News Category: Lumbar Spine

Typically, pain that radiates into an extremity is divided into radicular and pseuodradicular syndromes. Treatment presently differs, depending on the classification of pain as radicular or pseudoradicular. The pain is distinguished as nociceptive versus neuropathic. While radicular pain has traditionally been attributed to nerve root compression and is considered neuropathic, pseudoradicular pain has been attributed to non-nerve related structures such as facet joints, and piriformis syndrome and is considered nociceptive.

The authors of this study propose that current sensory testing is not adequate to appropriately distinguish between the two syndromes. Subclinical sensory loss in pseudoradiculopathy could mean that appropriate treatment is not being considered. The authors feel that Quantitative Sensory Testing, QST, is a reliable test of large and small fiber sensory nerve function in the two syndromes. They feel that it is comparable to nerve conduction studies.

Thirty patients with chronic low back pain radiating into parts of one leg were evaluated. Four independent experienced clinicians classified their pain as radicular or pseudoradicular. The clinicians agreed on the classification of 27 of the 30 subjects. The 27 were then included in the study. They administered the QST which consists of seven tests measuring 13 different sensory parameters. Sensitivity of the QST was verified for radiculopathy as well as pseudoradiculopathy.

The authors were able to demonstrate that subclincial sensory deficits in the pseudoradicular low back pain group were present using QST. In fact, profound sensory loss was detected in both the radicular and pseudoradicular pain groups. Vibration detection seemed to be the most sensitive of the parameters tested. Vibration sense was abnormal in 73 percent of the radicular subjects, and 47 percent of the pseudoradicular subjects. As a result of the study, the authors question whether there is a clear distinction between radicular and pseudoradicular syndromes. If this is the case, pseudoradicular low back pain might also require treatments to address neuropathic pain.

Low back pain that goes down the leg is often divided into two groups: radicular and pseudoradicular. Radicular suggests that pressure on the nerve root causes neuropathic pain. This type of pain travels along the nerve pathway down past the knee.

Pseudoradicular means like radicular pain but it’s not the same. The pain goes down the leg to the knee, but doesn’t go past the knee. The source of the pain isn’t pressure on the nerve. Instead, there is a mechanical cause. This could be from degenerative or inflammatory joint changes.

Treatment of the problem is based on an accurate diagnosis of the source of the pain. Special tests are performed to place patients in one of two groups. But there’s been some question about the real differences between these two groups.

In this study, a special battery of tests called Quantitative Sensory Testing (QST) is used. QST measures sensory stimuli including cold, warm, pinprick, pressure, touch, and vibration. Patients in three groups were tested. Results were compared between patients with radicular vs. pseudoradicular pain. The third group was a control group of healthy subjects without back or leg pain.

Most of the patients in the radicular group had sensory deficits as measured by the QST. They also had a loss of motor function in the foot. This symptom corresponds with the sensory changes observed. These findings confirm the pain is neuropathic in origin.

Some sensory deficits were also detected in the pseudoradicular group. These were milder or subclinical, meaning patients with pseudoradicular pain weren’t aware of any loss of sensation. The authors suggest this points to possible nerve fiber damage that hasn’t been unrecognized in pseudoradicular low back pain.

The results of this study show the need to treat both neuropathic and mechanical low back pain in some patients. The term mixed pain may be applied to this group.

The authors discuss the specific nerve fibers affected by radicular versus pseudoradicular pain (e.g., myelinated, unmyelinated, large, small, C-fibers). They suggest pseudoradiculopathy and radiculopathy are two types of the same problem. Each is on a continuum rather than two separate conditions. It’s important to make the distinction because treatment must address each problem differently.

When a new method of testing patients is developed, it’s not adopted for use everywhere until it’s been tested and retested. In this study, a group of British (UK) researchers used a U.S. method of predicting chronic low back pain in a group of British adults.

Adults with low back pain between the ages of 30 and 59 were included. Pain severity and duration and depression were measured in the same way as in the American study. The British researchers used the same methods and cut off values to predict chronic back pain as in the American study.

Both the US and the UK studies used the Chronic Pain Grade as a tool to measure outcomes at the one-year follow-up. Results were similar between the two groups. About half of the UK subjects and slightly more than half of the US adults had chronic back pain at the end of one-year.

The main difference was that twice as many people in the UK group at low-risk had chronic pain after one year. The reason for this is unclear. It may be due to differences in the way patients are referred to their physicians between the two countries.

It may be related to when (how soon after the back pain started) the data was collected. In the US group, the patients were tested three to six weeks after they first saw their doctors. The UK group was tested one to three weeks after consultation. It may be that the proposed way to predict chronic pain is more accurate if testing is done when patients return to their doctors for more care after the first visit.

