated disc for cauda equina, so this is an important distinction to make.

Pain, for people with cauda equina syndrome can come on very suddenly (acutely) or slowly (chronically). Regardless of how the pain comes on, it is usually quite severe. “Saddle anesthesia,” a loss of sensation around the genitals, is a very suspicious sign for this syndrome.

When reviewing the patient history to see if cauda equina syndrome is a possibility, beside the traumatic injuries that are possible, other things to watch out for are activities like weight lifting or chiropractic manipulation. Losing control of the bladder is another symptom, but occasionally, this is the reverse and urine is retained. Loss of bowel function is possible but not as telling for diagnosis as bladder dysfunction.

The different symptoms can also help tell doctors how the chances of recovery are for individual patients. For example, if a patient has problems with their bladder, they have a better prognosis if they have retention rather than loss of control. If a man experiences erectile dysfunction, this is usually not a good sign for recovery.

When testing, after x-rays, often the next step is myelography, which is using x-ray and dye to evaluate the vertebrae. This is being replaced now more with magnetic resonance imaging and computed tomography scanning, with MRI being the most reliable, doctors feel. However, MRIs can’t be done on all patients. Patients with metal hardware, such as pacemakers, clips to repair aneurysms, or metal fragments near vital organs or near the eyes can’t have an MRI because of the magnets used to make the images.

Some doctors may choose to do bladder studies, checking to see how well the bladder is working, but this isn’t considered to be a definite sign of cauda equina syndrome.

Once cauda equina syndrome has been diagnosed, it must be classified as incomplete or complete with retention. Incomplete cauda equina syndrome is diagnosed with the patients still have some function of their bowels and bladder, although they do have back pain and saddle anesthesia. Complete with retention is, as the name infers, with retention of urine.

Seeing as this is considered to be a medical emergency, surgery must be done as soon as possible but researchers don’t agree on how quickly it needs to be done. Delays in surgery could be caused by a delay in diagnosis, delay in testing, and/or delay for the surgeon or the operating room.

The authors of this article conclude that the surgery does have to be considered to be an emergency in order to decompress the spine, or remove the stress on the nerves. Most surgeons feel that this should be done within 24 to 48 hours of onset and diagnosis.

There’s a commonly held belief that once you’ve had an episode of low back pain (LBP), you are liable to have another. Studies estimate that the recurrence rate for LBP can be as high as 84 per cent. But the authors of this study challenge that thinking. They point out how research in this area has been flawed.

There are three common errors in research that have led to an over estimate of LBP recurrence. First, patients included in the studies may not have recovered from the first episode of back pain before they had a second episode. Technically, they have not had a recurrence but rather, persistence of symptoms from the first episode.

Second, some patients recover from their first episode of back pain but not right away. Their recovery may take months instead of days or weeks. Recovery so late means they were at risk of recurrence for a very short amount of time. Using that approach results in misleading numbers of patients reported to have a recurrence of low back pain.

Third, the definition of an episode of back pain isn’t always the same from one study to the next. This may be changing with some of the more recent studies as authors have become aware of the problem and are making efforts to use a more standardized definition.

The current definition proposed for future studies is as follows. An episode of low back pain is a period of pain in the lower back lasting for more than 24 hours. It is preceded by and followed by a period of at least one month without low back pain.

In this study, the authors estimate the one-year incidence of low back pain recurring in patients who had recently recovered from an episode of acute low back pain. They also tried to identify risk factors to help predict who might be likely to have a recurring episode in the next 12 months following the initial back pain episode.

Over 1,000 low back pain patients treated by general practitioners, physical therapists, and chiropractors were included. The study took place in Australia where these three professional groups are largely responsible for the care of low back pain patients. Only patients with nonspecific acute low back pain were included. Nonspecific means the source was unknown but not from a fracture, infection, tumor, or other serious disease.

Data was collected from each patient about their general health, psychologic status, occupation, and sociodemographics (e.g., age, gender, education). Use of tobacco, activity levels, and previous episode(s) of low back pain were also noted. By collecting a wide range of information, they hoped to be able to sort through all the variables and find those factors that were statistically significant. Significant or predictive factors could help point to those patients likely to suffer a second or recurring episode of low back pain.

