News Category: Lumbar Spine

Chronic back pain, a common disability, accounts for a majority of work disability costs. Although most people who have acute back pain don’t progress on to chronic back pain, there aren’t many ways to determine which patients are at higher risk of going on to chronic pain. If doctors could identify them ahead of time, secondary prevention, which means preventing further pain and injury, could be better targeted.

The authors of this article studied 1885 patents with lower back pain to see if they could determine certain predictors that would tell them if a patient was at high risk for needing work disability. Researchers interviewed the patients after they had submitted claims for lost work due to back injuries. The patients were interviewed about three weeks after the claim was made.

The information collected included social issues (if they smoked, worked full time, the type of job, education, etc), their ability to function at work and leisure activities, health care, psychological issues, and so on. Part of this information was obtained using the Roland-Morris disability questionnaire (RDQ) and the Short form 36 (SF-36). The researchers also looked at the medical records for further information.

What the researchers found was that the strongest predictor of someone taking off a year of work (one-year disability) was the severity of the injury (including if pain went down below the knee), followed by the type of specialist the patient saw, functional ability, how many places the pain was located, how stressed the job was, if accommodated work was available, and if the patient had had an earlier back injury for which they took off at least a month.

Using these findings, the authors pointed out that there are several things that can be done for patients with back pain to minimize the risk of them needed a prolonged period of time off work. For example, patients who saw chiropractors as their first specialist seemed to do better in recovering from pain. Patients whose employers were flexible and allowed them to do different work or brought them back on a modified schedule did better as well. Other issues, like relieving stress i the workplace could also be addressed.

Some issues can’t be addressed as easily, but if patients have pain that radiates down or has pain in multiple areas, this could be taken as a warning that the patient is potentially one who may end up with chronic pain issues.

Interestingly, the researchers found that although if someone did take off a month or more for a previous back injury, an earlier back injury on its own didn’t affect whether they would likely take a longer time off work this time around.

Surgeons do everything they can to prevent and/or reduce patients’ risk of complications. One of those complications is infection at the surgical site (called surgical site infection or SSI). Recovery can be challenging enough without adding delayed wound healing because of infection.

In this study, surgeons from Johns Hopkins University look into the risk and risk factors associated with removal of sacral tumors. Although tumors in this region are rare, they come with a host of problems. First of all, they don’t respond to radiation therapy. That means they have to be removed to ensure patient survival.

This type of surgery is called a radical resection procedure. The tumor and surrounding tissue are removed until the pathology report shows there are clear margins. Clear margins means there is a rim of normal tissue completely surrounding the tumor. The most common tumors in the sacral region are chondrosarcomas and chordomas.

Besides local infection, other possible complications of this surgery include nerve damage and injury of the blood vessels in the area. The removal of large areas of soft tissue can also leave the patient with impairments requiring extensive plastic surgery.

Looking back over five years’ worth of patients, the authors identified 46 patients with sacral tumors requiring radical resection. They reviewed a wide range of possible factors that could contribute to postoperative infection. Some of these risk factors included age, body mass index (obesity), tobacco use, history of diabetes, and previous history of lumbosacral surgery. Other potential factors studied included number of spinal levels exposed, size and type of tumor, blood loss, need for reconstructive surgery, and number of surgeons involved in the procedure.

The infections were also categorized carefully. Information was gathered and analyzed about the type of organism causing the infection (e.g., staphylococcus, e. coli), how soon the infection developed after surgery, how it was treated, and the final outcome.

The degree of amputation was also charted. About one-third of the patients had a low sacral amputation. Almost 10 per cent had the mid-portion of the sacrum removed. One-fourth had a high sacral amputation. The rest had either a hemisacrectomy (one side of the sacrum resected) or total sacrectomy (entire sacrum removed).

There were various complications such as breakage, misplacement, or pull-out of screws and/or rods. A small number of patients developed leaks of the cerebrospinal fluid (fluid inside spinal canal to protect spinal cord). And, of course, there were cases of postoperative infections, which was the focus of this study.

The treatment for surgical site infection was débridement and long-term antibiotics (four weeks or longer). The two main factors that seemed linked with postoperative infection after sacral tumor resection were a history of previous lumbosacral surgery and the number of surgeons involved in the operation.

Several other factors didn’t reach statistical significance but were described as a trend toward increased risk of surgical site infection. These included older age, complex soft-tissue reconstruction, and bowel and bladder problems.

The authors suggested that patients with sacral lesions are at increased risk for infection because of how close the open wound is to the rectum. There is the potential for cross contamination from feces (stool or bowel movement). And the surgeon often has to remove a large portion of the soft tissue, which also increases the risk of infection.

No matter what the reasons, the trauma of an infection that requires additional surgery (at additional cost) can be great. Identifying these predictive risk factors ahead of time can help surgeons screen patients carefully and plan the surgery accordingly. The high rate of infection (reported as high as 46 per cent) warrants studies of this kind.

Reducing the number of surgeons in the operating room may not be possible. Sacral tumor resection is a complex procedure requiring spine surgeons, general surgeons, plastic surgeons, and urologists. In large teaching hospitals, interns may also scrub and observe the operation. This (and other studies) support the idea that the more scrubbed members of the surgical team present in the operating room, the greater the risk of wound contamination with infection developing after surgery.

Controlling other factors such as patient age, history of previous lumbosacral surgery, and the removal of large amounts of soft tissues in the sacral area are less modifiable (or not modifiable at all). Other studies have shown that poor nutrition (represented by low albumin levels) can contribute to wound infection. It may be possible to prevent infections with better pre- and postoperative nutrition.

The authors report changes they have made in operative technique to reduce and/or prevent infection in sacral tumor resection. These include: 1) surgeons must be aware of the potential risk factors cited, 2) multiple hands in the wound may be needed but minimize this as much as possible, and 3) reduce the risk of contamination from bowel and bladder problems. This last suggestion can be done using glue to close the wounds and covering the wound for four to five days to create a barrier of protection.

New information on the role of psychological factors in chronic low back pain (LBP) is being reported and studied. One of the latest models for managing LBP is called the Fear-Avoidance Model (FAM). The idea is that fear of movement and fear of re-injury result in avoiding movement and eventually lead to loss of function and disability.

Studies show support for this idea. Pain-related fear affects how patients respond to their pain. Pain catastrophizing is a part of the problem. People who catastrophize tend to do three things. They think about their pain and can’t stop thinking about how much it hurts. They blow their pain out of proportion and are afraid that there might be something really serious wrong. And they feel helpless to change their pain, believing that there is nothing they can do to reduce their pain.

In this study, different physical therapy treatment approaches for low back pain were compared. Effectiveness of each method on pain intensity, pain catastrophizing, disability, and fear-avoidance beliefs was examined. Physical therapists use a treatment-based classification (TBC) system to identify which type of treatment should be used with each patient.

Some of the treatment categories used with this model include specific exercise, mobilization or manipulation, spine stabilization, or traction. The treatment-based classification approach is based on previous research done and validated by a well-known physical therapist (Tony Delitto, PT, PhD) from the University of Pittsburgh.

All the patients in the study had acute or subacute LBP defined as back and/or leg pain lasting between one week and six months. Ages ranged from 16 to 60 years old. Patients with chronic pain (lasting more than six months) were excluded from the study. This study focused on working with patients in the acute and sub-acute phase hoping to resolve behavioral issues and avoid chronic pain from developing.

