News Category: Lumbar Spine

For a long time, now we have had the understanding that disc surgery may not be any more effective than conservative (nonoperative) care. In long-term studies over 10 years or more, patients with painful back and leg pain from disc herniation had the same results with or without surgery. So, many patients toughed it out and avoided surgery.

But a new study from the Netherlands has some additional information to add that might change this practice. They found that the short-term benefits of disc surgery are actually a costs savings. The patient has less pain and better function early on. And even though the medical costs were greater, the cost to society was less.

How did they figure that? Well, decreased absenteeism and higher work productivity tipped the scales in favor of early surgical intervention. At the end of one year, the cost of early disc surgery to society was less than if the patient had struggled through a prolonged course of conservative care.

Looking at this problem from a purely statistical point-of-view, early surgery also translated into greater quality-adjusted life years (QALYs). QALYs is a way of measuring disease burden on a society. It includes both the quality and the quantity of life lived.

QALYs is a useful way to put a number on the benefit of a medical intervention such as disc surgery. They are based on the number of years of life that would be added by the treatment. Zero value (0) is used to represent death. Perfect health is assigned the value of one (1.0). If without surgery, the extra years would not be lived in full health, then the extra life-years are given a value between 0 and 1 to account for this.

A health economist studying this problem might offer the advice to do disc surgery to save money. But decisions aren’t always made in the health care system based on supply and demand or what’s best for society. Hospitals must look at what is the best use of their resources.

Patients with severe sciatica will likely get better sooner or later without surgery. Some experts argue that resources that might have been used to provide early surgery can be diverted to patients with more serious health concerns. Others stand firm in their belief that it is up to the patient to decide what’s best for him or her. Decisions should not be based on what’s best for society or the health care system.

Total disc replacement (TDR) is possible now for some patients in place of spinal fusion. Two of the disadvantages of spinal fusion are loss of motion at the fused segment and increased risk of adjacent level degeneration.

We know that disc replacements restore spine motion. But do they prevent accelerated degeneration at the level of replacement and at the next level segment above or below? That is the question that researchers attempted to answer with this study. It is the first study to compare degenerative changes in the discs and facet joints before and after TDR.

Patients with disc pain from degenerative disc disease were included in the study. One surgeon inserted a lumbar total disc replacement (TDR) in 46 patients. The ProDisc II device was used. The ProDisc is one of two types of total disc replacements. The other is called the CHARITÉ. Both types of implants are metal-on-polymer. The ProDisc is constrained in front-to-back and side-to-side shear but moves freely in twisting or rotational patterns. Reducing the shear force decreases the load on the facet joints.

Each patient was followed for at least two years. Results were measured first by comparing dynamic X-rays, MRIs, and CT images before and 26 months (or more) after surgery. Any changes in the discs or joints were compared with patient symptoms, range of motion, and function.

The researchers also looked at patient age, gender, height, weight, and vertebral level operated on. They also studied the relative size and position of the implant. They found improved pain levels and motion (flexion and extension) at the operated segment. There was very little sign of degeneration of the adjacent (next level) discs.

Facet (spinal) joint degeneration referred to as progression of facet arthrosis (PFA) was also evaluated. PFA usually occurs along with loss of disc height. As the discs degenerate, there is a loss of height or cushion between the vertebral bodies. This puts more pressure on the facet joints and creates changes such as bone spurs or hypertrophy (overgrowth) of the joint capsule.

It appears that PFA was more commonly seen in patients when disc replacements were placed at more than one level. PFA also occurred more often when the implant was placed off center. Women were affected more often than men. The reason for the gender difference is unknown at this time.

The most striking finding in this study was that disc and joint changes were fairly minimal at the adjacent segments. But changes were present in about one-third of the patients at the level of the TDR (also known as the index level). At the same time, there was improved pain, function, and quality of life even with the joint changes at the index level.

The authors point out two design flaws in their study. First, there was no control group (patients with degenerative disc disease who did not receive treatment). It’s possible that what they saw with the group in this study was nothing more than what would have happened anyway. That’s referred to as the natural history of a condition. And secondly, the sample size was fairly small. This same study should be repeated with a larger group of patients, including a control group.

For best results, surgeons are advised to make sure the implant is placed at the middle of the vertebral body on the frontal plane. This is especially important when TDRs are placed at more than one level at the same time. Malpositioning on the frontal plane puts an uneven load on the implant and on the facet joints. This can create further degeneration of an already compromised joint.