They were careful to only include patients who had low back pain lasting for more than 24 hours, less than six weeks, and who had recovered fully by the end of six weeks. Using these criteria, about one-third of the original 1,000 subjects were still left in the study.

The main measure was recurrence of low back pain. This was determined by asking patients to recall any episodes of back pain in the previous 12 months. They also had patients report their pain levels at the end of three- and 12-month periods of time.

The group reported a 24 to 33 per cent recurrence rate. This was much lower than the 47 to 84 per cent range reported by other researchers. The authors are quite certain that this difference was because they only used patients who had recovered from the first episode of pain. In this way, they avoided calling persistent symptoms or flare-ups as recurrent episodes.

A previous history of low back pain was the only factor that predicted a second episode. Patients with a prior episode of back pain were twice as likely to develop recurring symptoms as those who did not have a previous history of back pain. This was true no matter how old (or young) the person was at the time of the first episode.

The authors point out that the recurrence rate from their study was much lower than in previously published reports. Further analysis of their data also revealed that those patients who were worried about a future episode of back pain were more likely to have a second or recurring episode. This predictive factor is called perceived risk of persistent pain. It was determined through patient opinion of the risk of persistent pain self-rated from zero (no risk) to 10 (high risk).

They conclude that more accurate estimates of recurrence of low back pain than are currently available are possible. Definitions of pain episodes, recovery, and recurrence and methods of measuring these variables are important. These definitions must make it possible to determine when a new episode of back pain is occurring versus when a flare-up of the old episode is present.

Patients should not be allowed to define what recurrence means for themselves. With proper selection, researchers can restrict studies of this type to patients or subjects who have fully recovered and are therefore truly at risk for recurrence. In this way, a more realistic incidence of recurrence can be reported.

The annual worldwide cost of caring for people with episodes of acute low back pain is in the billions (90.8 billion in the United States alone). Predicting future episodes of low back pain as a means of possibly preventing further problems is a valuable tool. Although difficult to predict, doing so could potentially reduce the cost of medical care through prevention.

Future studies are needed to find out if the number of previous episodes of low back pain is important. If so, how many previous episodes are significant? Finding modifiable risk factors that can then be changed is another way to approach the problem of recurring low back pain. A good study design with standard definitions and time periods is advised. True recurrences should not be mixed up with flare-ups or persistent pain.

Back pain leading to disability is an everyday problem for far too many people. In fact, chronic low back pain is the number one cause of disability among men and the number two most common cause of disability in adults of both sexes and all ages.

Many people ask: how come with all the scientific advances in medicine, it’s so difficult to get a simple diagnosis for their back pain? That’s a good question. Low back pain can be a very complex and challenging problem. Most of the time, a clear and accurate diagnosis is impossible.

Medical tests such as X-rays or other imaging studies can show that there are degenerative changes present. As we age there are more and more signs of osteoarthritis, stenosis (narrowing of the spinal canal), and degenerative disc disease.

But many people develop moderate to severe changes without any symptoms whatsoever. Current beliefs are that just because there are radiographic signs of degeneration doesn’t mean that’s the source of the pain or other symptoms. So, once again, the medical community is faced with the fact that they often can’t pinpoint the exact cause of chronic back pain. And that can be as frustrating for the physician as it is for the patient.

Studies are ongoing as researchers actively look for the source of low back pain. Is it coming from the facet (spinal) joints? Patients with facet joint problems often have pain in the low back, buttock, hip, or groin regions. Extending the spine backwards makes this type of pain worse.

Is it coming from the disc? It starts in the low back or buttock and travels down the leg past the knee. This type of pain is called lumbosacral radiculopathy. Other symptoms of nerve involvement such as numbness and tingling in the calves, feet, or toes may be present.

Is it coming from the sacroiliac joint (SIJ)? It’s estimated that up to one-third of all low back pain is actually coming from the sacroiliac joint. This is where the sacrum at the bottom of the spine attaches to the pelvis on both sides. Sometimes the difficulty in making a clear diagnosis is because the pain is coming from more than one place. Patients often have facet or disc pain along with sacroiliac joint pain. All of these sources of pain are considered mechanical in nature. This means the problem involves the alignment and movement of bone or soft tissues.