Everyone was assigned to a treatment group based on the treatment-based classification system. They also received instruction in one of two methods to reduce fear-avoidance behavior: graded exercise or graded exposure.

Graded exercise starts by finding out how much exercise each patient can do before their pain stops them. This is referred to as exercising to pain tolerance. Then the patient is enrolled in a program that starts with that level of exercise or activity. The therapist guides the patient in building tolerance by slowly increasing duration, intensity, and frequency of the exercise or activity.

The graded exposure approach starts by looking at which activities patients are fearful of (e.g., lifting, carrying, twisting, bending). Each of those activities is then practiced under the supervision or guidance of the physical therapist. Patients start at a level that feels safe to them. They rate their fear before and after each activity. As their fear goes down, the frequency, intensity, and duration of the activity is increased. Then they are encouraged to start doing the same things at home on their own.

In a previous study, these same authors showed that physical therapy combined with graded exercise was helpful but only for patients with pain-related fear. Then another group published a report about the benefits of using graded exposure for patients with chronic LBP. Research so far has not answered the question of which method to use for patients with pain-related fear. So this study is to compare them both to see which one works better.

Everyone participating in the study filled out a variety of surveys and questionnaires to assess patient preference, satisfaction with treatment, pain intensity, disability, and fear-avoidance behavior. Well-known tools were used such as the Oswestry Disability Index (ODI), the Fear-Avoidance Behavior Questionnaire (FABQ), the Pain Catastrophizing Scale, and the Physical Impairment Scale (PIS).

Outcomes were measured by comparing baseline (before treatment) values with responses four weeks after treatment and again six months after treatment. Were there changes in fear-avoidance beliefs, pain catastrophizing, or physical impairment? Well, first of all, they noticed that everyone in both groups made progress. They had less pain, less fear, and less disability.

It did not appear that graded exercise was any more effective than graded exposure. And neither one of these approaches worked any better than treatment-based classification for patients with fear-avoidance beliefs. The original hypothesis of the study (patients with pain-related fear would get the most help from graded exposure) was not supported by the results. They were not able to replicate the previous study’s results showing that graded exposure was more effective than graded exercise in reducing fear-based back pain.

When trying to make sense of the results, the authors suggested that treatment-based classification may be effective enough that no other additional treatment add-ons are needed. Or maybe there are more effective ways to apply graded exercise and graded exposure than were used in this study. Perhaps the timing of treatment with these graded methods is important (i.e., stage of low back pain). Maybe like treatment-based classification, there are subgroups of patients who will respond better to graded exercise or graded exposure.

The authors recommend further studies with larger group sizes to help answer these questions. They also suggest it’s possible that pain-related fear isn’t the most important factor in explaining why patients progress from acute and subacute to a chronic state of low back pain. Finding risk factors (including psychologic or behavioral factors) remains an important need before specific treatment can be identified that will be effective in preventing chronic low back pain.

Investigators looking for the cause of low back pain (LBP) say there’s reason to believe the source could be the lumbar facet (spinal) joints. But the evidence is circumstantial. Injecting a numbing agent and antiinflammatory drug in or around the joint does produce pain relief. They interpret this to mean the origin of the pain is the facet joint.

But questions remain. They have not been able to show that there’s a direct correlation between the degree of arthritis present and the amount of pain relief experienced. Is the pain really coming from the lumbar facet joints? Is it because there are arthritic changes in the joint? Or is there something else going on?

In this study, CT scans of facet joints were taken of men and women ages 40 to 80 who were already participating in the famous Framingham Heart Study. The Framingham study started in 1948 in Framingham, Massachusetts. Over 5,000 adults between 30 and 60 years old were enrolled. They were interviewed, examined, and tested once every two years. The original participants are dead now, but their families continue to participate in the study. Three generations of families have been part of the study.

The group who were part of this low back pain study had been part of a larger group who had 8-slice multidetector CT scans done of the heart and coronary arteries. Those who indicated on the questionnaire that they had suffered low back pain in the last 12 months were enrolled in this separate study. They had a similar multislice CT scan of the abdomen, which included all of the lumbar facet joints (both sides).

Results were carefully analyzed and compared between patients with and without low back pain. CT scans were used instead of the more standard X-rays because they show both sides of the joint surfaces. Any bone spurs, overgrowth or thinning of the joint cartilage, and cysts show up clearly on CT imaging. Hardening of the joint capsule called calcification is also observable.

This study helped answer quite a few questions. It showed how common facet joint osteoarthritis is in adults based on age. For example, one-fourth of the adults younger than 40 years old had degenerative joint changes. An even greater percentage (74 per cent) of adults between 40 and 49 years old had signs of degeneration. And by the time they reached age 70 and older, 69 per cent were affected.

The areas affected most often were in the low lumbar (L45 and L5S1) regions. Severity of facet joint osteoarthritis was graded as zero (normal), one (mild degenerative changes), two (moderate degenerative disease), or three (severe changes). Besides seeing an increasing number of people affected as they got older, women of all ages were more likely to have facet joint osteoarthritis than men.

Other studies have linked hormone differences that may account for the gender differences. Cartilage is sex-hormone-sensitive tissue. There are more estrogen receptors on the facet cartilage of women. The effect of this hormone is to increase motion at the joints. For example, in the lumbar spine, women have more bending motion forward and to the side and more extension backwards. More segmental motion of the vertebrae and facet (spinal) joints leads to more wear and tear and thus, a greater amount of degeneration.

But none of the findings presented here were linked with the presence of low back pain. And that was a new and major finding of this study. The clinical implications aren’t clear yet. In other words, this information doesn’t change how we treat low back pain. There’s still the fact that facet joint injections have a positive benefit. Why that is so if the facet joints don’t generate pain remains to be explored and explained.

Finding the ideal patient for total disc replacement (TDR) surgery helps ensure successful results. Identifying subgroups of patients who should not have TDR surgery is also important. As the authors of this study sum it up so nicely, Patient selection is the primary key to achieving a favorable outcome.

One way to sort out factors in good and bad results for TDR is to perform retrospective studies. This means the surgeons take a look at the medical records of patients who have had TDR in the past. They analyze all the data collected and look for patterns that would sort patients into subgroups by best and worst outcomes for each type of implant.

In this study, the records of 203 patients at the Texas Back Institute Research Foundation who had a total disc replacement (Charite or ProDisc) were evaluated after the fact. Before and after testing of pain and function were used as the primary measures of success or failure. The data was collected from patients involved in two Food and Drug Administration (FDA) clinical trials.

Measures of success or failure are rather subjective. There is no standard definition of success/failure for this type of spine surgery. Each researcher makes his or her own definition, making it difficult to compare the results of one study to another. And depending on how broad or narrow the definition is that’s used, success rates can range from 23 per cent to 60 per cent. Without a set standard, what is one surgeon’s success could very well be another’s failure.

In order to avoid patients in the gray zone, the authors of this study evaluated patients at either extreme (very best and very worst cases). The gray zone refers to patients who could easily be considered a success or a failure depending on how those terms are defined. By looking at the results of patients who are at the extremes of outcomes, factors that relate to both conditions can be identified.