Surgeons have struggled for years to find a way to prevent complications after long spinal fusions to the sacrum for adult scoliosis. Years ago, long rods were placed on either side of the vertebrae. But there was a high rate of pseudoarthrosis (false joint or movement at the joint). Problems from the resulting flat back were also reported.

Over time, this surgery has changed but the problems haven’t gone away. For awhile, it looked like the procedure was more successful than it really was. That’s because the results were only reported for a couple years after the operation. But the real problems started later than that.

In this study, 50 adults who had a long spinal fusion for scoliosis were followed for at least five years. The fusion was from the sacrum up to T10 or higher. Most of the time, lumbar pedicle screws were used in the lumbar and sacral areas.

Instead of one long rod connecting the entire spine together, smaller segments were secured using special hardware called instrumentation. Special surgical hooks were placed in the thoracic spine. Stainless steel or titanium implants were preferred.

More than half the group had both an anterior (from the front) and posterior (from the back) fusion. The lumbar spine was fused to the sacrum. Some patients had only a posterior fusion. No artificial bone substitute was used in the fusion (only donor bone). In posterior fusions, bone taken from the patient (autograft) was mixed with bone from a bone bank (allograft).

Complications and problems were reported. These included pseudoarthrosis, nerve root injury with paralysis, wound infection, and urinary tract infection. More minor problems such as dural tears (lining of the spinal cord), blood clots, or minor heart events were reported as well.

Despite all efforts to prevent it, there was still a high rate of complications. No one died or suffered a spinal cord injury. But one-fourth of the group developed pseudoarthroses. Most of these didn’t occur until two years or more after the fusion operation.

The authors suggest structural support should be used with anterior fusions for adults with scoliosis. All lumbar levels should be fused anteriorly. Fusing the sacrum to the ilium (pelvic bone) is needed to secure a stable base. Some of the hardware may have to be removed later.

Chronic low back pain (CLBP) can really decrease a person’s quality of life. There are many ways to approach the treatment of CLBP. Back school is one method that’s been around since the late 1960s.

Back School is a prevention and education program to help patients understand and care for their backs. Information about anatomy, posture, lifting, and exercise is presented over a period of weeks to months. The goal is to raise patients’ awareness of their own bodies and to increase their ability to function in everyday life. It’s usually presented to a group of patients rather than on a one-on-one basis. Exercises are a part of the program.

In this study, the use of back school is evaluated in a group of women with CLBP. Two groups of women were compared. The first group received the back school program and medication. Meds included Tylenol (pain reliever), nonsteroidal antiinflammatory drugs (NSAIDs, pain reliever and antiinflammatory), and chlordiazepoxide (antidepressant). The second group just got the medications.

The main measure of results was quality of life (QOL). Women in both groups completed a survey of questions (SF-36) about physical and mental health. The questionnaire was completed before treatment and after treatment at three, six, and 12 months. QOL is reported using a score from zero (worst) to 100 (best).

The goal of this particular program was to help patients achieve the highest level of function possible. The program focused on empowering the women through education and self-awareness. Setting goals to improve quality of life was also included. A team approach was used. A PhD level educator, clinical psychologist, rheumatologist, and physical therapist were all part of the process.

The authors report scores increased for both groups. But the Back School group had the most significant improvement. Most of the change occurred during the first three months of the program. Scores did not differ between six and 12 months. This may be because direct weekly communication was stopped after three months. Without the added encouragement and motivation, QOL measures didn’t improve. They also didn’t get worse. Scores just stayed the same over time.

A back school program worked better than meds alone for this group of women. The results of other studies suggest this is because QOL measures look beyond physical impairment. Function and psychologic well-being are also addressed.

Adding medications to a back school program may help patients perform daily activities. The risk of disability was less when the women used healthier body mechanics and exercised to improve strength and flexibility.

There is some concern that research doesn’t support the use of epidural steroid injections (ESI) for spinal stenosis. Even more controversial is the use of opioid medications for pain from this condition.

ESI has become an intermediate step in the treatment of chronic low back pain from stenosis. When conservative care hasn’t helped and surgery is too invasive, ESI may be tried. But in this two-year study of over 13,000 Veteran’s Administration (VA) patients, the use of opioids went up after ESIs instead of down.