The results of this study show that testing methods used in the US healthcare system to predict chronic low back pain can be used in other healthcare systems and with other groups of people. Further study is needed to test other age groups (e.g., over age 60 years) and other population groups.

Predicting pain just on the basis of duration (how long it lasts) may not be a sensitive enough way to test patients. Duration of pain, level of pain intensity, and disability caused by pain may be more prognostic of future chronic low back pain.

There’s always a concern after spinal fusion about the segment next to the fusion. Will it hold up? Or will there be increased load at that level causing breakdown? Studies have shown changes observed on X-rays after fusion. Disc degeneration, arthritis of the facet (spinal) joints, and instability can be seen.

But do X-ray changes correlate with clinical outcomes? In other words, do patients with adjacent segment degeneration (ASD) have decreased function as a result of the changes? That’s the focus of this study from Korea.

Three groups of patients were evaluated by X-rays before fusion, after, and later at the end of two years. Group one had a fusion at one level. Group two had a fusion at two levels. And group three had more than three segments fused.

All fusions were done with the same posterolateral approach. This means the incision was done from the back and side of the spine. Screws and autogenousbone graft (bone harvested from the patient) were used to do the fusion. Outcome measures included pain, need for pain relievers or other drugs, activity level, and work status.

The results showed ASD in all three groups. The number of patients affected increased as the number of segments fused increased. Pain increased and function declined in all three groups. But the greatest change occurred in the group with the most levels fused. They had the worst clinical outcomes.

The authors confirm the belief that ASD does occur after spinal fusion. The worst cases occur in patients with multiple segment fusion. And function does decline when these changes are severe.

Surgeons must consider whether or not to include a spinal segment in the fusion when there are already degenerative changes present. Fusing more levels is not always the best answer. Clinical outcomes are directly linked to degenerative changes after fusion. This conclusion points to the need for better fusion methods or choosing disc replacement over fusion as the treatment choice.

Chronic lower back pain caused by radiculopathy (inflammation and irritation of a nerve root) is sometimes treated with a series of epidural steroid injections. The injection is meant to relieve the pain and symptoms caused by the nerve irritation. The usual schedule is one injection followed by more injections – one every two weeks – usually up to three injections total, if there are no improvements or only partial improvement.

The decision whether to use the series of injections has been found, by research, to depend on the treating physician’s personal preferences and experience, anecdotal (stories from patients and physicians) evidence of its success, and/or findings in the literature. However, according to the literature, there is no indication either way as to whether the series of injections is helpful or not, with a minimum or maximum of injections total for one patient or treatment.

The authors of this literature review sought to determine if there was evidence for the frequency and timing of such injections for patients with radiculopathy and if there is evidence to help determine what a partial response is. Finally, the authors wanted to draw up an outline for the type of research needed to clarify this issue.

While searching through the literature, the criteria for studies were that the injections be more than one per patient for radiculopathy and/or any evidence that helped establish a protocol for the injections, as well as studies that did only use one injection but had protocols that could have called for further injections if needed.

The researchers found 11 randomized controlled trials, one prospective controlled trial, and two prospective cohort studies, as well as one qualitative survey an five review articles that fit their requirements for this review. Some recommendations from the studies were:

1- “A 2nd injection be given a few days to a week after the first if there was evidence of negative or partial response. A third injection was rarely helpful. This was based on previous experience.”
2- “Long-term follow-up (average, 20 months) failed to show the efficacy of a second injection administered to patients whose pain did not respond within 24 hours to either injection.”
3- “Repeated injections could produce a more sustained effect.”
4- “There is no consensus on frequency and interval of injections.”
5- “Fewer injections were required than usually required with blind injections.”
6- “The protocol most closely mirrored local practice. There was no advantage to performing more than one injection.”
7- “Corticosteroids did not provide any additional benefit. Multiple injections may produce a more sustained effect.”

After reviewing the protocols and the study findings, the authors concluded that a second injection was commonly recommended before the introduction of fluoroscopic guidance to allow for more accurate injecting techniques. It has not been determined why the second injection was recommended. It was thought, in some instances, repeat injections could be needed if the first one missed the mark, particularly before the guided injections were available. One researcher said that the repeat injections had greater success, but a subsequent study found otherwise.