Patients in both implant groups had degenerative disc disease that did not respond to conservative (nonoperative) care. They did not have a history of previous spine surgery, osteoporosis (brittle bones), or significant arthritic changes of the facet (spinal) joints. Ages ranged from as young as 18 to as old as 60. Obese patients were not included. Everyone was followed for at least two years to be included.

Using a cluster analysis of the data, they found 40 of the 203 patients who fit in the best and worst subgroups. A long list of variables was considered when comparing both groups. Gender, age, body mass index, and smoking status were included. They also paid attention to surgical factors such as the number of spinal levels operated on and the final position of the implant (as seen on X-rays). Occupation, time off from work, and type of insurance coverage (Workers’ Compensation versus non-Workers’ compensation) were also included.

As might be expected, before and after improvements were very different between the best and worst groups. The two implants performed equally well so that was not the reason for differences between the two groups. The biggest factor separating the best from the worst was work status. Patients who were off work (sick leave or disability) the longest before surgery had the worst results.

The results of this study support findings of other studies that suggest it’s best to stay at work if at all possible for as long as possible despite ongoing back and/or leg pain. If surgery is eventually needed, the results may be better in the long-run. Other studies have reported that implant positioning made a difference in the final results. This study was unable to show the same type of relationship between implant position and clinical outcomes.

Patients are screened very carefully before receiving a total disc replacement. Yet, despite very rigorous rules for inclusion versus exclusion, there are still some patients who do not respond well after surgery. According to the results of this study, careful screening is important and should also include work history/work status. Anyone who is not working at the time of surgery (and especially those who have been off work for a long time) should be reviewed carefully before being considered for a total disc replacement.

In this case report, a physical therapist recognized the need for emergency care for a patient with low back pain. The patient was a 38-year-old woman who was five and a half months pregnant. She was initially seen by her physician with a complaint of low back pain. The pain had come on without any known cause.

The medical exam was reportedly unremarkable. At the time of the physician’s exam, her symptoms were mild and common for a normal second trimester pregnancy. But when she arrived at the physical therapist’s clinic, she was unable to walk and was using a wheelchair to get around. This was a major downturn in her condition since the appointment with her physician.

The therapist recognized four red flags indicating a need for medical attention: 1) insidious onset (no known cause), 2) no diagnostic imaging was done, 3) symptoms had progressed (gotten worse) since she was last seen by her physician, and 4) symptoms of were present bilaterally (on both sides).

She had weakness, numbness, and tingling in both legs. She could not feel herself urinating, which is a sign of a cauda equina lesion. Deep tendon reflexes (test of neurologic function) were normal at the knee but absent at the feet.

Cauda equina syndrome is a serious neurologic condition. There is a sudden loss of function of the nerve roots of the spinal canal below the conus (end of the spinal cord). The spinal cord travels down the spine inside the spinal canal. The canal is a circular opening formed by the vertebral bodies.

The spinal cord ends around the first or second lumbar vertebra in most people. After that, there is a mass of nerves called the cauda equina. Translated literally, this means horse tail. As part of the cauda equina, nerve roots branch off from the spinal cord from L1-5 and S1-5.

Anything that compresses the function of the cauda equina can disturb the nerves. The most common problem leading to a cauda equina lesion is a central disc prolapse. This means the disc located between two vertebrae (in this case between L4 and L5) pushes straight back and presses on the spinal cord.

The therapist escorted this patient to the emergency department and requested a medical examination and lumbar magnetic resonance imaging (MRI) study. The results showed a disc protruding at the L4-L5 level. The disc was pressing on the cauda equina. All of her symptoms were from a cauda equina syndrome.

Immediate surgery was performed despite the pregnancy. The risk of permanent paralysis with this kind of problem is too great to treat progressive cauda equina in any other way. Surgery to remove the bulging disc (discectomy was done. No harm was done to the baby with the MRI or the surgery. The child was born six weeks after the discectomy without complications.

Massage, rehabilitation, yoga, exercise, back school, rest, or do nothing — what’s the best way to approach back pain? These are just a few of the treatment options patients have to choose from. What’s the evidence to support one over another? That’s what this study attempted to sort out.

The authors conducted a systematic review to compare the effectiveness of three specific treatments for low back pain (back school, fear-avoidance training, and patient education). A systematic review is one of the most respected types of studies. It involves a careful search of all the studies published on a single topic. Once those studies have been identified, they are reviewed for design, content, patient base, and quality. Only high-quality studies are included.

In this study, effectiveness of treatment was measured by pain, disability, and sick leave. Cost effectiveness and the use of health care resources were also evaluated. The type of professional who provided and supervised the treatment was recorded along with the setting in which patients were treated.

The authors compared each one and reported on whether the evidence was limited or conflicting, no evidence, or conclusive (moderate-to-strong evidence). Whenever possible, the data was combined or pooled to give greater statistical validity. This could only be done when the studies involved reported results in a similar way and when like groups of patients were tested. Each of the treatment approaches was described in detail. Here’s a brief review:

Patients usually have expectations as to how treatment of a problem will work and how effective it will be. This is no different among patients who have lumbar intervertebral disc herniations, a bulging or slipped disk in the lumbar (lower) region of the back. These expectations can be harmful at times. If a patient has high expectations for results and the results are not as good as they expected, there is big disappointment and patient dissatisfaction. The reverse can also be true too, a sort of placebo effect. If a patient expects to feel better, there is a chance that he or she may feel better because it was expected.

Researchers have tried to understand how expectations are related to outcomes. In an attempt to understand, GK Lutz and colleagues found that patients who had surgery for sciatica and who expected a quick recovery had the same type of recovery as those who didn’t have those expectations, but the first group of patients were more satisfied in the end. In another study, this time with patients who had pain from spinal cord injuries, JA Turner and colleagues found that if the patients expected good relief from their pain medication, they ended up with good pain relief. However, they didn’t have the same effect with placebos.

In a different study involving patients who had spinal surgery for spinal stenosis, narrowing of the spinal canal, done by MD Iversen and colleagues had a bit of a different result. The researchers found that patients with high expectations of being able to move around again after surgery did have a better outcome and they were more satisfied with the results. But, patients who had high expectations for pain relief instead had more pain and they weren’t as satisfied with the surgery.

Patient preference for treatment also appears to play a role in what may work and may not. The authors of this study wanted to find baseline characteristics of patients who had intervertebral disc herniation and who preferred certain treatment options over others. They then wanted to see if these preferences made a difference in the outcome.

The researchers reviewed 740 patients with the disc herniation. Their preferences were noted using a five-point scale of definitely nonsurgery, probably nonsurgery, not sure, probably surgery, or definitely surgery. They rated their expectations of the treatments for pain, swelling, numbness, weakness, and function. They were also asked about any expected harm from surgery. This five-point scale was: no chance, small chance, moderate chance, big chance, or certain. Function expectation was rated s expected benefit (surgery), expected harm (surgery), expected benefit (nonsurgery), and expected harm (nonsurgery).

The results of the study showed that more patients preferred to go the surgical route (67 percent) over nonsurgical (28 percent), with 6 percent being unsure of what they preferred. Those who preferred surgery were generally younger, had lower levels of education and high levels of unemployment. They also complained of more pain than the nonsurgery or unsure group, worse functioning (mental and physical), more pain-related disability, had had their pain for longer periods, and were more likely to be taking opioids, controlled drugs like morphine.