Not only that, but the number of patients to have spinal surgery after ESIs didn’t change either. In fact, patients who had more than three ESIs were more likely to take opioids and still ended up having lumbar surgery.

The results of this study point out again that ESIs are being used inappropriately for lumbar pain from spinal stenosis. Opioid use does not decline after ESI. Doctors are encouraged to avoid using treatment methods for which there isn’t enough evidence to support.

ESIs have been shown effective in the treatment of sciatica or radiculopathy (nerve pain from pressure on the spinal nerve roots). It’s use for patients with spinal stenosis without radiculopathy hasn’t been shown effective. More study is needed to find out who can benefit from ESI.

Criteria for patient selection are needed to ensure treatment success. Evidence-based guidelines are also needed for number of injections, frequency and timing of injections, and when to use repeated injections.

Patients with chronic low back pain (LBP) may fear re-injury enough to avoid movement. This concept is called kinesiophobia (fear of movement). A constant cycle of pain, fear, disuse, and depression can be the result of kinesiophobia.

In this study, psychologists and physical therapists got together to test chronic LBP patients for kinesiophobia. Patients with chronic LBP filled out four separate surveys of questions about function, pain, perceived disability, and fear of movement/reinjury. Then they performed four tests of reaching high and low targets at slow and fast speeds.

Right before each movement test, the patients rated the pain as they expected it to be. Then after the test, they re-rated the experience. The expected and experienced (actual) harm were analyzed and compared for two groups. Group one had low levels of kinesiophobia. Group two had high levels of kinesiophobia.

The results showed that high kinesiophobia patients had lower function in daily activities because of back pain. They were more likely to report higher pain levels than patients with low kinesiophobia. Women with high kinesiophobia were more likely to predict catastrophic results of movement activities than men with equally high levels of kinesiophobia.

The high kinesiophobia group was more likely to overpredict pain ratings with activities. In other words, the predicted pain level was much higher than the actual experience. That was true for the first time they tried an activity. The second time they performed the same movement, their pain ratings were the same as the low level kinesiophobia.

And although their fear was less the second time doing the same activity, their fear went right back up when starting any new (even slightly different) activities. They were unable to apply what they learned about specific movements to general movement.

These findings provide physical therapists useful information when working with fearful LBP patients. A slow, graded, and progressive rehab program aimed at practicing movements and reducing fear can help overcome kinesiophobia.

Failure rate for lumbar fusion is ten to fifteen percent. Because it takes months for the bone to incorporate to complete fusion, there is interest in finding materials that could hasten and improve the fusion rate in the lumbar spine. The present accepted surgical procedure involves transpedicular stabilization and placement of autologous bone graft material in the disc space within two titanium cages. Autologous bone is harvested from the iliac crest. The authors compared the success of this surgical procedure with subjects who underwent fusion with bone from the tibia combined with engineered tissue. The engineered tissue was called fibrin/polyglactin-poly-p-dioxanone, PGLA-PPD fleece.

Twenty-four subjects were studied, 11 in the control group using iliac crest bone, 13 in the study group using periosteal bone cells from the tibia within PGLA-PPD fleece. There was less pain associated with tibial periosteal harvesting than with iliac crest cancellous bone harvesting. However, iliac crest bone harvesting is done at the same time as the fusion, where as surgery for harvesting of the periosteal bone cells must take place weeks prior to lumbar fusion.

The subjects in the study group had tibial periosteal bone harvested 10 weeks prior to lumbar surgery. Venous blood was also taken for cell culture. The bone cells were digested and cultured for six to eight weeks. They were then embedded in a fibrin gel. They were then placed on resorbable carrier fleece made of PGLA and PPD. This material was then placed in the titanium cages in the intervetebral space. The same hardware, screws and rods were used for fixation in the study group as the control group. All of the subjects underwent fusion at L4-5 or L5-S1, except one subject had fusion at L5-6.

All of the subjects were mobilized in physical therapy the day following surgery. None were given a back brace or support. The subjects were evaluated by dynamic radiographs and computed tomographic reconstructions at three, six, nine, and 12 months after surgery.