The authors of this study point out that their own study was limited in a few ways. They used a particular grading system to choose the articles to include in the review and this grading system may have affected the findings they drew from the studies. As well, the cause of the patients’ radiculopathy wasn’t always understood or known. They conclude that the evidence for repeat injections is limited so it is not possible to suggest guidelines for the number of epidural steroid injections for radicular low back pain. They also suggest that a randomized controlled trial with patients who have a confirmed single diagnosis, with set symptom duration, and who received guided injections, would be the most appropriate type of trial.

Degenerative lumbar spinal stenosis (DLSS), a condition in which the spinal canal narrows and puts pressure on the nerves and the spinal cord, is thought to affect 13 percent to 14 percent of people who seek medical help for lower back pain. Doctors don’t know much about the true incidence nor the natural cause and prognosis of DLSS.

The authors of this literature review wanted to find an evidence-based tool to help physicians improve the quality and efficiency of care for patients with DLSS.

The Spinal Stenosis Work Group of the North American Spine Society (NASS) Clinical Guidelines Committee developed an evidence-based clinical guideline on DLSS. Here are the results:

• Degenerative lumbar spinal stenosis is a clinical syndrome that is comes across with buttock or leg pain, with or without back pain. There is diminished space for the nerves in the lumbar spine. Symptomatic lumbar spine stenosis has provocative (which means it can be brought on purposely) and palliative (which means it can be eased) features, which include exercise or positionally induced neurogenic claudication, pain in the back and legs (provocative), and relief from symptoms by bending forward, sitting, or lying down (palliative).
• Patients with mild to moderate DLSS rarely have neurological (nerve) decline.
• When an older patient presents with an abnormal gait (walk) and a history of severe pain in one or both legs, which is relieved when at rest, DLSS should be considered, particularly if the Romberg test, a test to check balance, is abnormal, and if pain in the thigh is worsened when the leg is extended.
• Magnetic resonance imaging (MRI) is the most appropriate non-invasive test for diagnosing DLSS.
• If patients cannot have an MRI or if MRI findings are not conclusive, a computed tomography myelography (CT myelography), a scan using contrast dye, may be helpful.
• If patients cannot have an MRI nor a CT myelography, a CT scan would be recommended.
• In order to determine the outcome after treatment, the Oswestry Disability Index (ODI) and the Zurich Claudication Questionnaire can be used. Other appropriate tests include the Maine-Seattle Back Questionnaire, Oxford Claudication Score, Shuttle Walking Test, and the Exercise Treadmill Test.
• Regarding treatment, there isn’t much evidence that medications are helpful in this instance, including intranasal or intramuscular calcitonin, methylcobalamin, or intravenous lipoprostaglandin E(1). Intranasal calcitonin may provide some short-term relief, but the data suggest that this is not very well backed up.
• While there isn’t any good evidence in the literature that physical exercise and/or exercise (stand alone treatment) are useful as treatment for DLSS, physiotherapy may be helpful for patients who have symptoms of neurogenic claudication.
• The literature suggests that using contrast-enhanced fluoroscopy to guide spinal injections helps to improve the accuracy of the treatment.
• Use of interlaminar epidural steroid injections, without guidance, as well as radiographically guided transforaminal epidural steroid injections, have been found to provide short-term relief (two to three weeks) in patients who have neurogenic claudication. As well, multiple guided injections may work long-term in some patients.
• A corset worn to protect and support the lumbosacral spine (the lower part of the back) can help relieve pain on walking but research doesn’t show any evidence that the effect remains when the corset is taken off.
• Traction, electrical stimulation, and transcutaneous electrical stimulation are treatments that may be tried, but there is insufficient evidence in the literature that they are useful.
• Many patients with mild-to-moderate DLSS end up needing surgery. If the patients have received treatment for between two to 10 years, about 20 percent to 40 percent end up needing surgery. However, if they have not been receiving treatment, 50 percent to 70 percent will need surgery.
• If the patients have severe DLSS, surgery is effective about 80 percent of the time. It is effective about 70 percent of the time if the patient has mild-to-moderate DLSS.
• If the patients have surgical decompression (surgery for the DLSS) alone and not other interventions, if they have severe symptoms, surgery is effective about 80 percent of the time. However, if they only had medical intervention, the rate is about 33 percent.
• Some patients have a lumbar fusion, whereby the bones are fused together. The literature shows that decompression with fusion is better than decompression alone.
• Up to now, the long-term results for surgery is promising at good or excellent results for 50 percent to 79 percent of the patients.

Scientists have discovered many changes in the back muscles in people with low back pain (LBP). They have reported decreased strength ratios between flexor and extensor muscles. Reaction times, endurance, and coordination are reduced.