Although expecting higher complications with surgery, patient in the nonsurgical group said that both nonsurgery and surgery, equally, would be successful. Those who were unsure expected a greater benefit from surgery, while those who preferred surgery felt that nonsurgical care would be more harmful than surgery and that they had high expectations from the surgery.

There were many reasons why one approach was preferred over the other, including the desire to be able to continue working and participate in activities, which was the main reason for the surgery choice. Doctors’ recommendations played a role in the decision but not more one way over the other. The researchers did find a significant influence was earlier experience with treatments that didn’t involve surgery. Almost 20 percent of the group that preferred surgery stated that they had had previous nonsurgical treatment that was unsuccessful.

Overall, the authors of this article found that patient expectations do play a large role in how successful surgery or nonsurgery procedures turn out for spinal surgery. Those patients who wanted surgery were more adamant about their choices than the nonsurgical group. The authors pointed out that the group make-up may have something to do with this though. About 80 percent of the patients in the study were recruited by surgeons.

It was also noticed that patients who didn’t want surgery were quite a distance away from being convinced that surgery may be better. They felt that the benefits of nonsurgical treatment far outweighed any risks that may result from surgery. Findings like these may help doctors understand why their patients choose specific treatments over others. In this case, patients who had high expectations of the benefits of nonsurgical treatment were convinced by these expectations. Therefore, it’s important that patients be well assessed and informed about their benefits and risks so that they have all the necessary information to make the right decisions.

Over the years, there’s been a lot of debate about the source of pain felt in the sacroiliac joint (SIJ). Is it coming from the joint itself? From outside the joint? Or both? Injecting a numbing and antiinflammatory (steroid) agent into the SI joint has convinced scientists that pain can come from the joint. Relief of pain after injection is proof of that.

But what about the many patients whose pain isn’t relieved by an injection into the SIJ? Would injecting this same pain reliever and steroid outside (but near) the joint help? In this study, the surgeons split the total usual dose of medication in half. They injected half into the SIJ and the other half under the posterior sacroiliac ligaments at the S1-3 level.

Patients included in the study had low back pain along with pain in the buttock, thigh, groin, or lower leg. The back pain was below the L4 level in the region of the sacroiliac joint. All patients had been treated by a physical therapist but did not respond to therapy. Those that had a previous injection for other problems such as spinal stenosis, facet syndrome, or disc herniation were allowed in the study if that injection failed to improve their symptoms.

Since this group of researchers had already published a study on the benefit of intraarticular injections, they could compare the results of this new split injection with results from the standard single injection. By doing so, they hoped to be able to show that sacroiliac joint pain isn’t just caused by problems inside the joint. And they believed that the current practice of using intra-articular injections to diagnose sacroiliac joint dysfunction underestimates the true number of patients affected by this problem.

Their thinking was that it’s possible for soft tissue structures surrounding the joint to generate the same pain pattern as the joint itself. They also took the opportunity to see what kind of long-term results the patients got with injection therapy. Finding a treatment with long-lasting results would be very helpful in managing this painful condition.

Pain (rated from zero to 10) was used as the main measure of success. Everyone kept a pain diary with pain ratings from before the injection, three weeks after the procedure, and again three months postinjection. Follow-up was kept fairly short to avoid the problem of evaluating new pain patterns that might develop. The evaluation and treatment of new problems could interfere with the comparison of SI joint intra-articular and extra-articular injections.

The authors used a second tool (the AIAT) to measure functional outcomes. This self-report survey was developed for use by the pain clinic where this research was done. The AIAT measures overall improvement in daily activities such as housework, shopping, childcare, work, and mobility. Points are awarded and a score of zero (worse), one (no change), two (slightly better), three (greatly improved), or four (restored to normal) determines the results. It is a tool that has been tested and validated for measuring patients’ (with back pain) responses to treatment.

Change in scores from before to after treatment offer a way to measure response rate as a change in percentage. Success was defined on the pain scale as a 50 per cent change (improvement) from before to after treatment. A score of three or higher on the AIAT test was considered an indication of success. Scores from the two tests (pain and function) were cross checked to see if one could predict the other. Any differences between the two groups were reviewed carefully.

The results showed that the combined procedure had better results than the intra-articular injection alone. Improvements were more noticeable at three months after treatment (compared with three weeks after injection). From a statistical analysis point of view, the combined block procedure had a sensitivity level of 88 per cent, a specificity of 49 per cent, and a positive-predictive value of only 44 per cent.

Sensitivity shows how well the diagnostic test determines a true positive for SIJ pain (the patient really does have an SIJ problem). Specificity reflects the ability of the same test to show a true negative (the person really doesn’t have an SIJ problem). Positive predictive value is the proportion of the total number of patients in the study with a positive test who were correctly diagnosed. This value is more clinically meaningful than sensitivity but all three measures (sensitivity, specificity, and positive predictive value) are all important ways to evaluate a new test procedure.

Patients who had their symptoms more than three years, who smoked, or whose symptoms were made worse by walking, climbing stairs, and standing were more likely to have a negative outcome from the combined procedure. For the single injection treatment, age and duration of symptoms had a weak effect on the response to treatment at the three-month check-up. Older patients and patients whose symptoms had been present the longest seemed to have the poorest response rate. Correlation between the two tests was quite strong. This means if one test was positive, it’s likely the other test will also be positive.

All in all, it looks like injecting a numbing agent and steroid into the SI joint and also around the posterior interosseous ligament is a successful treatment for patients with chronic SI pain. The results support and confirm the findings of several other studies that reported sacroiliac joint pain can come from outside the joint. The number of patients who experienced pain relief with the dual blocks increased by 47 per cent over just the single injection.

Despite these reported findings, the authors point out that the evidence wasn’t enough to make the claim that a combined sacroiliac and S1-3 injection is clearly better than a single sacroiliac injection alone. The next step in this research process is to compare four groups of patients: 1) single intra-articular injection, 2) single extra-articular injection, 3) combined intra- and extra-articular injection, and 4) placebo injection. Only when these additional studies are done, will we know for sure how common a true SI joint problem is and which block technique works best.

Evidence-based medicine requires periodic review of published studies to see what’s new. In this article, the results of six random-controlled trials (RCTs) on acupuncture for low back pain (LBP) were reviewed. This brings us up-to-date on the latest evidence regarding acupuncture as an effective treatment tool for LBP.

Only six new trials were included in this systematic review. These six were published in the last two years since the previous systematic review was performed. There were many more studies done (1,606 with 40 of them random controlled trials) but they had to be high-quality to qualify as acceptable evidence. Only the six included were considered high enough quality to be selected.

High-quality means each study had at least 40 subjects per group. The number of people who dropped out of the study did not exceed 20 to 30 per cent (based on length of follow-up). And proper analysis of the data was conducted.

Among the studies considered, all types of treatment comparisons were made. For example, acupuncture was compared with sham treatment. Acupuncture was compared with no treatment. Some looked at the results of acupuncture compared to traditional methods. Other studies compared acupuncture alone versus acupuncture combined with traditional (conventional) therapy.

In each study, the treatment procedures were checked for adequacy. In layman’s terms we would say the technique used had to be up to snuff. In other words, the protocol used had to match what was published in textbooks, taught in up-to-date programs, and practiced in advanced clinical settings. Details of acupuncture treatment such as points selected for needling, number of points needled, length of time needles were kept in, and number of sessions were evaluated.