According to dynamic radiographs, at the three month interval, none of the control group were fused, and one of the study group subjects had evidence of fusion. However, at six months, 63.6 percent of the study group demonstrated fusions and 20 percent in the control group. At nine months, 90.9 percent of the study subjects demonstrated fusion compared to 40 percent of the control group. At 12 months, 90.9 percent of the study subjects and 80 percent of the control group demonstrated fusion. CT demonstrated earlier fusion in the study group as well, but a lower overall fusion rate at 12 months for each group.

Periosteal cells appear to be a viable substitute for harvesting iliac crest bone in spinal fusion surgery. Periosteal cells impregnated in polymer fleece appear to have advantages in terms of earlier consolidation of bone than iliac crest bone. The authors suggest that this technique be approved for lumbar fusion surgery.

Low back pain is a huge problem in the United States. Every year, billions of dollars are spent on the management and treatment of this condition. But there’s not a lot of agreement among health care professionals on what this treatment should be.

The American College of Physicians (ACP) and the American Pain Society (APS) have offered some guidelines for first-line therapy. They discourage the use of diagnostic imaging and tests on a routine basis. They encourage the use of self-care. Oral analgesics such as Tylenol or nonsteroidal antiinflammatory drugs should be used first. Exercise and spinal manipulation are important nonsurgical and nondrug approaches to chronic low back pain.

This guideline is directed at patients with nonspecific low back pain. Nonspecific means there’s no known cause for the problem. There’s no infection, fracture, or tumor to point to as the cause. Imaging and testing procedures all appear normal with this group of patients.

But another group, the American Society of Interventional Pain Physicians (ASIPP) is concerned about these proposals. They are concerned that third party payers and insurers will refuse to pay for services when they are needed. Reducing access to necessary testing and treatment isn’t going to help patients in pain.

All groups agree that selecting the right treatment is based on understanding which services are known to help select groups of patients. Treatment outcomes are improved with properly chosen patients.

More research is needed to continue identifying subgroups of back pain patients who can benefit from each individual therapy. Doctors must read the literature to know when there is evidence to support one type of therapy over another. Without proof to show a treatment is effective, it should not be applied.

Physicians can expect new guidelines every three to five years as the research is reviewed and summarized that often.

One of the main symptoms of lumbar spinal stenosis (LSS) is intermittent claudication. Intermittent means the symptoms come and go. Claudication refers to limping caused by cramping pain or discomfort in the lower legs.

Increased pressure on the spinal cord or spinal nerve roots from a narrowed spinal canal is the main cause of this problem. It is usually a degenerative process that comes on as we age. A loss of circulation to the spinal area makes the problem even worse.

The results of this study may be of interest to patients who are looking for a conservative treatment plan to treat their stenosis. Only patients with intermittent claudication from nerve impairment who also had poor blood flow were included. They were given an intravenous (IV) infusion of prostaglandin E1 (PGE1) for two weeks. This was followed up with oral (by mouth) PGE1.

PGE1 dilates or opens up the blood vessels in the epidural space (inside the spinal canal. If symptoms aren’t improved after PGE1 treatment, then sugery may be needed.

The results were measured before and after treatment. Measurements included distance walked before stopping because of pain, spinal stenosis rate, and function. Stenosis rate refers to the area of spinal canal opening seen on MRI and CT myelography testing. Function was assessed using a special survey of subjective symptoms and objective findings.

The authors report that PGE1 was helpful in alleviating painful walking. The treatment was safe. It did not appear to be linked with the patient’s age, severity of stenosis, or claudication distance. Level of function did seem to make a difference. Patients with more severe symptoms had less response to the PGE1.

Researchers are hopeful that treatments like PEG1 can benefit patients with painful intermittent claudication from lumbar spinal stenosis. This would be good news for patients who either don’t want or can’t have surgery for any reason.

Despite years of research, the cause and treatment of back pain remain a mystery. Scientists say its more complex than they ever imagined. Some experts say that thanks to all those studies we know much more about what we don’t know than about what we do know!

Having said that, it’s important to see what has been accomplished over the years. First, back pain research is being done around the world. That’s new in the last 10 years. There’s an international group called International Forum on Primary Care Research on Low Back Pain. They have made large strides in quality and quantity of back pain research.

After they created the group, they set up a research agenda. A new field of research around back pain was developed. So far, we don’t have new solutions to the problem of back pain. But we know more about where we went wrong in our thinking in years past. As a result, we have stopped using treatments and tests that weren’t effective.