The amount and speed of postural sway (trunk movement away from and back to the midline) are increased. Even the number of muscle fibers and the way the muscle fibers work together during muscle contraction are less.

Given these changes, it makes sense that exercise can be used to improve structural, neural, hormonal, and metabolic changes in the muscular systems. With the right kind of exercise, it’s possible to improve strength and structure with the goal of decreasing pain and increasing function. But it’s not clear yet what type and how much exercise works best.

In this study, the effect of isometric exercises of the arms is measured on back and abdominal muscle strength. The researchers asked the question, Are upper-extremity exercises able to load the core stabilizing muscles enough to build strength?

Fourteen healthy adult women were tested in a biomechanics lab in Finland. Surface electromyography (EMG) electrodes were used to test the strength and load of back and abdominal muscles during five test exercises.

A special standing frame was used to measure muscle performance. The series of exercises used for the arms was described in detail with photos included. Positions and exercises that produced the greatest activation of trunk and abdominal muscles were reported.

Shoulder extension using both arms at the same time brought about the greatest EMG changes in the abdominal muscles. Pulling the arm back (like pulling an arrow and the string back on a bow) fired up the deep back muscles on the opposite side. This motion is called horizontal shoulder extension.

The authors concluded that these two exercise motions can be used to build strength and endurance in trunk muscles. Exercise programs of the arms do produce enough load to be included in a rehab program for patients with low back pain. It is necessary to support the pelvis during the activity in order to prevent torque (twist force) on the low back area.

The authors of the study reviewed available studies to determine the efficacy of spinal injections in the management of chronic low back pain (CLBP). Spinal injections are also used in the diagnosis of CLBP. While conventional medicine suggests that 75-90 percent of low back pain is non-specific, studies using flouroscopic guided diagnostic procedures may better identify various sources of low back pain. The results of the studies suggest that 67-75 percent of low back pain cases can be accurately diagnosed. In fact, among the studies, 30-50 percent of low back pain was determined to be caused by internal disc disruption, 13-19 percent the result of sacroiliac joint dysfunction, and 15-17 percent due to facet joint pain.

The three spinal injections evaluated for efficacy in the management of CLBP were caudal epidural steroid injection (CESI); interlaminar epidural steroid injection (ILESI); and transforaminal epidural steroid injection (TFESI). The medications typically administered are a corticosteroid and local anesthetic which provide potent anti-inflammatory properties as well as neural stabilizing effects.

When evaluating available studies, the authors felt that critical features to be assessed were the route of injection, number of injections, clinical presentation, diagnostic evaluation, length of follow-up, and outcome measures.

The authors of the study concluded that there is evidence to suggest that non-target specific ESIs are effective for short-term improvement in nonspecific CLBP. There is not enough data to suggest that there are Long-term benefits of spinal injections in the management of CLBP. The authors note that there is a lack of randomized controlled studies with the above criteria to evaluate efficacy of specific spinal injections in the management of CLBP. The authors do suggest however, that TFESIs are likely most appropriate in targeting discogenic pain when confirmed that the disc is the source of the CLBP.

The authors reviewed available random controlled trials and controlled clinical trials evaluating the efficacy of physical therapy modalities in the treatment of chronic low back pain (CLBP). These modalities included three electrotherapeutic modalities to include transcutaneous electrical nerve stimulation (TENS); electrical muscle stimulation (EMS); and interferential current (IFC). Physical agents that were evaluated included ultrasound, hot packs, and cold packs.

The search indentified 36 potential articles on electrotherapeutic modalities and physical agents for the treatment of CLBP. All but six were excluded in the analysis. These six studies evaluated the efficacy of TENS for CLBP. Overall, it was found that high and low frequency TENS appears to have an immediate impact on pain intensity. Results favored high-frequency TENS. No short-term or long-term pain benefits or impact on perceived disability were found.

There were no eligible studies to evaluate the efficacy of IFC, EMS, ultrasound, hot and cold packs in the treatment of CLBP.

Management of chronic low back pain (CLBP) has proven to be very challenging. The authors sought to evaluate the most commonly prescribed medications and their efficacy in CLBP.

The authors of the study reviewed existing literature on the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs); muscle relaxants, and simple nonopioid analgesics in the treatment of CLBP. The NSAIDs included nonselective products such as ibuprofen and naproxen. The newer products are considered selective NSAIDS and include COX-2 inhibitors such as etoricoxib, celecoxib, and refocoxib. Antispasmodic agents included two main categories, benzodiazepines and nonbenzodiazepines. Simple analgesics included acetaminophen and tramadol, capsaicin and lidoderm patches.