The results were measured in different ways as well. But the most typical outcome measures were pain intensity, function, disability, general health status, and return to work (yes versus no, length of time off work). There was moderate evidence that acupuncture was better than no treatment. At the same time, sham acupuncture worked just as well as true acupuncture. Sham acupuncture means the needles were not placed at true acupuncture points, they were only inserted a little way into the skin, and they were not stimulated (moved or twisted) like true acupuncture needles would be.

There was moderate evidence that acupuncture was effective for short-term relief of pain. Relief of pain was directly linked with improved function, so it was inferred that acupuncture also improved function. There was conflicting evidence for pain relief over a longer (intermediate) amount of time.

When acupuncture was compared with other treatment (e.g., electrical stimulation, medication, massage), there was a wide range of results. Massage produced better short- and long-term results for improved function and pain relief. There was no difference between acupuncture and self-care. There was evidence that acupuncture combined with conventional therapy had the best results. But problems with study design and fewer than 40 patients in a group weakened the evidence.

The main difference in findings from the last systematic review to this current, updated review is a strengthening or confirmation that acupuncture treatment is favored over no treatment at all. Likewise, combining acupuncture with other more conventional therapies also provides good results. Comparing acupuncture against conventional therapy (an either/or situation), the evidence is not conclusive. The one change brought by the new evidence is that sham acupuncture may be just as good as true acupuncture. In the past, acupuncture was favored over sham treatment.

This type of systematic review update helps direct research. New data can be reported and conflicting data analyzed further. In this case, the reason for no difference between acupuncture and sham treatment must be examined in greater detail.

Future studies will have to address the best way to choose control groups. What constitutes an acceptable sham treatment? Should the same needles be used? Are special nonpenetrating needles needed? How far from the true acupuncture meridians can needles be inserted for sham treatment? These and other questions must be considered.

And along with re-evaluating control groups and sham treatment approaches, the patients themselves must be reviewed in the study design. Should patients with all types of back pain be included in one group? Should researchers separate those with back pain from those with back and sciatica (leg pain)? How much improvement is enough to say the treatment was successful (improved, much improved, very much improved)?

What constitutes real change? A 20 – 30 – or 50 per cent decrease in pain? What should the cut-off point be for meaningful clinical improvement? Even though there are still many questions to be answered, as a result of this updated systematic review, the European Guidelines for nonspecific back pain will include acupuncture as an effective treatment for chronic low back pain. There is enough evidence that acupuncture is cost effective when compared with other treatments.

It seems that whenever we read health news, there’s at least one article that touts the newest and best way to prevent back pain, particularly back pain at work. Since back pain is one of the most common complaints of pain in the developed world, it’s not surprising that so many people have an opinion on how best to handle it. But, there’s one problem: there is no clear way to prevent back pain at work and there’s no indication that work is causing it, according to researchers.

The authors of this article say that while there is no determined way to prevent back pain, there may be a place for goals that aim to reduce the effects of back pain, which include missing work and being disabled. That being said, even this area isn’t as clear cut as they would like.

The topic has been addressed by many experts. Most recently, there was an editorial in the BMJ (British Medical Journal), by Niels Wedderkopp, MD, PhD, and Charlotte Leboeuf-Yde, DC, PhD. The authors wrote that it may take time before doctors are able to identify effective ways to prevent further pain and disability, though, since there are still many unknowns.

It’s precisely because of all the uncertainty in the whole area of back pain and back care that companies can make some of the claims they do. For example, Forbes magazine recently ran an article titled “How to prevent pain at work.” In this article, the author appeared to let people believe it’s a known fact that back pain is a repetitive stress disorder, with the idea that the majority of people spend the majority of their time at work. If you calculate the number of hours in a day, most people don’t spend more hours at work than anywhere else.

The author also blamed physical activity and different actions at work as the root cause of most back pain. Research has shown that there are some causes of back pain that can be traced back to work, but it’s not been shown in any way that it’s the main cause. The author mentions other factors that may increase the risk of back pain, but again, without any scientific back up.

While you should always be aware of your back and how your lifestyle may contribute to back pain, if you have it, the author of the Forbes’ article continued on about solutions for back pain at work. They included examining their habits to see what may be causing the pain, avoid sitting too long or too much, move about regularly at half hour intervals, examine their workspace for ergonomic correction, avoiding unnecessary stress, and finally, stretching throughout the day.

While many of these suggestions may sound good, they haven’t been proven to help reduce the incidence or the severity of back pain in the workplace. For example, exercise is necessary for a healthy and strong back. However, what type of exercise and/or stretching you do greatly depends on the type of back injury and pain you have. Doing the wrong exercise or the right exercise incorrectly could cause more harm than good.

The recommendation to limit sitting time is something that Jan Hartivigson, DC, PhD, and his colleagues studied in 2000. Their findings couldn’t connect the length of time sitting as a risk factor for back pain. Another study done in 2007, by Angela M. Lis, PT, MTA, and colleagues, found limited evidence of sitting being a risk for back pain. And, this was only in occupations in which people were sitting for more than half a day and were either using awkward postures or poses, or their work environment caused vibrations. Sitting, by itself, wasn’t a risk factor.

Ergonomic chairs are a big seller these days as it seems like everyone is recommending them to reduce back pain. Unfortunately, in many cases, the people buying these chairs may just be wasting their money. In a set of guidelines called the European Guidelines on Prevention in Low Back Pain, released recently, there was no evidence that could support buying one particular ergonomic chair over another in order to prevent back pain.

Other comments by the author of the article were ideas that have been thrown out but never proven, such as being sure your wallet isn’t in your back pocket when you sit. There was an idea that this would cause a back problem called wallet sciatica, but again, this has never been proven.

All in all, it seems that back pain recommendations can be pulled out of the blue and sold to the general public because there isn’t any one set “this is what causes back pain.”

Farming is a very physical job – from lifting heavy and awkward objects, pushing and pulling animals, equipment and objects, to working or riding with machinery that have strong vibrations. As well, there is a tremendous amount of pressure on the farmers to work within specific time frames (for planting, harvesting, and so on), which doesn’t allow for them to rest or take time off when they feel they may need it. Because of the lifestyle, researchers have assumed that farmers would be at high risk of developing back injuries and back pain, but this doesn’t seem to be so.

The authors of this article reviewed the findings of a long-running study from Sweden to see if this assumption was correct. The study looked at back pain in farmers, but the researchers didn’t find that lifting heavy objects played a role in back pain in the farmers. The researchers were also unable to find a connection between the psychosocial (mental and/or emotional) status of the farmers in relation to back pain, although psychosocial issues could and did play a part in sick leave and disability payments in both farmers and non-farmers.

What these findings did for researchers though, was to suggest that the previous idea that physical activity and back pain went hand-in-hand and that back pain usually was seen as a traumatic injury, wasn’t true. In fact, more physical activity could actually help protect the back. Therefore, attempts to help prevent back injuries among farmers through ergonomics may be misguided, researchers suggest. This is likely because injury-prevention techniques that are taught are based on lessening the load on the back, not encouraging the back to be stronger and able to carry the load.