One thing hasn’t changed. Just as many people are affected by back pain as ever. There seems to be no slowing down the number of people with this condition. And that means the amount of money spent on diagnosing and treating low back pain is on the increase, too.

Scientists specializing in back pain point out that researchers must find new ways to look at an old problem. It’s important to recognize that back pain is much more than just back pain. There are complex physical, mental, and social factors that lead to chronic low back pain in all age groups.

Injury isn’t the main factor in back problems. Neither is degeneration from aging. These are taking a back seat to the understanding that genetics has a more important role. Finding ways to prevent back pain remains an important research goal.

The research movement focused on back pain is moving forward. More progress has been made than it seems at first glance. Giving up old ideas takes time. This is especially true when there aren’t new ideas to replace them yet.

But scientists are predicting a breakthrough. Now that they are looking at belief systems, emotions, fears, and personal concerns of patients, there’s bound to be a new model of understanding soon.

In this update on lumbar disc disease, the authors start out with a detailed review of the normal, healthy disc anatomy. Four tissue layers are described and discussed. These include the outermost annulus, the inner annulus, the transitional zone, and the gel-like nucleus pulposus.

The intact disc provides support for the spine and acts as a shock absorber. The discs also transmit and transfer force and load on the spine. In contrast, the degeneration of the disc occurs slowly over time. This reduces the effectiveness of the discs to accomplish these tasks.

The nucleus starts to lose fluid and dry up. A damaged disc cannot spread the load evenly. The result is even more strain on the disc structures. Besides the breakdown that occurs naturally over time, there are other risk factors.

It turns out that smoking (once thought to be the number one risk factor in disc degeneration) is only a minor player. Likewise, heavy lifting isn’t a big risk factor. In fact, competitive weight lifters have fewer problems with disc degeneration than the general adult population.

Genetics (positive family history) is highly linked with early onset of herniated lumbar disc. Patients with disc herniation before age 21 are five times more likely to have a close family member with this same condition.

So, what really happens with disc degeneration? A key factor is nutrition and fluid loss. Over time, the disc loses the ability to exchange fluids properly. Thin fibers are replaced with thick ones. Cross-links form between layers of tissue. These links bind the disc layers together and prevent smooth, fluid movement.

Eventually, there is a loss of stiffness and fluid pressure. Bulging, herniation, and decreased disc height occur as a result. The endplate starts to give way. The endplate is a protective piece of fibrous cartilage between the disc and the vertebral bone. The endplate helps move nutrients into the disc and waste products out.

The authors present MRI pictures of various disc problems. Annular tears and displaced nuclear material lead to changes in the nearby soft tissue structures. Even a small change in the disc height can create change in the facet joints, foramen (opening for spinal nerve roots), and supporting ligamentous structures.

Not everyone has painful symptoms with disc degeneration. Figuring out which structures are causing the pain can be difficult. Knowing how to treat the problem is even more challenging. Lumbar stabilization exercises seem to work well when done properly.

Studies are ongoing to find the most effective treatment methods for degenerative disc disease. Some of the approaches under investigation include exercise, traction, and lumbar manipulation. Injection of growth factor or stem cells into the discs is being done on animal models at the present time.

Lumbar spinal stenosis is a common problem as we age. Narrowing of the spinal canal puts pressure on the spinal cord or spinal nerves. Back and leg pain that increases with activity such as walking can be very disabling. Spinal surgery is one treatment option for this condition.

Many studies have concluded that spinal surgery in adults aged 65 and older is risky. It should not be approached lightly. But what are the risks? And who should avoid spinal surgery?

In this study, data from the National Inpatient Sample (NIS) is used to answer these questions. Information from millions of patients from over 1,000 hospitals in 37 states is available in this database. From 1993 to 2002, almost half a million people had a lumbar laminectomy for spinal stenosis.

Analysis of the results for these patients showed the following:

Spinal fusion is known to cause degeneration of the adjacent vertebral segment (next to the fusion). Many studies have been done to understand and possibly prevent this from happening. This is the first study to look at the effect of lumbar fusion or lumbosacral fusion on the sacroiliac joint (SIJ).

The SIJ is formed by the sacrum and pelvic bones on each side of the sacrum. It is the lowest segment of the spine before the coccyx (tail bone). Force from the upper body is transferred down the spine to the SIJ. Small movement at the SIJ occurs and affects movement of the lumbrosacral spine (where the last lumbar vertebra attaches to the top of the sacrum).