NSAIDs are indicated for muscle aches and pains, backaches, and arthritis. Muscle relaxants to include cyclobenzaprine, metaxolone, methocarbamol, and carisoprodol are indicated for acute painful musculoskeletal conditions. Baclofen and tizanidine are indicated for upper motor neuron induced spasticity. Benzodiazepines such as diazepam are indicated for muscle spasticity, local painful musculoskeletal spasm, and anxiety.

Among the simple nonopioid medications reviewed were acetamenophen, tramadol, capsaicin plaster, and lidoderm patches. Acetamenophen is indicated for mild muscular aches, backaches, and arthritis. It should be avoided in patients with liver disease or who consume more than three alcoholic beverages a day. Tramadol is indicated for moderate to moderately severe chronic pain and acts on opioid receptors as well as serotonin and norepinephrine reuptake. It can increase risk of seizure and suicide risk however.

After reviewing available literature, it appears that NSAIDS are effective in short-term relief of CLBP. Given possible adverse side effects of nonselective and selective NSAIDs, their costs, and costs associated with side effects such as gastrointestinal complications, myocardial infarction, worsening congestive heart failure and renal disease, it is suggested that a nonselective NSAID is more cost effective for low risk patients. For patients who are high risk, a nonselective NSAID plus a proton pump inhibitor seemed to be the most cost effective.

Studies did not provide evidence that muscle relaxants were beneficial for long-term use in CLBP.

Tramadol 200mg to 400mg daily or in combination with acetaminophen was shown to improve CLBP and disability. Review of studies using capsaicin showed moderate to poor efficacy. There were no randomized controlled trials available to evaluate the efficacy of lidoderm patches in CLBP.

The incidence of low back pain is common, with most cases being self-limited, with no persistent or serious sequelae. There is only a small percentage of cases that result in disabling non-specific chronic low back pain, CLBP. The cause of CLBP is poorly understood.
The authors found that there are no clearly defined clinical practice guidelines for surgical intervention in chronic low back pain, in the absence of serious structural disease such as instability, infection, or neoplasm. Structural findings of disc degeneration, annular disruption, and end plate changes are commonly seen in patients with CLBP but are also common in cross-sectional studies of asymptomatic populations.

There are generally two schools of thought on the clinical approach to non-specific CLBP. One is the pain generator approach and the other is the psychosocial/economic approach. Since there is the absence of serious spinal disease in non-specific CLBP, any decision regarding the appropriate use of surgery for CLBP must also consider the psychosocial and economic context of the patient. Studies show that disabling CLBP develops more frequently in patients who have a high level of fear avoidance, psychological distress, disputed compensation claims, involvement in tort-compensation system, or job dissastisfaction.

The authors reviewed available studies involving the three general categories of procedures currently used for the surgical treatment of CLBP in the absence of significant spinal pathology. These included fusion, disc arthroplasty, and dynamic stabilization.

Four randomized controlled trials, RCTs, involving lumbar fusion for degenerative disc disease were reviewed. In one study, fusion had favorable results for only 16 percent of participants compared to six percent in the nonoperative group that received usual care. In the other three studies, there were only small differences noted between the fusion and nonoperative groups. The nonsurgical groups had fewer complications and had better coping strategies, the fusion group in one of the studies had a modest improvement in the Oswestry Disability Index.

While clinical trial studies of disc arthroplasty or replacement showed better outcomes than fusion, long-term studies are not available.

Dynamic stabilization can involve the use of devices such as dynamic or static interspinous spacers, pedicle screw-based or pedicle rod-based posterior dynamic stabilizing systems, and total facet replacement systems. The authors conluded that there is not sufficient clinical evidence available to evaluate the efficacy of dynamic stabilization in the management of CLBP.

The authors concluded that there is currently insufficient evidence to draw any firm conclusions that surgical options for the treatment of CLBP are effective.

The authors reviewed available literature on the efficacy of trigger point injections in the management of chronic low back pain (CLBP). Trigger points are defined as firm, hyperirritable loci of muscle tissue located within a taut band, in which external pressure causes a local twitch response and jump sign which in turn provokes referred pain to distant structures. Trigger points may be considered active meaning that they cause spontaneous pain; or latent, meaning they cause pain only when compressed.

Trigger points have been injected with local anesthetic, saline, sterile water, steroids, nonsteroidal anti-inflammatory drugs, botulinum toxin, 5-HT3 receptor antagonists. Another technique is dry needling where no medication is used.

The authors found that there are no randomized controlled studies that evaluate the efficacy of trigger point injections or dry needling in patients with chronic low back pain. They note that recent European guidelines and other prominent guidelines for the treatment of CLBP do not support the use of trigger point therapy. In spite of a lack of evidence, the authors of the review support trigger point injection or dry needling in the myofascial pain patient that is resistant to other conservative non-invasive therapies. Studies do not support the use of injected corticosteriods. They also feel that the high costs of botulinum toxin do not support its use, with the possible exception of a highly resistant case of CLBP.

Adults with scoliosis often complain of low back pain (LBP). But so do adults who don’t have scoliosis. Not much is known about LBP associated with scoliosis in the adult population. This study compared frequency, intensity, and duration of LBP in this group compared to a control group. The control group were matched for age and sex. They all had LBP but the did not have scoliosis.

Everyone was examined by one physician and had X-rays taken. For the patients with scoliosis, the degree of curvature was measured. For most of the patients in both groups, the pain started around age 50. For some patients, the pain was constant (present every day). Others reported the pain comes and goes.

Severity (frequency and duration) was the same between the groups. The scoliosis group had less frequent episodes. The pain came on slowly and without apparent cause. There were no acute bouts of extreme pain for them.

The scoliosis group was more likely to have groin and leg pain. This was linked to rotation and dislocation of the vertebrae from the scoliosis. Intensity of pain was linked with the severity of the curve for the scoliosis group.

From the results of this study, the authors made several suggestions. First, scoliosis in childhood should be treated appropriately (bracing or surgery when needed) and in a timely fashion. Second, more intensive preventive rehab should be directed at adults with scoliosis. Third, surgery to stabilize rotary dislocation should be considered.

Future studies are needed to assess the psychosocial and behavioral factors in adults with scoliosis who have LBP. Regular follow-up for prevention and treatment may be needed for adults with scoliosis to prevent episodes of back pain. X-ray screening to identify rotational dislocations may be a good idea.

If you’ve got a herniated disc, should you have it removed? Does the location and type of herniation make a difference in how your back feels? These are the two questions studied and discussed in this article.

Patients involved in this study were 18 years old or older and had a disc herniation. Symptoms included low back pain (LBP) and sciatica (pain down the leg). Some patients had other neurologic signs and symptoms such as a positive nerve root tension sign, numbness, or weakness.

Herniations were confirmed by imaging study. They included discs that were protruding, extruding, or sequestered. Protrusion describes a situation where the inner disc material has pushed into (but not past) the outer covering. The amount of disc material is equal across the base of the protrusion.

Extrusion refers to the central disc (nucleus) that has pushed through and past the outer covering. The base of the extrusion is narrower than the amount pushing out. Sometimes this is also called a disc prolapse. If the disc material gets pinched off and separated from the rest of the disc, it’s called sequestration.

The patients were divided into two groups. One group received conservative care including physical therapy, education and counseling, and non-steroidal anti-inflammatory drugs (NSAIDs). A home exercise program was part of the physical therapy. The second group had a discectomy (surgical removal of the disc).

Results were measured based on the presence of back and leg pain and pain ratings (frequency and severity) for both. Patients were followed for two years. During this study, some of the patients crossed over.

This means that some who were assigned to the conservative care group ended up having surgery. And some who were supposed to have surgery decided to have non-operative care instead. The researchers took this into consideration when analyzing the data.

The results showed that leg pain improved for patients in both treatment groups. This supports findings in other similar studies. Back pain was also better in both groups. But the patients who had a discectomy had better overall (back and leg) pain relief compared with the conservative care group. This was true for everyone no matter what kind of herniation was present. And the improvements were still present at the end of two years.

The findings of this study suggest discectomy is an effective treatment choice for disc herniations of all kinds. Patients benefited equally whether they had disc protrusion, extrusion, or sequestration.

Posterior spine surgery (from the back of the spine) is usually done with the patient in a certain position. This position is prone (face down) with the belly hanging free. The patient is in a face down kneeling position with the hips and knees bent.

This position helps keep pressure off the abdomen to reduce bleeding into the epidural space. The epidural space is inside the spinal canal but outside the spinal cord.

The problem with this position is that it places the low back in a position of flexion. The natural swayback curve called lordosis straightens out and curves in the opposite direction. There is some concern about the loss of lordosis that occurs when the hips are flexed. It’s important to avoid a flat back after lumbar fusion.

In this study, before and after lordosis measurements are taken via X-rays. Patients were compared using two different operating tables. The goal was to see if different positions during the procedure make a difference in the lumbar spine. All patients had a one- or two-level posterior lumbar interbody fusion (PLIF).