Treatment guidelines for chronic low back pain have shifted over the years. Rest is no longer advised. Patients are encouraged to stay active and keep moving. A short period of rest is acceptable for acute episodes or flare-ups. But with chronic low back pain, physical activity is a central key to improvement. Over-the-counter pain relievers and antiinflammatory drugs may be advised. When depression and/or sleep disturbance add to the problem, other medications may be prescribed.

This type of treatment often works well for mechanical pain. And when the source of back pain is determined to be mechanical, then it may be time to see a physical therapist. The therapist will evaluate posture, musculoskeletal alignment, and movement and formulate a plan of care. This may include manual therapy (a hands on approach to restore joints and tissues to their normal state) and prescriptive exercises.

A regular, daily routine of exercise is important to improve (and maintain) conditioning, flexibility, strength, and endurance. For some patients, lifestyle changes such as weight loss and quitting smoking (or other tobacco use) are necessary. Some studies have shown a benefit of acupuncture, massage, and cognitive-behavioral therapy. Combining two or more of these additional treatment approaches seems to help the most.

If the pain is not mechanical, then the physician will look for a potentially more serious problem such as fracture, infection, or tumor. The extent of the investigation will depend on the physician’s interview with the patient. The doctor takes into consideration the patient’s personal and family history, clinical presentation, and any red flag signs and symptoms. At that point, additional clinical tests, lab values, and imaging studies may be ordered.

Anyone with a history of trauma, cancer, use of systemic steroids, HIV infection, or other systemic illness may need special attention and more specific treatment. Children under the age of 18 and older adults (over age 50) require a second look-see to rule out the possibility of a more serious condition (other than mechanical back pain).

Certain symptoms such as a sudden, unintended loss of weight, severe morning stiffness, difficulty urinating, skin rashes, or bodily discharge will alert the physician to the need for immediate action. These kind of serious problems are rare and affect less than 10 per cent of back pain sufferers.

Most of the time, chronic low back pain responds well to a program of managed care. Chronic back pain suffers often find relief through a combined program of education, postural changes, and exercise. Understanding how activities with too much bending or twisting can add to the stress on the spine is essential.

Patients who understand the mechanical nature of their pain report the greatest satisfaction with their progress. Knowing that recovery is possible with time, exercise, and self-care can go a long way to alleviate the stress and anxiety that often comes with chronic pain of any kind.

There’s a new kid on the block in research and health care delivery systems. Birthed by the World Health Organization (WHO), it’s called the International Classification of Functioning, Disability, and Health or ICF. This article is designed to help health care providers understand what the ICF is and how it applied to patients with low back pain.

First, the ICF is a classification scheme with many categories used as a tool to describe the severity and course of a physical condition or disease that affects a person’s function and ability. It’s a model that can be adopted and used by health care workers around the world. Having a common tool of this type will make it possible to conduct and report on research in the same way worldwide.

Second, in the new classification scheme, the focus has shifted from assessing, measuring, and talking about impairments, disabilities, and handicaps to now focus on body functions and structures and activities and participation. Two other components within the ICF classifications include environmental and personal factors.

Each of these five components also have subsets or qualifiers to help define the level of functioning and health for the problem being described or evaluated. A scale from zero (no problem) to four (complete problem) is used to then quantify (put a number or percentage for) the subset.

Shifting to this new classification scheme will give everyone a common language to discuss health and ability (not disability) for patients with chronic and complex problems. Setting goals, planning treatment, and evaluating results will be framed in a positive light now. Communication within the health care team and with the patient will be improved by the use of language everyone can understand. Insurance companies will use it to manage cases and propose health care plans.

Now, within that framework, the authors of this article describe and discuss a subset of categories called the ICF Core Sets for Low Back Pain (LBP). This is one of 15 Core Sets for chronic problems such as stroke, multiple sclerosis, obesity, and diabetes mellitus.

The Core Sets for low back pain actually contain 78 ICF categories. They range from mobility and self care to sleep, energy and drive, and mental function. Other examples of categories include muscle tone and power, ability to maintain or change position, dressing, toileting, and mobility skills such as crawling, walking, or running. Once these categories have been assessed for a patient, there is a very comprehensive picture of the problems that person is having with function, health, and life situations.