All patients in this study had a posterolateral (from the back and side) fusion of the lumbar spine or lumbrosacral spine. Bone graft was harvested from the patient’s own iliac crest (top of the pelvic bone). The graft material was packed inside titanium-threaded cages and placed between the bone segments being fused.

Three groups of patients were compared. The control group was made up of healthy adults without spine problems. The fusion group was divided into two subgroups. The first subgroup had a fusion to L5. This was called the floating fusion group. The second fusion subgroup was the fixed fusion group. Their fusion was to S1.

CT scans were used to measure degeneration at the SIJ following fusion. Imaging was done before surgery, two weeks after surgery, then again, one year and five years after surgery. SIJ degeneration was seen on CT as areas of erosion, sclerosis (hardening of the soft tissues), or bone spur formation. Any sign of bone fragments, joint space narrowing, or cysts was also defined as SIJ degeneration.

As might be expected, SIJ was much more common in the fusion group (both subgroups) compared to the control group. The group with a fixed fusion had the greatest amount of SIJ (on both sides). The amount of SIJ degeneration did not appear to be linked to the number of fused segments. The area of fusion seemed to have more of a cause-effect (more SIJ degeneration with S1 fusion than with L5 fusion).

The authors suggest the force delivered to the pelvis is higher with a sacral fusion thus causing a greater effect on the SIJ. The authors also report that removing bone from the iliac crest seems to have a negative effect on the SIJ. SIJ degeneration is more likely after graft harvest. The reason for this is unknown since no damage is done to the SIJ during the graft removal.

Chronic low back pain (CLBP) is a common problem in the developed world. Because of the wide variety of patients affected, the methods of injury, and the injuries themselves, it has so far not been possible to develop a one-size fits all approach to managing CLBP nor providing accurate prognosis. The authors of this article sought to determine if there could be a multidisciplinary outcome in CLBP that could be predicted with a model.

The researchers recruited patients who had experienced CLBP for longer than three months and had not had spinal surgery within three months. The 163 patients were randomized to the control group or the intervention group; measurements were obtained at the start of the study (T0), in the week after treatment (T1), and then again four months after treatment (T5). The control group was called the “waiting list” group and their T1 assessment was done eight weeks after T0, T5 was done at 6 months after T0.

The patients in the treatment groups participated in the Roessingh Back Rehabilitation Program, RBRP, within two to three weeks of randomization. The program is based on the assumption that patients with CLBP develop a deconditioning syndrome: back pain causing limited activity, which leads to lowered physical capacity, which then leads back to overloading of the back. The treatment attempts to help the patients reduce this thinking and improve their physical conditioning and learn more about their back and its function.

The treatment also includes physiotherapy, sports, education, and occupational rehabilitation. The patients are required to be in the program a minimum of 90 percent of the time; groups consist of eight participants.

Data were obtained from both groups using the Visual Analog Scale (VAS), a scale of zero to 10, with zero being no pain and 10 being the most severe, work status (“yes” to full-time or part-time work, “no” to not working), the Multidementional Pain Inventory, MPI, to measure the psychosocial aspects of pain, sick leave as reported by the employee, financial compensation, depression, and fear of physical activity.

Twenty-one patients were lost during follow-up, but didn’t affect the final analysis. Patients who were in the control group were allowed to use their regular interventions during the non-treatment period. The researchers found that, at eight weeks and six months follow-up, the patients showed fewer physical limitations and a higher quality-of-life in both groups. This meant that there was no difference in the overall outcome, regardless of the group that subjects were in. The authors write, “Our hypothesis that less pain, the ability to work, and classification as DYS [dysfunctional] or ID [interpersonally distressed] predicted more improvement after rehabilitation treatment was not supported. However, the value of several predefined factors for improvement after rehabilitation treatment was partly confirmed.” This was shown by the higher quality-of-life outcomes in the control group at short-term follow up.

The authors concluded that their study did not support the idea that a clinical prediction model would aid in the prognosis of CLBP, but that the patients’ feelings and actions (fear avoidance, pain intensity, etc) may contribute to prognosis.

The authors present two unusual case reports of patients who had severe sciatica symptoms. Imaging studies demonstrated gas-filled cysts that had migrated into the nerve root of the cauda equina. These findings are quite rare. Both patients underwent surgical laminectomy. This allowed removal of the cyst with decompression of the involved nerve root. Repair of the dura mater which covers the spinal cord was necessary due to its disruption.
Both patients had resolution of their severe sciatica symptoms following surgery.