The patients were divided into two groups. Group one was placed on a special surgical table called the Wilson frame. Group two used the OSI Jackson spinal table. Hip flexion was about 30 degrees using the Wilson frame. The OSI Jackson spinal table positioned the hips in about 70 degrees of hip flexion.

The authors reported no difference in the amount of total lumbar lordosis between the groups. This was true for measurements taken before, during, or after the operation. There were some changes in the amount of segmental lordosis (just at the level of the fusion).

This study showed that the position of the hips is important but more to prevent bleeding than to maintain spinal position. The position of the vertebrae is affected more by the type of fusion cages used. Lordosis is maintained better when it is built into the angle of the cage. It’s important to keep the natural lordosis in the lumbar spine after fusion. It’s not possible to do so using a position of hip flexion.

Future studies may evaluate the effect of using hip extension just before the metal rods are inserted. This might help maintain the amount of lordotic position needed. Preventing blood loss is a higher priority than preserving lumbar lordosis. The hope is that both can be accomplished in the future.

In this study, MRIs were used to evaluate the results of two different surgical procedures for disc removal. The two operations included microdiscectomy and sequestrectomy. In a previous article by the same authors, the clinical results (changes in pain, function, and patient satisfaction) for these same two groups of patients were reported.

All patients included were between the ages of 18 and 60. They all had a single-level lumbar disc herniation. Both procedures were considered minimally invasive. This means they were done with a tiny incision, and the surgeon used a special operative microscope.

Microdiscectomy removes the entire disc. Sequestrectomy only removes loose pieces of the disc. These are fragments that have broken off. They are in the intervertebral space. The disc itself is not punctured or entered by any surgical instruments during a sequestrectomy.

Results after two years showed that functional outcomes were better after sequestrectomy. More patients with a microdiscectomy had further deterioration of the operative segment. MRI results confirmed the benefits of sequestrectomy over microdiscectomy.

Microdiscectomy caused greater post-operative disc degeneration. There was a loss of disc height and endplate changes with microdiscectomy. The endplate is a piece of fibrous cartilage between the disc and the vertebral bone. In fact, the rate of endplate degeneration doubled in the microdiscectomy group compared with the sequestrectomy group. These changes did not occur as a result of patient age or sex. The changes were not linked with the surgeon who did the surgery either. The size, location, and type of disc herniation weren’t factors determining endplate changes.

The major finding of this study was that changes in the endplate may be linked with poor results after microdiscectomy. Endplate degeneration (not disc protrusion) may be the real cause of failed-back surgery syndrome (FBSS).
FBSS refers to continued or worse back pain after surgical disc decompression via microdiscectomy or sequestrectomy. Since the disc isn’t penetrated by sequestrectomy, this procedure is less likely to cause endplate changes or FBSS.

There’s no cure for chronic low back pain (CLBP). There’s not even a best treatment known for certain conditions. Take for example, a herniated disc. Studies have not been able to show that one treatment is better than another for mild disc protrusion. In this article, overall research results are reported using minimally invasive nuclear decompression for disc protrusion.

Decompression refers to taking pressure off the spinal cord or spinal nerve from the protruding disc material. The specific decompression technique used was the disc nucleoplasty. Nucleoplasty is the removal of just the inner core of the disc, leaving the outer covering intact.

A radiofrequency device vaporized the disc material. High-voltage bipolar radiofrequency energy heats up and destroys the inner nuclear portion of the disc. This thermal ablation technique seems to cause the disc to implode inwardly.

The result is a lower nuclear pressure thus reducing tension on the nerve tissue. In fact, reducing volume inside the disc by even just a small amount causes a large drop in intradiscal pressure. The effect is immediate. The advantage of this method over a spinal fusion is the low cost and minimally invasive approach.

It’s not known yet how the decrease in nuclear pressure affects the outer portion of the disc. And it’s not clear how much of the nuclear tissue must be destroyed to have the desired effect. It’s possible that only a few, small channels need to be made into the disc center via thermal ablation. Studies so far support the idea that removing large amounts of disc material is linked with worse symptoms and delayed return to sports participation.

Studies report between 20 and 80 per cent effectiveness of nucleoplasty for disc herniation. Measures used to assess results included pain relief, patient satisfaction, and improvements in sitting and standing. This wide range of response may be due to the size of the study and the lack of complete follow-up data. None of the studies had a valid control (comparison) group.

The authors believe that surgical decompression is a good way to treat disc herniation. In the future, this technique will be improved. Minimal tissue will be destroyed. Restoring disc tissue to normal may even be possible. At the very least, disc height will be maintained. And if the disc collapses, it will do so slowly enough to allow the body to adjust.