In 1989, S. Holmberg and colleagues studied over 1000 farmers and 769 non-farmers, comparing their musculoskeletal (bones and muscles) system. The farmers reported more injuries to the hand, forearm, lower back and hips than the non-farmers, according to the study findings. Following that study, the team looked at the impact of physical work on the musculoskeletal system and resulting symptoms. In this study, the researchers found that the farmers had fewer neck and shoulder injuries than the non-farmers. The pain was equal among both groups in the hand and forearms, and knees. Back injuries weren’t as clear though.

When back pain was reported, were two contributors: lifting objects awkwardly or lifting heavy objects, but it was the awkward lifting that contributed the most to the back pain. But, the researchers pointed out that the increase in workload didn’t have any impact on the back, nor did vibrations from machinery. Again, because there wasn’t a clear connection between work load and back pain, the current preventative strategies wouldn’t have an effect on the farmers but, rather, a broader approach would be needed. The broader approaches should include psychosocial and socioeconomic factors. As a result, Holmberg and his team undertook another study looking at these factors.

What the researchers found was, again, there didn’t seem to be a connection between various psychosocial factors, social networks, or lifestyle and back pain, using medications for back pain, or taking sick leave. While all these may have an effect on back pain, they affected both farmers and non-farmers at the same rate. But, the research doesn’t stop there. Dr. Gary MacFarlane, as part of a group called the European League Against Rheumatism (EULAR), undertook to study existing information on how psychosocial issues can affect not only back pain, but other musculoskeletal pain. One issue that frequently comes up in studies on psychosocial issues is how psychosocial factors can predict the severity and longevity of pain.

MacFarlane found seven reviews on the connection between psychosocial factors and back pain in the workplace. For the most part, the reviews found that there was a strong connection between high work demands, low colleague and survivor support, low job satisfaction, and back pain. However, the most recent review on the topic doesn’t back up these findings. In fact, those researchers concluded that there was no such connections at all.

So, this means that researchers still don’t know the role of psychosocial issues and back pain, but it’s likely safer to err on the side of caution and work on the assumption that there is a connection, albeit an unproven one at this point.

Lumbar spinal drainage using a needle to draw out the cerebrospinal fluid (CSF) is a procedure done during brain surgery. The procedure is called a lumbar drain. Removing CSF helps the brain relax. The technique can also be done when there is a spinal CSF fistula. A fistula is an abnormal connection or passageway between two areas that normally do not connect.

Usually the needle used to tap into the CSF is put in place using fluoroscopy. Fluoroscopy is a type of real-time X-ray that allows the surgeon to see the needle moving through the tissue. One advantage of the fluoroscopy technique is that a portable unit can be brought to the patient’s bedside. The procedure can be completed without moving the patient. This type of X-ray improves accuracy but exposes both the patient and the surgeon to radiation.

In this report, doctors from the Departments of Radiology and Neurosurgery at the Albert Einstein College of Medicine in New York report on the use of computed tomography to guide the lumbar drain. They used the case of a 62-year old man with a brain aneurysm as an example. An aneurysm is an abnormal thinning and dilation (or ballooning) of an artery (blood vessel).

Surgery was done to remove the aneurysm. But there was a leak in the CSF after the operation. The surgeons were unable to get a lumbar drain placed using fluoroscopy. After multiple attempts to place a lumbar drain using bedside fluoroscopy, this patient was transported to the CT scan suite. The lumbar drain was placed in one attempt.

The CT scan allows safe and accurate placement of the needle from skin to spinal canal. The needle enters the thecal sac where the CSF is located. The thecal sac is made up of two separate but closely linked layers of lining called the dura mater and the arachnoid mater. The sac protects the nerve roots from pressure injury while the fluid supplies nutrients.

Each cross-sectional slice provided by the CT image allowed the surgeon to choose the right needle angle. Measurements to gauge distances are given in millimeters. If there is any doubt about correct placement of the needle, a contrasting dye can be injected through the needle into the CSF. The dye is taken up by the CSF and confirms proper needle placement.

When standard bedside fluoroscopy has been done with multiple punctures of the dura (lining around the CSF), it may not be possible to get the CSF to flow. This is because tears in the dura allow leakage of the CSF, which reduces the pressure within the CSF. Low CSF prevents CSF flow. This is another situation when computed tomography can be used for lumbar drain placement.

And there is the added advantage of being able to see the needle enter the thecal sac with the option of using a contrast dye to confirm proper needle placement. CT scan also shows if there have been any blood vessels punctured along with the formation of a hematoma (collection or pool of blood). Hematomas must be treated immediately to prevent further complications.

The authors suggest using CT-guided lumbar drain placement in complicated cases. CT scans give the surgeon a chance to examine and study the patient before surgery. The lumbar drain placement technique can be planned down to the millimeter.

Surgeons at the Spine Institute (University Hospitals of Cleveland) are trying to find evidence to suggest bracing after spinal fusion for degenerative spinal disorders is advised. They would like to know if wearing a brace helps stabilize the spine and produce a better result.

There are multiple factors and variables in making this decision. Not all can be studied at once. But an awareness of each one can be helpful when studying one particular aspect of the decision. For example, spinal fusion can be done anteriorly (from the front of the body), posteriorly (from the back), or posterolaterally (at an angle between the back and side). The results of a brace or corset must be compared among these three approaches before a set of guidelines can be made.

The surgery may be with or without instrumentation (metal plate and/or screws). The use of instrumentation may or may not make a difference — but we don’t know that because there aren’t enough studies to give us convincing evidence one way or the other. The same thing could be said about the results of bracing after fusion without instrumentation.

If the goal is to provide a stabilizing effect, then it’s possible the type of support used would make a difference. And there are all types of support options. The two main choices are a molded, rigid orthosis (plastic brace) and a wrap-wround canvas corset (with or without metal stays).

When and how long to wear the support is another factor to consider. Should it be worn just at night while sleeping? All day (every day around the clock)? For four weeks? Six weeks? Longer? We simply haven’t had enough studies to examine the evidence around each of these factors.

In this study patients were compared after a posterior lumbar fusion both with and without bracing. Pedicle screws and bone graft from a bone bank were used in the procedure. For the group that wore a brace, the canvas type of corset with adjustable metal supports (stays) was used. The stays were placed inside the corset and positioned on either side of the spine. Patients who wore the corset kept it on full-time for eight weeks (except to bathe). They gradually weaned themselves off the supportive aid over the next four weeks.

Everyone was followed for two full years. The authors measured general health, function, complications, and number of patients who had further surgery after the fusion. Surveys used to measure before and after results included the Dallas Pain questionnaire (DPQ) and the Short Form-36 (SF-36) instrument.

After following all patients for two years, there was no difference in outcomes between the two groups. In other words, there was no advantage (or disadvantage) in wearing a corset type support after lumbar spinal surgery in patients with degenerative spinal disease. Patients in both groups improved measurably. There were an equal number of complications and need for another operation in both groups.

X-rays were taken to evaluate the fusion. Bridging of the bone across the fusion site seen on X-ray was a sign of a successful fusion. The rate of failed fusions was equal between the two groups (with and without the corset). The incidence of fusion failures went up as the number of levels fused increased. For a one-level fusion, the nonunion rate was 20 per cent. For a two-level fusion, the rate increased to 28 per cent. Three-level fusions had a much higher rate of nonunion (63 per cent).

It’s possible a different brace would have different results. This group of patients had a degenerative spinal condition. It’s possible that other diagnoses might respond more favorably to the external support. And perhaps the level of fusion (upper lumbar spine versus lower lumbar spine) makes a difference.