While most gas-filled cysts in the spine are felt to be from herniated discs, there was no disc material found in the tissue removed during surgery in the two cases reported. The authors felt that likely the disc material had degenerated.

The authors believe that computed tomography myelography is preferred over magnetic resonance imaging for diagnosis of the cyst. Discography is felt to be the only method able to confirm communication between the disc space and the cyst.

Narrowing of the spinal canal called stenosis is a common problem among older adults. Back and leg pain from this condition can be very disabling. Surgery to remove a piece of the vertebral bone may be helpful. This procedure is called a decompressive laminectomy. Removing this fragment of bone takes the pressure off the spinal cord.

Laminectomy for spinal stenosis is more likely to relieve the leg pain than the back pain. Up to one-third of all patients having a laminectomy for lumbar spinal stenosis continue to report low back pain after surgery.

In this study, researchers used X-ray findings to study patients with lumbar spinal stenosis. They looked for factors that might predict which patients will end up with residual low back pain. All patients had stenosis at one level causing painful symptoms. Laminectomy was performed on each patient.

After the operation, patients were divided into two groups based on pain response. The recovery group had improvement in test scores for pain and function. Symptoms in the nonrecovery group were unchanged. The difference between the two groups was compared using X-rays of the lumbar spine.

The authors found two important factors. These included having a flat back and the loss of lumbar mobility before surgery. Patients with both of these were most likely to have a poor result after a laminectomy for lumbar spinal stenosis. They had ongoing residual back pain that never went away.

Studies so far have suggested that avoiding LBP after surgery for lumbar spinal stenosis is difficult, if not impossible. The results of this study point to the idea that the key to success is in choosing the right patients for this type of surgery.

The angle of the lower lumbar spine and motion in the lumbar area are the most important factors. A natural curve in the low back called lumbar lordosis and normal lumbar motion seen on X-rays before surgery predict a more successful result.

These findings suggest that X-rays can be used to identify patients who might benefit the most from laminectomy for spinal stenosis. Factors such as age, gender, and duration of symptoms did not seem to make a difference in relieving pain.

The authors reviewed available literature to evaluate the timing and outcomes of surgery for Cauda Equina Syndrome, CES. Two stages of CES have been reported. These are incomplete cauda equina syndrome (CESI) and cauda equina syndrome with retention (CESR). Compromise of urinary function that can be permanent is usually what prompts surgical intervention. Most surgeons feel that surgical treatment for CES should be on an emergent basis, the sooner the better in order to avoid permanent damage. However, studies have not demonstrated this to be the case.

In addition to impaired urinary function, rectal and sexual function may also be affected. Most persons with cauda equina syndrome will also have sensory deficits in the saddle area. Pain in the low back and or legs can also occur.

The cause of CESR in the literature that was considered for review was herniated lumbar disc, with or without spinal stenosis. In the United States, it is hypothesized that 0.12 percent of herniated discs result in CES.

The authors reviewed available literature involving the timing of surgery for CESR. Patients’ perceived urinary function following surgery was the outcome that was evaluated. Function was categorized as normal, fair, and poor. While the analysis of the available literature was difficult, the authors state that the findings of their study support early surgical intervention for CES in order to achieve the most desirable outcomes.

Chronic low back pain (CLBP) is very common in the developed countries and the majority of cases, 95 percent, are nonspecific in nature, despite the obvious pain.

Pain provocation tests can be reliable in determining the cause of some types of back pain. The authors of this study wanted to determine the reliability and discriminative ability of referred pain provocation in patients with non-specific lower back pain.

The procedure measured the pressure pain threshold (PPT) for the referred pain provocation test and researchers compared the results of standard pressure procedures with their new cross friction algometry procedure. An algometer measures pain that is caused by pressure.

The standard procedure involves asking the patient to point, with one finger, where the most intense pain is. At this point, the examiner palpates the area with one finger to find where it is most tender. When this pain is confirmed, with the question “is this the pain you are complaining of?”, this is considered local pain. However, if applying pressure at the spot produces pain in another area, this is called referred pain.

The new procedure, according to the authors, seemed to be more valid and reliable than the standard procedure. The steps were to ask the patient to point with one finger where the most intense pain is. This area is then pressed by the investigator by one finger or an elbow until the maximum tenderness is located. Deep cross-friction is then applied with the elbow in the area of the tenderness, not just the trigger point that was just located. If this produces pain in a distant area, again, this is referred pain. The deep cross-friction is done until the RP threshold is reached.

Forty-two patients with nonspecific lower back pain participated in the study. Assessments of the pain were done with the McGill Questionnaire (MPQ), which included a pain chart and a visual analog scale (VAS), and the standard Oswestry Disability Questionnaire (ODQ) for lower back pain. Using the pain chart, the patients identified their painful zones: region 1 – central or on both sides of the lower back in the lumbosacral region, region 2 – LBP that radiates into the gluteal region or thigh, region 3 – LPB with radiation to the leg but not beyond the ankle.

Following completion of the tests, among the patients who were considered to have “moderate” LBP, 52 percent had no RP and 48 percent did have RP in the leg, as they had shown in their pain drawings. Using the MPQ, the researchers were not able to determine which patients had additional RP and, although the VAS and ODI did differ, the researchers weren’t able to find clinical importance to the finding.

The authors wrote that their study found that the new technique, cross-friction algometry with the aid of a Fischer algometer, could be a viable and reliable method to find referred pain in patients with nonspecific lower back pain, as well as pain in one leg.

Chronic low back pain is increasingly common in the developed world. It is estimated that one quarter of those with low back pain visit their doctor for help, but most do not continue after three months, although 60 to 80 percent still have pain, even after one year.

Researchers have investigated psychological influences of back pain, trying to see if any of these factors made a difference in pain and, if so, how:

• fear avoidance
• catastrophizing
• depression
• expectations
• belief about the future

The authors of this study investigated the perception of patients with nonspecific chronic low back pain to see if changes affected the outcome, and how illness perception affected clinical outcomes six months later.

Researchers reviewed completed questionnaires from 1591 patients at the beginning of the study and from 810 at six months. The mean age of the patients was 44 years.

Disability from low back pain was measured with the Roland and Morris Disability Questionnaire (RMDQ), which scores from zero (no disability) to 24 (total disability). Perception of back pain was measured by using the Illness Perception Questionnaire (IPQ).

The researchers found that at least three out of five participants had missed at least one day of work due to back pain; 63 percent reported back pain that was present for less than three months and 11 percent had back pain for more than three months.

There were noted differences among patients who thought they would have good clinical outcomes and those who did not. Those who had better clinical outcomes:

• perceived less serious consequences from the back pain
• reported fewer emotional responses, such as fear and anger
• reported fewer symptoms that were blamed on their back pain
• felt strongly that they had some control over what was happening

The authors conclude that these findings “have practical implications for the primary care management of patients with back pain and emphasize the need to elicit and address patients’ unhelpful perceptions of their back problems.”

In this study, workers with occupational back pain are asked to rate their satisfaction with care based on who provided that care. Health care providers included surgeons, medical doctors, osteopathic physicians, chiropractors, and physical therapists.

The workers involved in the study were all at least 18 years old. Each one had filed a workers’ compensation claim for occupational back pain. Satisfaction with care was assessed by survey. The same survey was filled out before care, one month later, six months later, and after one year.

The researchers were interested in finding out if health-care satisfaction differed based on provider type (who provided the care). They also looked at the effect of patient satisfaction on workers’ rates of return-to-work.

Overall satisfaction was based on answers to questions about the provider’s bedside manner and effectiveness of care. Bedside manner was described as consisting of listening, being courteous, offering good explanations, and taking the patient’s pain seriously. Effectiveness of care referred to getting a good diagnosis and thorough treatment that improved patient pain and function.

Analysis of the data showed that workers tend to be more satisfied with active treatment. This refers to interventions offered by chiropractors, physical therapists, and surgeons. Patients receiving passive care by physicians were less likely to be satisfied with the results.

Previous studies have shown that satisfaction with back care also depends on workers’ socioeconomic status, work environment, and severity of injury. This study now adds type of provider as another important factor. Patients return to work more often when satisfied with provider care.

The results also showed that effectiveness of care was more important than bedside manner. The authors pointed out that bedside manner may be easier to evaluate for patients. It’s obvious when a health care provider is rude, not listening, or appears uninterested in a patient. It’s less clear what makes for optimal care.