For now, the nucleoplasty should be tried before the more invasive spinal fusion or removal of the entire disc. Nucleoplasty is not recommended for patients with back pain alone. The chances of pain relief are 50-50 (same as not having the surgery). The procedure is best done on patients with mild protrusions causing back and leg pain.

Intradiscal electrothermal therapy is a minimally invasive treatment for patients with disc-related pain. On the continuum of care, it falls someplace between a conservative (nonoperative) approach and the more invasive spinal surgery.

Doctors are finding that IDET is most successful when used with certain patients. Carefully screening patients before accepting them for this treatment yields the best results.

In this study, diagnostic tests were done first to confirm the disc as the source of pain. MRI, discography, and CT scans were used to make the diagnosis. Each patient had low back pain that did not respond well to at least six months of conservative care.

Heat was applied to the disc through an intradiscal catheter (thin tube inserted into the disc). Heat destroys collagen fibrils and cauterizes granular tissue that forms as a result of an inflammatory response. Nerve fibers are also destroyed but without destabilizing the spine.

Patients were tested before and after treatment. Measures included pain intensity, function, and health-related quality of life. Follow-up was at least one year. Most patients were retested at 12, 18, and 24 months after IDET.

Success was defined as a two-point (or more) improvement in pain (measured on a scale from zero to 10) and at least a 10-point improvement on the SF-36 test. The SF-36 test provides a measure of physical and mental health.

Results were reported as successful for 75 per cent of the patients. Improvement in sitting, standing, and walking was very noticeable. Quality of life in the areas of emotional and mental health was also greatly improved. There were no cases of infection, nerve damage, or other post-IDET complications.

The authors conclude that IDET provides a middle step between conservative care and surgery for many patients. Clear radiographic evidence of internal disc disruption is needed before using this treatment approach. IDET has the added benefit of preserving the disc and spinal motion. If unsuccessful, then surgery can be considered at a later date.

Many research studies have been focused on patients with chronic low back pain (CLBP). It’s clear that exercise is the first treatment choice. But what kind of exercise? And should it be used alone or after some other treatment?

In this study, changes in pain and disability are measured in patients with CLBP. Two groups are compared. The first group received Swiss ball exercises supervised by a physical therapist. The second group received advise about exercise.

All patients in both groups received manipulative or non-manipulative treatment first for four weeks. Then they continued their rehab program either with the supervised Swiss Ball exercises or the extra exercise advice.

The basic advice was to stay active and exercise. Pictures of exercises known to help with LBB were provided. Patients in the exercise advice group were told to do two sets of 10 repetitions of the exercises every day. They kept a journal and recorded how often and how many exercises were done.

The main measure used to compare the groups was self-report measures of LBP disability. Several patient surveys (e.g., McGill Pain Questionnaire, Oswestry Disability Index) were used to determine disability. Disability was also measured in terms of pain intensity and muscular strength and endurance. Electromyography (EMG) measured muscle fatigue.

The Swiss ball exercise group reported a faster reduction in disability in the first eight weeks of the program. Pain intensity also decreased more in the exercise group during the first eight weeks. Patients in the exercise group had a higher sense of well-being compared to the advice-only group.

Long-term results were not different between the two groups. But this may be related to the tools used to measure the results and not a true reflection of the changes observed in the patients. It’s likely that the Oswestry Disability Index can’t accurately measure long-term post-treatment effects.

The authors conclude that an exercise program for patients with CLBP can speed up their recovery and get them back to work or sports play faster. The reason for this appears to be an increase in their sense of well-being. The supervision was more important than the actual type of training.

Injection of hyaluronic acid (HA) into the knee has been successful in the treatment of knee osteoarthritis. This treatment is called viscosupplementation. It has also been tried in the shoulder, hand, hip, foot, and ankle. In this small (pilot) study, HA injection was used in 13 patients with lumbar facet joint arthritis.

A single injection was given into the affected joint(s) using fluoroscopy. Fluoroscopy is a form of X-ray that allows the surgeon to see inside the spine while inserting and advancing the needle for injection. With this tool, accurate placement of the injection is made possible.

The authors report there was no pain relief or improved function with HA injection of the lumbar spine. Viscosupplementation is an attractive alternative to steroid injections. Steroid injections have not been very successful. But these early results don’t support the use of HA injections over steroid injections.

It’s possible that viscosupplementation has a place in the treatment of patients with chronic low back pain. The challenge for researchers is to identify who those patients are. And it’s also possible that a single HA injection wasn’t enough to cause measurable change. Further studies are needed to identify the optimal dose and frequency for this treatment.