Success may vary depending on the goals of therapy. For example, the idea of wearing a brace to limit motion may have different results when compared with using a brace to decrease pain, increase function, or improve fusion rates. The authors suggest that more studies are needed to look for different subgroups of patients who might benefit from bracing after spinal fusion.

When a patient presents with pelvic pain and a history of trauma, the physician suspects pelvic instability. In this study, the use of X-rays taken with the patient standing on one leg called a single-leg stance was evaluated in the diagnosis of pelvic instability.

The entire pelvis is formed by the sacrum (wedge-shaped bone at the base of the spine), the coccyx (tailbone at the bottom of the sacrum), and the hip bones. The upper (socket) portion of the hip is made up of the ilium (pelvic crest), ischium (bones you sit on), and pubis (birth canal ring).

The pubis symphysis is in front of the body where the two pelvic bones come together. This is the area of interest in the current study. A disruption of the connective tissue between the two pelvic bones at the symphysis pubic can cause pelvic instability. Disruption can be defined as translation (movement of the pubis on one side up or down), widening (separation), or impaction (narrowing or overlapping of the space between the two bones).

Separation of the symphysis pubis is referred to as symphyseal diastasis. Since this area is connected together by soft tissue, there is a certain amount of normal give. This slight shift can best be seen by comparing the position of the symphysis pubis when standing first on one leg and then on the other (single-stance).

Experts propose that normal motion in this area is up to 0.5 mm in men and up to 1.5 mm in women who aren’t pregnant. Pregnant women (or women who have had multiple births) may have up to a 3.0 mm shift. For the purposes of this study, anything 0.5 mm or more was a sign of change in alignment and considered a positive response for pelvic instability.

Trauma such as a car accident, childbirth, or a fall is the most common cause of pelvic instability. In older adults with osteoporosis (brittle bones), stress fractures can occur that also lead to disruption of the symphysis pubic and pelvic instability.

The diagnosis of pelvic pain is difficult. Identifying instability can be equally difficult. X-rays are usually taken in the standing (on two legs) position and supine (lying on the back). But these views don’t always show pelvic instability even when it’s present.

In this study, single-leg stance X-rays (standing on one leg at a time) were used to diagnose this type of pelvic instability in 38 patients. One-fourth of the group had a history of a car accident. One-fourth suffered trauma during childbirth. Four patients had osteopenia (decreased bone density; this is the step before developing osteoporosis) and eight others had other causes linked with this problem.

The results of single-leg stance were compared with two-legged and supine views. Twenty-five of the 38 patients (two-thirds of the entire group) did have pelvic instability using the single-leg stance method of assessment. No one had diastasis using the two-leg standing position. Only two patients showed diastasis in the supine position. When level of pain was compared with patients who had a stable vs. unstable pelvis, there was no difference between the two groups.

This study showed that pain was not a good measure of pelvic instability. But the single-leg X-ray, a simple, inexpensive, diagnostic tool, can be very helpful. A history of preceding trauma, older age, or abnormal motion in the pelvic area is reason enough to order this type of X-ray view. Damage to any part of the pelvic ring can result in disruption of any other portion of the ring. A positive single-leg stance X-ray signals the need for further evaluation.

The authors of the study performed a literature search to evaluate the role of specific core muscle strengthening with physical therapy for low back pain, LBP, in golfers. They also evaluated the trunk flexibility and type of golf swing.

It is expected that 55 million people will participate in the sport of gulf by 2020. It is a popular sport among those over the age of 50. This means that degenerative changes in the spine of older golfers, and forces generated during the golf swing, could increase the incidence and impact of LBP. Low back pain makes up 26 to 56 percent of golf related symptoms. Low back pain is most often caused from muscle strain, internal disc disruption, and facet joint capsule trauma.

The golf swing generates considerable forces. Axial twisting, compression, shearing forces, and lateral bending forces during the golf swing may be problematic. Knowledge of proper swing mechanics may help reduce injury. There are generally two types of golf swing styles. One is the modern golf swing, and the other is the classic golf swing.

One study demonstrated that golfers with LBP tended to exceed their trunk rotation during their swings. The modern golf swing restricts the hips, and emphasizes shoulder turning and trunk rotation. It also tends to increase lateral bending of the trunk and hyperextension of the spine on follow through. This golf swing tends to emphasize power and distance.

The classic golf swing allows hip turning. This reduces the torque on the lumbar spine. There is also less lateral bending of the trunk and shearing forces on the spine with this type of golf swing.

The authors suggest that proper conditioning to avoid imbalances in the trunk muscles, strengthening of the stabilizing trunk muscles, flexibility exercises, warming up for 10 minutes before playing, and coaching of a more classic golf swing could be beneficial to golfers with LBP.

Which is better? Surgery or nonsurgical care for lumbar disc herniation (LDH)? Surely by now enough studies have been done to identify the preferred choice. But, in fact, a review of five of the largest randomized controlled trials (RCTs) still couldn’t answer the question.

And the reason for that is poor study designs, high crossover rates, and large differences in the way results were measured. Crossover refers to patients who were in the surgery group and decided to switch to the nonsurgical group and vice versa.

In this report, orthopedic surgeons reviewed those five randomized controlled trials (RCTs). RCTs are supposed to offer the highest level of evidence that a specific treatment is effective. Levels of evidence are reported from Level I through Level IV. RCTs are usually level I and II studies. This means they are high-quality and offer conclusive (Level I) evidence or lesser quality but strong (Level II) research evidence.

Each of the five studies reviewed were published sometime between 1966 and 2007. Over 1,000 patients were included. The studies were all comparative. That means they compared the results of lumbar discectomy (removal of the disc) against nonoperative care.

As suggested by the name (randomized trials) each person was randomly assigned to one of these two groups. Patients in each group could have been treated either way. Anyone who needed emergency treatment (especially surgery) was not included. Everyone had painful symptoms for at least six to 12 weeks before entering the study.

The biggest red flag in these studies was the high rate of crossover. As much as 40 per cent of the surgical group decided not to have surgery and ended up in the nonsurgical group. And a full third of the nonsurgical group crossed over and had a discectomy. In one of the five studies, more than half of the patients in the nonoperative group had surgery.

When that happens, the researchers can analyze the results and report them based on the initial treatment (before they crossed over). This is called intent-to-treat (ITT) analysis. Three of the five studies approached the problem in this way. One study reported the outcomes both ways: as treatment assigned and treatment received.

Clinical outcomes and complications varied among the studies. The complication rate varied from 1.6 per cent up to five per cent. Problems during or after surgery included bleeding, sciatica, dural tears, and recurrent herniation.

The general trend was for improved results with surgery during the early follow-up. Long-term results were the same between the two groups for all measures. Measures included pain, function, and level of disability. Despite millions of dollars and multiple centers’ involvement, we still don’t have a clear answer about the best way to treat lumbar herniated disc (LDH).

The authors suggest rethinking the use of randomized controlled trials (RCTs) for patients with LDH. Improving care for patients with this diagnosis may require a different research approach. For one thing, RCTs only include patients who sign up and agree to be in the study. What about patients who don’t enroll? Would they have the same or different results? Can we apply what we learn to everyone (those who join studies and those who don’t)?