Even though there are multiple ICF categories, the beauty of the model is that it allows for one instrument that can be used around the world. Results of research and clinical study can be combined and compared for better statistical significance. In this way, research results can be unified. The ICF provides a standard now for describing function in patients with chronic low back pain. That may not sound like much, but it’s the first time any such standard has become available.

The ICF Core Sets provide the basis for what should be assessed as a measure of outcome. It tells us how to measure what we measure. And we don’t have to throw out popular instruments already in use for assessing low back pain. Tools such as the commonly used North American Spine Society Lumbar Spine Outcome Assessment Instrument, Oswestry Disability Index (ODI), and the Roland-Morris Disability Questionnaire can be linked to the ICF.

Physicians treating patients with chronic low back pain can use the ICF Core Sets right from the start. At the first appointment, the patient’s history, symptoms, and clinical presentation can all be documented in the medical record using the ICF Core Sets. Documentation can be done quickly and easily with a checklist on paper or electronically.

The data can be used to set goals, manage rehab, and assess the effectiveness of treatment. These elements are referred to as the Rehab-Cycle. The Core Set has a place to record how the patient feels about his or her situation. There’s a separate section for the health professional to document all findings, including lab studies and X-rays or other more advanced imaging. In this way, a systematic approach makes it possible to identify and record all potential problems to be considered.

In order to better understand this new system, the authors present a case study of one patient (Mr. Smith) for whom the ICF Core Sets was used. In this way, they were able to show the reader how the new terminology is used in the evaluation and implementation of treatment. They also walk the reader through one Rehab-Cycle for Mr. Smith, including the development of a modified treatment plan and new goals.

Disc degeneration, the break down of the discs in the back, is a major cause of lower back pain in adults. When looking at an x-ray at the discs, the healthy discs have a white center (nucleus), while the annulus seems dark. The nucleus will get darker as the disc degenerates until it becomes black, which means complete degeneration. Although the actual definitions for the breakdown may vary, most researchers believe and agree that it is likely caused by fluid loss in the center, compression of the disc so it loses height, and little breaks (fissures) in the bone.

Doctors don’t understand exactly the reason what role the fissures or ruptures have in lower back pain, but they do suspect that it is when the degeneration is at the moderate level that the most pain occurs, rather than when the degeneration has become severe. The authors of this study tested this theory by studying 412 patients who were divided into three groups: those with completely normal discs (white nucleus), those with severely degenerated discs (black nucleus), and those where were in between (gray nucleus).

All the patients were 40 years old and the group was fairly equally divided between men (199) and women (213). They all completed a questionnaire regarding how much pain they experienced in the back and legs, their physical activity, leisure activities, and several demographic measures, such as income and education levels. Magnetic resonance imaging (MRI) was done on all patients to see the extent of the disc degeneration, if any.

The results of the questionnaires and tests found that patients in the no degeneration group and those with moderate degeneration both complained of about the same levels of lower back pain in the previous year, while those with severe degeneration complained of significantly more lower back pain. Statistically, the overall lower back pain was measured at 69 percent, regardless of whether there were gray discs. A significant difference was found when black discs were present though. Those patients who had no black discs measured in at about 60 percent while those with black discs were at 86 percent if they had two.

The authors wrote that their findings determined that it wasn’t the moderately degenerated discs that were causing the bulk of lower back pain from disc degeneration, but it was the severely degenerated ones that were the main cause. They point out that this is a significant finding because patients who have more than one black disc have double the risk of developing lower back pain.

Orthopedic surgery, particularly on the back, can be tricky and cause complications. However, when surgery is done, it usually improves a person’s quality of life considerably. This is important to note because it could be tempting to not do surgery sometimes but studies have shown that people with spinal problems may have a lower quality of life than even those who have cancer or heart failure. The authors of this study wanted to see how surgery affected quality of life, so they performed a study by following 777 patients with different orthopedic (bone) problems, not just of the back.

The patients were divided into 12 groups. One group included those who had cancer in the bone in an arm, another had artificial shoulders that had come loose, another had knee problems, and so on. During the study, 184 patients didn’t complete the questionnaires and were considered lost to follow up. All patients completed a questionnaire before surgery and then completed it again one year after surgery. The researchers used the EuroQol (European Quality of Life scale) and the SF-36 (36-Item Short Form Health Survey, version 1) as the questionnaires.

The results of the questionnaires showed that patients who underwent spinal surgery for spinal stenosis (narrowing of the spine), spondylolisthesis (stress fractures in the spine that have shifted), instability, or chronic lower back pain, had a poorer quality of life than any of the other patient groups. Among all the patients who had surgery in all groups, it was those who had surgery for spinal stenosis who had the best quality of life improvement, followed by those who had ankle surgery because of osteoarthritis.

Other surgeries, such as disc surgery, did improve quality of life, but not to the high level that it did for spondylolisthesis. Those who had surgery for chronic low back pain didn’t see big changes in quality of life.

These were the results of a few of the groups:

Total hip replacement: Physical functioning and quality of life improved, and pain decreased significantly.
Total knee replacement: Similar to the hip surgery but a not as significant difference in change of quality of life.
Revision hip surgery: Didn’t have as big an impact as the original hip replacement.
Spinal stenosis with laminectomy: When the back surgery involved removing part of the damaged bone, there was a great improvement in the quality of life, as with the total hip replacement.
Chronic lower back pain: Not much difference in quality of life before and after one year but the physical functioning was improved.

The authors of this study concluded that back surgery for some issues is beneficial to the point that it definitely improves the quality of life in many patients. However, this isn’t so for all surgeries, particularly for chronic back pain that doesn’t have such a distinct and identifiable cause.

When a patient has a ruptured lumbar disc, which is in the lower part of the back, there are a few options for treatment. They boil down to surgical or nonoperative treatments overall. There has been a lot of debate over which approach is better and several studies have looked at the various techniques and patient outcomes.

The authors of this article added to the bank of information by undertaking a four-year study that looked at the results of surgery versus nonoperative treatment for lumbar disc herniations. Researchers recruited 501 patients who were randomized to the trial and 743 who would be observed only. To qualify for the study, the patients had to have back pain for at least six weeks, have an obvious disc herniation, and be eligible for surgery. They were then offered to be included in the trial or in the observation group. If patients were randomized or chose nonoperative treatment, they had either injections to manage the inflammation and pain, activity restrictions, or restricted medications, narcotics for the pain.

To assess the patients, researchers used the Bodily Pain (BP) and Physical Function (PF) scales and a version of the Oswestry Disability Index, at six weeks, three months, six months, and every year following. The researchers also looked how the patient reported their status, work ability, and satisfaction with the outcome.

In the randomized group, 245 patients underwent surgery (57 percent by the end of year one and 59 percent by the end of year four) and 256 had nonoperative treatment. In the nonoperative group, 41 percent ended up having surgery by the end of year one and 45 percent by the end of year four. The numbers were similar in the observational group. Among the 743 patients, 521 chose to have surgery and 95 percent of them had it by the end of year one. However, if they hadn’t had it by then, they didn’t have surgery later on, unlike some in the randomized groups.

When looking at the characteristics of the patients in the randomized group and those in the observational group, the researchers found that those who chose to be in the observational group were generally in more pain, felt the pain was worsening and preferred surgery than those who chose to be in the randomized group. In the randomized group, the patients were younger, more likely to be unemployed or on sick leave, more likely to be receiving compensation, have higher body mass index, more pain and more dissatisfaction with treatment.

Patients who had surgery did have the risk of complications associated with the procedures. There was also a difference between the patients who had surgery from the randomized group and those who did from the observational group. The randomized group tended to have lightly longer operating times and slightly more blood loss during surgery. Other issues, such as a need for repeat surgeries didn’t show a difference between the two groups.

The authors wrote that there was an issue of nonadherence, patients not sticking to their treatments, in both groups. Some patients waited before having surgery while others who weren’t going to have surgery chose to anyway and the other way around. Because of this, it can be difficult for researchers to determine the “intent” of whether treatment would be effective or not. That being said, overall, the results did show that surgery did show a better outcome for patients in the end.