Can we really say patients are equally good candidates for either group? That’s a value judgment without evidence to back it up. And the authors mention one other point of contention. Patients who have the worst symptoms tend to improve the most no matter what group they are in. And the more severe the symptoms, the more likely that patients in the nonsurgical group would cross over to the surgical side. These factors can affect the study results.

The authors conclude by saying that the validity of these studies was seriously compromised. Randomized controlled studies may not be the best way to identify optimal treatment for lumbar disc herniation.

The authors of a Japanese study evaluated various factors that they thought could be associated with lumbar intervertebral disc degeneration. Lumbar intervertebral discs degenerate with normal aging. Degeneration of discs precedes lumbar disc herniation and lumbar spinal canal stenosis. Using magnetic resonance imaging, MRI, they were able to evaluate 1,347 intervertebral discs from L1/2 to L5/S1 in 270 subjects with a mean age of 68.4 years who volunteered for the study.

Recent studies have determined that heredity plays a role in degenerative discs. The authors were interested in acquired factors that could be associated with degeneration of discs since they can be modified. Prevention by improvements in lifestyle could reduce degeneration of discs, and associated lumbar degenerative diseases. The authors sought to clarify the associations between identified disc degeneration according to MRI, and suspected risk factors including atherosclerosis and cardiovascular risk factors. Other acquired factors considered in the study included body mass index, body mass density, occupation, participation in sports, smoking, and alcohol use.

Atherosclerosis was evaluated using pulse wave velocity, PWV. This is a measurement of the speed a pulse travels between two points. The greater the resistance of the blood vessel, the faster the speed. Lipids and glycosylated hemoglobin were measured from blood samples. Body mass index was calculated using height and weight of the subjects. Ultrasound of the heel or calcaneus was used to determine BMD. Questionnaires and telephone interviews asked the following questions. Have you ever experienced low back pain, LBP, during your lifetime? Do you smoke cigarettes? Do you drink alcoholic beverages? Have you ever engaged in an occupation that involved lifting weights of more than 10kg for more than one third of your working hours? Have you worked as an occupational driver? Have you ever participated in a sport more than three times per week for more than five years, and if so, what kind of sport?

The degree of disc degeneration was evaluated with MRI using the Pfirrmann grading system. However, because in this older population, the signal intensity and disc height measurements did not correlate well, the authors chose to use signal intensity as the most accurate measurement of disc degeneration. The authors analyzed each level separately. Results indicated that aging was correlated with degenerative discs from L1/2 to L4/5; high BMI with degeneration at L2/3, L3/4, and L5/S1; high low density lipids with L4/5 and L5/S1 disc degeneration; high PWV with L1/2 and L2/3; low BMD with L5/S1; occupational lifting with L1/2 and L4/5; and sports with L5/S1. Gender, triglycerides, glycosylated hemoglobin, history of LBP, current smoking and drinking habits, and occupational driving had no correlation to degenerative discs. The authors note that the sample size of smokers was likely too small for statistical accuracy.

The authors conclude that prevention of acquired risk factors such as high BMI, high LDL cholesterol, occupational lifting could affect the onset of degenerative discs and lumbar degenerative diseases.

Lower back pain is a very common injury and complaint but what is surprising is that many women are affected, just as men. Researchers find it surprising because – as a rule – women live more healthy lives than men and tend to do less manual labor than men. That being said, women do tend to be at risk for developing chronic pain disorders and they tend to react more to injuries and traumas than men. In one study of over 5000 people, women were more likely to have back pain, although there was also a higher number of people who complained of back pain who were overweight, those who tended to have physical symptoms as a reaction to psychological triggers, had little social support, as well as those who were sedentary, smokers, the elderly, and/or in lower socioeconomic groups. However, even taking all those factors into account, women still had more back pain than men.

The authors of this article wanted to review the findings of a study that looked investigated the incidence of lower back pain to see how women presented with lower back pain and the course it takes, compared with men. The authors also wanted to find out if the sex of the patient affected if and how they sought medical help.

There were data from 1342 patients, 778 of whom were women. The patients all completed questionnaires before and after being seen by a general practitioner. The patients were contacted again after four weeks, six months and one year. Patients’ ability to function was assessed using the Hannover Functional Ability Questionnaire (HFAQ).

After the data were gathered, the researchers found that women were, in generally, more likely to have more problems functioning with their lower back pain than men. They also were more prone to recurring back pain or chronic, long-term back pain. Finally, women also tended to have more depression with the back pain. As for use of the healthcare system, at first it appeared that women sought help more than med, but that evened out. Although women did use more medications then men, they missed less work than men, although the amount wasn’t significant.

The authors concluded that knowing that there is a difference in how women experience lower back pain should encourage research into sex-specific care.

In the last 30 years, as the Baby Boomers became adults, the management of low back pain (LBP) has changed. Baby Boomers were born between 1946 and 1964. Parents of Baby Boomers were more likely to expect the doctor to make all the decisions. But patients today are active consumers. This has resulted in a new concept of patient care called shared decision-making.

In this article, spine surgeons get together and discuss this new idea. They also review a separate issue of wide regional variations in patient care. Surgical care especially seems to have large differences in how low back pain is treated from one area of the country to another. In other words, patients with the same type of problem may be treated one way in one geographical location and receive different care elsewhere.

Today’s focus on evidence-based medicine is helping sort out whether this variation problem occurs as a result of physicians’ lack of awareness of up-to-date treatment guidelines or if it is due to a lack of physicians in a geographical area. This outcomes movement is expected to help provide the evidence needed to make medical and/or surgical decisions about care for low back pain.

As part of the evidence-based and outcomes movement, we have new research information about low back pain. We’ve always known the number of people affected by back pain on any given day of the year is pretty high. This is referred to as point prevalence. But the pain doesn’t last and symptoms usually go away within the first couple of days-to-weeks.

This progression of symptoms and symptom resolution is referred to as the natural history.

Knowing the natural history of acute low back pain helps physicians feel confident in prescribing limited bed rest (one to two days max), short-term use of analgesics (pain relievers), and physical therapy or chiropractic care.

More advanced test procedures can be ordered when pain does not improve with this management approach. For example, constant and severe pain may be an indication of something more serious such as a tumor or infection. The results of the X-rays determine the next step. This could be referral to another specialist. Or it may be persistence in getting the individual better with a continued program of conservative (nonoperative) care.

Physicians now have an algorithm to follow regarding further testing procedures with MRIs and other more advanced imaging. An algorithm is the step-by-step decision-making process used by health-care professionals. It relies on a flow of: if this happens, then that should be our next step.

In this paternalistic model, the physician is still determining when to order X-rays or MRIs and when to refer to another health care professional. Exercise, manual therapy, behavioral therapy, or functional activities programs are just a few of the conservative care options.

The authors report no new information about more invasive treatments (e.g., lumbar disc injections, intradiscal electrothermal treatment). There are no new breakthroughs in lumbar spine surgery (e.g., fusion, disc replacement). Disc replacement preserves spinal motion but the procedure costs more and the final outcomes aren’t better than with fusion. Fusion is considered a last resort after failure of nonoperative care.

And after looking over all the studies and comparing current practice, the authors say it looks like physician factors (rather than a lack of evidence) does indeed account for the wide regional differences in the way low back pain is treated.

Patients should be made aware that the recommended plan of care (POC) for chronic low back pain is as follows: