News Category: Lumbar Spine

Successful total disc replacements (TDRs) may depend on choosing the right patient for the procedure. In this study, age of patients is considered as a possible factor in patient selection. In general, there isn’t much known about the effect of age on outcomes for spinal surgery.

It makes sense that older adults with other health issues might have poorer results. This would be true for all types of spine surgeries when comparing older with younger patients. But research does not bear this out. In fact, some studies have shown younger patients have inferior results after spinal surgery.

Only patients with the Charité device were included in this study. The device was implanted at one level (L4-5 or L5-S1). There were two groups based on age. The first group was between the ages of 18 to 45. The second group were 46 to 60 years old. The groups were compared by measuring motion, pain, and function. Adverse events and patient satisfaction were also included as outcome measures.

There were no differences reported between the two groups in amount of blood loss or time it took to do the surgery. There wasn’t much difference before and after surgery in terms of motion. The younger group has slightly more increased motion. Pain and disability were improved in both groups. Patients in the older group tended to report greater satisfaction with the results.

Overall, it did not appear that age had any effect on clinical outcomes. Patients in both groups had similar results. These findings suggest that the probability of success with TDR does not depend on age. Although choosing patients carefully is required for a good result, age is not one of those requirements. This conclusion is based on short-term results. Further studies are needed to focus on the effect of age on adjacent-level disc degeneration over a longer period of time.

Patients who have an artificial disc replacement (ADR) are selected carefully. They must meet certain criteria to be included. Older age, osteoporosis, and previous spinal surgery may exclude them. In this study, the effect of a previous back surgery is reviewed.

All patients were part of the CHARITÉ Investigational Device Exemption (IDE) study. Two groups were included. One group received the CHARITÉ ADR. The other group had a back fusion with a BAK cage. There was a subgroup within each of those groups of patients who had a previous back surgery. The prior operations included discectomy, laminectomy, or facetectomy.

Comparisons were made between patients who had a previous back surgery and those who had not. Measurements were taken before and after surgery up to two years later. Return to work status was reviewed. Pain levels, function, reoperation rates, and adverse events were also compared.

There were no significant differences between the two groups using these measures of outcome. The authors concluded that patients with the three types of previous surgeries mentioned had the same benefit from a one-level ADR as patients who have an ADR as their first operation.

The authors confirm that careful patient selection is still the key to a successful outcome with ADR. Failures and other problems can be avoided by choosing patients who meet the standard criteria. Patients who have had a previous back surgery do not have to be excluded on the basis of that factor.

Low back pain (LBP) is an increasingly prevalent disorder in the developed world. The cost of LBP is growing but there are no consistent measures to qualify and quantify the actual cost resulting from LBP.

The total economic cost is made up of issues that affect the LBP and its treatment alone, not costs associated with any other illness or disorder. These costs include direct costs, which include actual payment for services or products. Many of the costs are obvious, such as paying for doctor visits, medical devices, and medications, but many other costs are not often considered. These types of cost include the cost of transportation to attend appointments, meals to be eaten while at appointments, and renovations to living accommodations, to name a few.

Indirect costs are commonly thought of as lost wages or lost productivity (cost to the employer), as well as productivity loss at home and the cost of hiring help in the home. The third are the intangible costs, which are the value of the decreased enjoyment of life, for example.

The authors of this article reviewed several studies done over the past few years and found 27 relevant studies examining the costs of LBP. The studies were from Australia, Belgium, the Isle of Jersey, Japan, Korea, the Netherlands, Sweden, the United Kingdom, and United States. The studies were done in varying fashions, with varying approaches, making direct comparisons difficult. Another aspect that cannot be ignored in comparing studies are the delays between data collection and study publication. The authors use the example that two studies published at the same time could be reporting data from either 2 years earlier or as many as 11 years earlier. This would affect the cost totals considerably.

Despite all the differences, the common thread was the important economic burden of LBP, regardless of geography. That being said, the case definition of LBP did vary between studies. As well, the type of help sought by patients with LBP affected direct costs. For example, in the US, patients were more likely to seek out the assistance of a chiropractor than were patients in the UK (31 percent compared with 2 percent). Also challenging was the separation of treatment and cost between LBP and other health issues that patients may have that were unrelated to LBP.

In conclusion, the authors write that regardless of the many differences in the studies, a common thread that would decrease costs related to LBP was an early return to work by the patients. This, however, may be easier said than done as this involves cooperation between the patient, employers, clinicians, and third party payers. Further studies are needed in the US in order to determine actual costs.

Chronic lower back pain (CBP) is increasingly common in the Western world. With the commonality of the back pain comes an abundance of pain relief options – so many that it can be confusing and difficult for patients to be properly informed of the options, making it virtually impossible to make informed decisions. The issue reaches beyond the patient to the treating physicians and the third-party payers as they all try to find the best and most economical way of treating their patients.

Unlike other areas in medicine, such as cardiology or neurology, treatment options for chronic LBP do not always have the extensive clinical research to back up claims of effectiveness.

The authors of this article have compared the myriad of available treatment and management options to a supermarket with all its offerings. The authors write that this is a good comparison, considering that it often seems as if they are shopping when attending commercial displays at spine meetings, along with their promotional material.

The market for LBP management treatments is large; it is estimated that 85 percent of people will experience LBP at some time in their life. The cost of LBP is high, both directly and indirectly. People with LBP often cannot work (indirect cost) and their treatments can be costly (direct cost). The authors refer to a review that states direct costs of LBP, in the US, are estimated to be at 12.2 billion to 90.6 billion dollars annually – about 45 to 335 dollars per person per year.

The treatments, as the authors explain, can be divided into 10 different supermarket aisles, with each aisle chock full of therapies. Aisle 1, for example, contains pharmacological treatments, including nonsteroidal anti-inflammatories (NSAIDs), muscle relaxants, and other types of medications to manage pain. Aisle 2 contains the manual treatments, such as manipulation and massage. Other aisles contain surgical options, lifestyle therapies, and even alternative or complementary treatments.

An important issue that comes to light is the difficulty in choosing between the different options. Seeing as there are over 200 different options, it is not a simple thing for a clinician to keep track of them all – keeping in mind that new treatments become available regularly. Not only must the physicians be aware of the different options, they must be aware of all aspects of the treatments, including the relative harms and benefits for each individual patient.

Often, when patients develop chronic LBP, they try to treat themselves first or they do research to see what treatments might be best for them. To do this, they have to choose which healthcare professional would best manage their care. According to the authors, this means deciding between many different groups of professionals: anesthesiologists, occupational medicine specialists, orthopedic surgeons, neurosurgeons, neurologists, pain management specialists, osteopathic physicians, physical medicine and rehabilitation specialists, internists, and family physicians (doctors); massage therapists, occupational therapists, pharmacists, physical therapists, psychologists and sport trainers (allied health); and acupuncturist, chiropractors, faith healers, homeopaths, napropaths, and naturopaths (alternative medicine practitioners). However, just knowing the available practitioners may not be any help if the patients don’t understand the educational and professional background behind each group. Usually, they must take the professionals’ word of experience at face value.

Now, taking all the different types of healthcare providers who may be able to treat chronic LBP and throw in that each one within the groups may – and do – have a different approach to treatment. The example in the article refers to how one surgeon may favor one surgical approach to another, while another surgeon may only use the other approach. Different analgesics in different combinations may be prescribed, alone or with manual treatments, or other types of specialties.

Looking at just the amount and combinations of treatments available is overwhelming, but then there is the aspect of what the authors call “branding.” Some practitioners feel that their way is the best and only way to treat chronic LBP and they may belittle or thwart any attempts of the patients who may want to seek alternate therapies. Instead of working with each other, the practitioners work against each other. This is best evidenced by how many doctors feel about chiropractics or some alternative medicines. This causes patients to be confused or maybe even deceitful in a way, because they may seek other types of help but not want to mention this to their primary caregivers.

Another concern is the commercialization of treatment for LBP. The authors use the example of patients who look for information on the Internet and are directed to commercially sponsored sites or discussion groups. This type of activity may keep patients away from sites that may offer more objective and effective interventions.

The authors conclude that articles reviewing treatment for chronic LBP should follow a specific format for professionals to be able to assess the treatment’s efficacy and viability. The articles “should clearly define and describe a particular intervention, explain the theory or scientific evidence regarding efficacy, discuss potential or known harms, and summarize this evidence for nonexperts.”

There are many treatments and therapies available to help manage chronic lower back pain (CLBP), with some working for some patients and not for others. One treatment that is gaining popularity is massage, likely one of the earliest and most primitive methods of treating pain.

The authors of this study reviewed the literature to find examples of trials done involving massage as a treatment for CLBP, compared with other treatment methods. The massage could be only on the lumbar area or the whole body. Some of the different techniques of massage performed are Cyriax, effleurage, petrissage, friction, kneading, or hacking. The common types of massage, either as a primary intervention or as an add-on treatment, are acupressure (Shiatsu), Rolfing, Swedish massage (SM), reflexology, myofascial release, and craniosacral therapy. The massages were performed by a licensed massage therapist, physical therapist, or chiropractor.

While it is not understood how massage may be beneficial, one theory is massaging the affected muscles may either induce biomechanical changes, thus influencing nerve activity or massaging could help release endorphins and serotonin, increasing the pain threshold.

Before massage therapy is initiated, a full patient history and physical examination should be performed to rule out any contraindications for massage. These contraindications include, but are not limited to, acute inflammation, skin infection, nonconsolidated fracture, burns, deep vein thrombosis, or active cancer tumors.

The authors reviewed the literature and found articles comparing massage with different treatment options. In a systematic review from 2002, it was concluded that massage therapy could be useful for patients with nonspecific subacute or chronic lower back pain, particularly if the massage was combined with exercise and education.

Among the randomized controlled trials reviewed, the study authors found the following:

– massage therapy was significantly better than sham therapy for pain and short-term function (1 high-quality study)
– acupressure massage was significantly better than standard physiotherapy (1 high-quality study and 1 low-quality study)
– massage was significantly better than exercise for short-term function (1 high-quality study); massage and exercise were similar in outcome in both short- and long-term follow-up
– massage and relaxation therapy provided the same amount of pain relief on the first day of treatment; the massage group experienced less pain immediately after first and last treatments (1 low-quality study)
– massage was significantly better than acupuncture in function, but no difference was noted in pain, numbness or tingling (1 high-quality study)
– massage showed better symptom relief and function compared with self-education, after 10 weeks, but the differences were gone by 52 weeks (1 high-quality study)
– acupressure stimulation followed by acupressure with aromatic lavender oil was more effective for short-term pain relief than was usual care (1 low-quality study)

In two high-quality studies comparing acupressure with classic (SM) massage, combined with exercise, the results showed that acupressure was more effective, providing more pain relief and improved function.

When comparing the experience of the massage therapists, the researchers found that experience did provide significant benefits to the patients.

Although some patients did complain of post-massage soreness or irritation, no serious adverse events were reported.

The authors of this study conclude that there “is strong evidence that massage is effective for non-specific CLBP…There is moderate evidence that acupressure may be better than SM, especially if combined with exercise.”

Spinal manipulation (SMT) to treat lower back pain (LBP) has been performed for generations, dating as far back as 2700 BC, it is thought. Since 1895, SMT has been primarily the domain of chiropractics, when it became a profession. With the increasing prevalence of lower back pain in the Western world, SMT and spinal mobilization (MOB) – similar to SMT but without the thrust – has become increasingly popular as a treatment.

Although there are different subtypes of SMT, the premise is the same, the most common is the application of a high-velocity, low-amplitude (HVLA) thrust to the spine with the practitioner’s hand to distract spinal zygapophyseal joints.

Before any type of SMT, the patients must be thoroughly assessed to rule out any reasons why SMT should not be performed. These contraindications include presence of a malignancy, infection, spondyloarthritis, or neurological conditions that would not be appropriate for SMT. Other red flags include fever, unrelenting night pain or pain at rest, pain with below knee numbness or weakness, leg weakness, loss of bowel or bladder control, progressive neurologic deficit, direct trauma, unexplained weight loss, and history of cancer.

After evaluation of the patient, the practitioner positions the patients, with torso, hips, arms, and legs according to the type of treatment to be performed. The practitioner’s treatment hand is placed over the super or inferior vertebra of the target spinal motion segment. A slow force is applied to preload the target spinal joints and then a HVLA thrust is administered. The procedure is considered to be a controlled medical act in many places, only to be performed by a licensed practitioner, such as doctors of chiropractic. Some doctors of osteopathy are qualified to perform the maneuver as well.

The authors of this article searched the literature for randomized controlled trials to assess the efficacy of SMT and MOB for management of chronic LBP. The authors noted that official guidelines for the management of LBP have been developed in several countries, however, they often become outdated quickly because of the number of on-going and new trials. In searching for study results of SMT, the authors found a systemic review that concluded SMT was not an effective intervention and it was not a recommended treatment. However, as the authors point out, the review was very limited because of “an incomplete quality assessment, lack of prespecified rules to evaluate the evidence, and several erroneous assumptions.” They also pointed out the bias in the system against chiropractors.

In looking at other studies, findings indicated the following:

– moderate evidence for its effectiveness in chronic LBP, as well as that of MOB. For patient-related pain, SMT with exercise appeared to be similar in effect to prescription nonsteroidal anti-inflammatory drugs (NSAIDs) with exercise. As well, SMT and MOB appeared to be superior to usual medical care and placebo for very short-term pain and similar to usual medical care and placebo in the short term.
– moderate to strong evidence for predominantly chronic LBP
– strong evidence that SMT is similar in effect to medical care plus exercise or exercise instruction
– moderate evidence that SMT is superior to usual medical care alone
– moderate evidence that SMT is similar to physical therapy, both short term and long term
– moderate evidence that SMT/MOB is superior to physical therapy and to home exercise in the long term.
– limited evidence that SMT is superior to hospital outpatient care for pain and disability
– limited evidence that SMT is superior to SMT/MOB over short term to physical therapy, home back exercise, traction/exercise/corset, no treatment, and placebo

At the time of writing the article, there were three full-scale randomized controlled trials in progress, one comparing trunk exercise to SMT, investigating the effectiveness of SMT in the elderly, and one evaluating pretreatment prediction rules for positive outcomes.

When assessing adverse events, SMT was associated with mild localized soreness or pain (temporary). In one study of 1058 patients who underwent 4712 session total, 53 percent reported local discomfort, 12 percent headache, 11 percent fatigue, 10 percent radiating discomfort, and 5 percent dizziness. Most adverse effects occurred within 4 hours of the procedure and were mild to moderate in severity. There have been rare severe adverse events reported with SMT, including lumbar disc herniation and cauda equina syndrome.

In conclusion, the authors stated that there is evidence for efficacy of SMT and MOB in the treatment of chronic LBP and that future trials should “examine well-defined subgroups of LBP patients according to validated and reliable diagnostic classification criteria, establish the optimal number of treatment visits, and evaluate the cost effectiveness of care using appropriate methodology.”

A common technique used to treat chronic lower back pain (CLBP) is intradiscal electrothermal therapy (IDET), also called intradiscal electrothermal annuloplasty. IDET is chosen for select patients in an attempt to avoid surgical interventions to treat CLBP.

Using heat to treat intervertebral discs is supported by the success of using heat in shoulder repairs, making shoulders more stable. Although the mechanism is not completely understood, theories of its function include alteration of biomechanical properties of the vertebral segment from the heat, decreasing stiffness; contraction of collagen leading to decrease in disc herniation size; sealing of annular tears; denervation; and decreased intradiscal pressure.

IDET is accomplished with a few different techniques. In general, a catheter is introduced into the annular fissure and heat is applied. Following treatment, patients are generally monitored for one to three hours and are warned that a slight increase in pain may occur, lasting from two to seven days. In some cases, this may be longer. Patients often wear braces and, although they are encouraged to do exercise, such as walking, they are not given physical therapy for at least one to two months. Maximal improvement seems to be by three months following procedure, but may take up to six months. Many patients are still experiencing some sort of relief as late as two years after the procedure.

The authors of this article searched the literature for studies and reviews of studies examining the efficacy of IDET in the treatment of CLBP. One meta-analysis of 17 studies involving IDET, with a follow up of six to 24 months following the procedure, there was a mean decrease in pain as measured by the Visual Analog Scale (VAS), which measures pain on a scale from zero to 10, with zero being no pain and 10 being the worst pain possible. In this meta-analysis, pain was reported to drop by 2.9 points. Using the Short Form 36 (SF-36) to measure function, the researchers found a decrease in pain of 18 (out of 100), as well as a mean decrease in the Oswestry Disability Index (ODI) of 7.0 (out of 100). The authors of this meta-analysis concluded that there was compelling evidence of IDET’s efficacy and safety in treating CLBP.

However, another meta-analysis, which has since come under criticism, looked at the same studies but came to a different conclusion. Although these authors found a mean improvement in the VAS of 3.4 and an ODI improvement of 5.2, plus the notation that only 13 percent to 23 percent of the patients went on to have surgery, the author concluded “the evidence for efficacy of IDET remains weak and has not passed the standard of scientific proof.”

Other reviews agreed with the first mentioned above. One found that measurements of 18 IDET studies had similar outcomes to patients in 33 studies of patients who underwent spinal fusion.

When looking at randomized, controlled trials, the authors found that carefully selected patients, those with SF-36 pain scores of 36 and disc protrusions that did not exceed 4 mm, did show a statistical difference in VAS (7.4) to the control group (4.9) There was no statistical difference in the SF-36, however, 33 percent of patients in the control group worsened, compared with only six percent in the IDET group.

Observational studies report a mixture of findings. In some studies, there was a decrease in VAS among IDET patients, while in others were more positive.

Complications to IDET are a possibility but are not frequent. One retrospective study of 1675 IDET procedures plus an analysis of data from 35,000 catheters, found only six nerve root injuries were reported, six cases of post-IDET disc herniation, 19 cases of catheter breakage, 8 cases of superficial burns at the entry point and one case of post-IDET bladder function. Infections and neural injury have been reported as well.

The authors conclude that IDET is a minimally invasive technique that provides a modest improvement but in a safe method than other invasive therapies.

The health benefits of regular activity and exercise have been clearly shown in many studies. Adults have been advised to exercise at least 30 minutes every day if possible. National and international guidelines are for 30 minutes of moderately or vigorously intense physical activity five to seven days each week. But patients with osteoarthritis (OA) have great difficulty following this guideline.

For those patients who have a total hip replacement (THR), activity after surgery remains important. Their level of independent living may depend on it. In this study, scientists at the Center for Human Movement Sciences in the Netherlands try to predict the amount of physical activity that patients engage in after a THR.

They used two well-known surveys to measure physical activity after THR. The first was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The second was the Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH). Patients with their first (primary) THR and those who had a second (revision) THR were included. The operation was done at least one year before the study began.

The WOMAC indirectly predicts level of activity because it measures pain, stiffness, and decreased physical function. The SQUASH measures the frequency (how often), intensity (effort), and duration (time per day) of regular physical activity.

The information gathered using these two tools can be compared to the recommended national and international guideline. Patients were asked questions about leisure-time and sports activities, travel, and household activities. Information on work and school activities was also reported. Results were summarized based on two categories: patients met the guidelines or patients did not meet the guidelines.

The authors report that the WOMAC score was not a good test to use when predicting physical activity after a THR. Only 60 per cent of the adults surveyed could be classified into one of the two categories correctly. These results may be explained by the fact that physical activity may not be linked just with physical ability or limitations. It may be that social, psychologic, or environmental factors play a part in the level of physical activity after THA.

Using the WOMAC along with the SQUASH may be a better measure of activity. In this way, it is possible to identify physical limitations in function and learn something about physical activity patterns. The SQUASH only takes a few minutes to complete. The survey is self-administered, which means the patient can fill out the survey without any help. Another survey that might work equally well (if not better than the SQUASH) along with the WOMAC is the International Physical Assessment Questionnaire (IPAQ).

More research is needed to find a reliable and valid measure of physical activity after THR that’s easy to complete. The results of this study did not support the use of the WOMAC for this purpose.

Getting back to work after a low back injury can be a challenge for some patients. Work-related injuries can lead to fear of re-injury. Workers may think they cannot perform their job again without pain. This is called fear avoidance behavior (FAB).

In fact, studies show that a worker’s beliefs about his or her ability to get back to work is the strongest predictor of who will still be off work a month after the first episode of low back pain (LBP). Patients can be tested for FAB using a special survey called the fear-avoidance belief questionnaire (FABQ).

Based on these findings, scientists think that patients at risk for chronic LBP may be able to avoid a chronic work-related disability. The idea is to identify people at risk of not being able to return to work. Then the next task is to find ways to treat these folks and prevent chronic disability.

In this study, patients with high levels of FAB were divided into two groups. Both groups received physical therapy two to three times each week. The PT program included treatment of pain and improvement of flexibility, strength, and coordination. The treatment was given to everyone in both groups by the same therapist. The patients were treated by the therapist until they could go back to work.

The first (education) group received education and counseling. They were given ways to manage their pain. They were also taught the value of physical activity and exercise. The second (comparison) group received an educational pamphlet that was also given to the first group. This brochure described common exercises used for back pain. Ways to improve posture and work strategies called ergonomics were also given to all patients in both groups.

The comparison group was not given advice on activity, exercise, or pain management strategies. If they asked any questions about these topics, the therapist gave a brief answer. The education group had ongoing discussions with the therapist about their pain and activity level. They read (and discussed with the therapist) a special booklet on back pain that wasn’t given to the comparison group.

How well these two groups did in their recovery was judged based on the number of days before they could return to work (RTW). RTW meant they could resume their former job tasks and duties. The authors report a big difference between the two groups. The education group RTW within 45 days of their injury. But after 45 days, one-third of the comparison group was still off work.

Analysis of the FABQ scores and number of days it took workers to RTW showed a significant link between these two factors. Therapists treating patients with work-related LBP can use the FABQ to identify FABs. High scores can identify patients at risk for delay in returning to work due to FAB. Adding education and counseling to the regular treatment/rehab program may help prevent these delays.

In 1969, the Swedish Back School began with a goal of helping patients learn about spinal anatomy and physiology, as well as ergonomics. These back schools are now used throughout the Western world to help patients cope with chronic lower back pain (CLBP).

There are subtypes to the back schools, including brief education and fear-avoidance training. Researchers have found that the ideal patient for back school education is middle-aged, experiences yearly recurrent episodes of CLBP, has been out of work for short periods, and finds it difficult to sit or stand for periods more than 30 minutes at a time. The ideal patient for brief education is a young, manual laborer who has been out of work for less than eight weeks for the first time. With normal range of motion, he/she tries to avoid pain and has tense and painful muscles. Finally, the ideal patient for fear-avoidance training is a patient who has moderate-to-severe pain and cannot participate in ordinary activities, and has been advised to avoid activities that can aggravate the back pain, such as golf or tennis.

In defining these educational approaches, the authors of this article write that back schools can be defined as group education, training and exercise, that is delivered by a healthcare provider. They often take place in an organized environment. Brief education, on the other hand, is a short-contact type of exchange between the patient and the healthcare provider and can be offered through pamphlets, patient-led groups, even online (Internet) groups. Fear-avoidance training uses exercises and techniques to encourage a return to normal activities.

These educational approaches should be used for patients who have nonspecific, mechanical CLBP, with no serious somatic or psychiatric comorbidity.

In reviewing studies that assessed the efficacy of these educational approaches, the authors found:

– conflicting evidence that back schools are not effective in reducing recurrences of LPB compared with usual care or no intervention
– limited evidence that back schools are less effective than exercise
– moderate evidence that back schools are not better than waiting list, any intervention, placebo, or exercises for reduction of pain
– conflicting evidence that back schools are better than waiting list, no intervention or usual care for return to work
– strong evidence that brief education is not more effective than usual care for return to work
– conflicting evidence that brief education in a clinical setting is more effective than usual care in reducing disability
– limited evidence that brief education provided by a back book is less effective than massage, yoga, and exercise
– conflicting evidence that brief education by back book is more effective than waiting list for pain reduction
– limited evidence that brief education is more effective than massage and no intervention for reduction of disability
– limited evidence that brief education is more effective than massage and no intervention for reduction of disability
– limited evidence that brief education is less effective than yoga and massage for reduction of disability
– no evidence for return to work when brief education is provided by a back book or Internet discussion
– moderate evidence that fear-avoidance training emphasizing exposure is more effective than graded activity with regard to fear avoidance, pain, disability, and return to work
– limited evidence for effectiveness with regard to pain, disability, and return to work compared with usual care

The authors conclude that, although they cannot recommend back schools as management for chronic lower back pain, some positive findings do encourage the need for future studies. They recommend the use of fear-avoidance when warranted.

Pain after back surgery can slow a patient down. Recovery and rate of return to daily activities, including work can be affected. Morphine is a common drug used to control the pain. But as an opioid, morphine has some drawbacks.

In this study, antiinflammatory drugs are combined with morphine to see if less morphine can be used. A special type of antiinflammatory called cyclooxygenase-2 (COX-2) inhibitors are used. Coxibs have fewer problems with bleeding and blood loss compared to other types of antiinflammatories.

Three groups of patients were included based on the type of surgery done. The first group had a discectomy (disc removed). The second group had a decompression laminectomy. A small portion of the bone over the herniated disc was removed to take pressure off the spinal nerve root. The third group had a spinal fusion (after discectomy).

Surgery was done from a posterior (back of the spine) approach in all cases. Patients were allowed to use patient-controlled analgesia (PCA). This means they had a pump that could release morphine into their system as needed.

Patients in all three groups either received the morphine/coxib combination or a placebo (liquid with no drug). The drug or placebo was given 30 minutes before the operation. It was given again every 12 hours after surgery for 48 hours. The PCA pump was removed at the end of the second day.

Results were measured based on pain levels (at rest and during movement), total morphine used, and the patient’s subjective ratings. Patients receiving both drugs at the same time had significantly better results.

Ninety per cent (90%) of them had at least 50 per cent improvement after 48 hours. This compared to 58 per cent of the patients in the PCA morphine-alone group who had 50 per cent improvement. The benefit of the combined drug was seen in all three groups.

The authors also noticed that pain wasn’t the only effect patients were interested in. They were willing to trade-off pain relief for fewer side effects from the drugs.

At the same time, it was observed that the combined drug provided pain relief at rest and during movement. Morphine used alone gave only reduced pain at rest. It made no difference in pain levels during movement.

Looking at the social side of patient’s with chronic low back pain (LBP) has changed how we treat this problem. Experts agree that patients with chronic LBP who have difficult or complex social and psychologic factors in their lives may need a different approach than those who don’t.

This model is called the biopsychosocial model of spine care. It is the topic of this article with the goal of bringing us up to date on the subject. Although this model has been useful in managing patients with chronic LBP, there are still some concerns about it.

First, using this model may overemphasize the social aspects and under treat the spine. Second, it is still a theory and needs further evidence to support its use. Third, do we really know if using the biopsychosocial model results in better outcomes than other treatment approaches?

And finally, does this model, which uses a multidisciplinary approach, lead to increasing medical costs? Spine specialists, physical therapists, chiropractors, massage therapists, and behavioral counselors are just the short list of health care providers who are involved. And pain management specialists of all kinds may be added in as well.

Results of the first studies on the biopsychosocial approach to chronic LBP are just now being published. Patients report better results with this approach compared to standard care. But whether the results last and at what price remains to be determined.

The author suggests a continued close look at how this approach has changed health care for chronic LBP patients. We must be careful not to fall into the trap of using the wrong measures to examine outcomes of treatments.

Degenerative disc disease (DDD) is not an uncommon problem as we age. Treatment with conservative care to combat pain, loss of motion, and decreased function is advised first. If nonoperative care fails, then surgery may be the next step.

In this study, a specific type of artificial disc replacement (ADR) (FlexiCore Intervertebral Disc) was compared to spinal fusion. The fusion was a circumferential fusion with bone graft and metal screws. Circumferential means the bones were fused together on at least three sides of the two vertebral bones. Patients with DDD at one level (either L45 or L5S1) were included in both groups.

The FlexiCore is a metal-on-metal ball and socket type of ADR. There are two flat metal plates — one against each vertebral bone. The ball and socket device is sandwiched between the two base plates. This design makes normal intervertebral motion possible. By preserving motion, further degeneration at the next level is avoided.

The surgical techniques for both procedures were described step-by-step by the authors. Several measures were used to compare the results of these two methods. Operative time, blood loss, and length of hospital stay were compared.

Pain levels, range of motion, and disability before and after the surgery were also used. X-rays were used to evaluate motion at the involved disc space. Three types of motion were recorded: translational, angular rotation, and lateral bending.

Previous studies of other ADRs report that the use of these devices for single-level DDD compares favorably with the results of fusion. This study adds to that data. Six weeks after surgery, the FlexiCore group had better pain relief and function than the fusion group. Function continued to improve up to the two-year follow-up visit.

The metal-on-metal ADR had less wear and tear and less translational (sliding) movement than other implants that had polyethylene (plastic) parts. The advantages of ADR over fusion include preserving intervertebral motion and preventing degeneration at the next level.

Choosing patients carefully is a key to success with ADRs. Surgeon skill and experience are also important. As technology and design of the implants improve, we should continue to see better and better results with ADRs.

The authors of this study worked in collaboration with the College of Physicians and the American Pain Society to develop evidence-based guidelines on low back pain, evaluating how well different therapies work. They conducted an evidence-based review of studies published between 1966 and 2006.

The guidelines pertain to both acute and chronic conditions.

The first recommendation suggests that a focused history and physical examination should be conducted to place patients in one of three categories. These categories were non-specific low back pain, back pain with radiculopathy or spinal stenosis, and back pain associated with another specific spinal cause. The history should also include assessment of psychosocial risk factors which predict risk for chronic disabling back pain.

The second recommendation suggests that imaging should not be obtained routinely in patients with non-specific low back pain.

The third recommendation suggests that diagnostic imaging should be performed when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of the history and physical examination.

The fourth recommendation suggests that MRI or CT be performed in patients only if they are portential candidates for surgery or epidural steroid injecton.

The fifth recommendation suggest that patients should be provided with information regarding thier expected course and use of self-care options, and to remain active.

The sixth recommendation suggests the use of medications with proven benefits. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.

The seventh recommendation suggests that for patients who do not improve with self-care options, clinicians should consider spinal manipulation for acute low back pain, and for chronic low back pain, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.

In this study, the records of 1,320 patients were reviewed to look for cases of recurrent lumbar disc herniation. All patients were treated with a subtotal lumbar discectomy (SLD). This operation removes the entire soft nucleus (center) of the protruding disc. The outer covering called the annulus remains in place.

There is some question about whether just removing the disc fragment is better than doing a SLD. There is also concern that fragments may be left behind that could cause problems later when any part of the disc remains.

Reviewing a large number of patients who had a SLD will help show if SLD is an acceptable way to treat disc herniation. Out of the 1,320 records, 14 cases of reherniation were found. They had to have occurred in the first year after the procedure to be counted as a complication. This is a low rate of complications of this type (about one per cent).

All reherniations were at the same level as the first herniation. Some were reherniated in a different direction. Ten of the 14 patients reported some traumatic event that caused the reherniation. These events included lifting, twisting, jogging, falling, and driving over a deep pothole in the road.

The group of patients with reherniations was compared to another (control) group of patients. The control group did not have any problems after this same surgery. The researchers compared results of the clinical exam and operative notes for both groups. Disc material removed was also examined and classified for comparison.

Type of disc defect was not linked with reherniation. The authors report the main difference between the groups was the amount of neurologic involvement before surgery. The reherniation group had a more significant amount of motor and sensory loss.

These problems present as numbness, tingling, weakness, and muscle atrophy (wasting). They occur as a result of the disc pressing on the nerve root. Sometimes the damaged disc leaks irritating chemicals that can cause these same symptoms.

The authors concluded that SLD is a safe and effective way to treat a herniated disc. The incidence of disc reherniation was very low. However, the surgeon should pay attention to any patient who reports new symptoms after a specific event or recurrent trauma. This could be a sign of reherniation.

Chronic low back pain, a common ailment among older adults, can result in depression, decreased appetite, difficulty sleeping, and decreased quality of life. To manage this pain, researchers say that up to 1/3 of older adults have used alternative, or complementary, medicine, such as meditation.

The authors of this study wanted to assess if a mindfulness meditation program for people 65 and older who had lower back pain would be beneficial. To do this, researchers enrolled 37 patients, 65 years old or older, who had chronic back pain for at least 3 months, to participate. They were randomized to be in the treatment group of mindful meditation or the control group with no intervention.

Patients in the intervention group attended 8 weekly 90-minute sessions where they were taught the meditation techniques. The first few sessions involved teaching the participants how to meditate and to review the homework and support material. The participants were taught the body scan, where, the authors write, the patients were “in a lying position, the participant is guided to place their attention non-judgmentally on each area of the body from the toes to the head,”, sitting practice, which is “focused attention on breathing while sitting on a chair or on a meditation cushion on the floor,” and walking meditation, which is “mindful slow walking with focused attention on body sensation and/or breathing.”

All patients were assessed before randomization into either group, immediately at the end of the intervention at 8 weeks, and again 3 months later. Patients who were in the control group were immediately switched into the meditation group after completing the 8 week course.

Measurements included pain intensity, through the McGill Pain Questionnaire Short Form (MPQ-SF) and the SF-36 Pain Scale. Pain acceptance was measured through the Chronic Pain Acceptance Questionnaire (CPAQ), quality of life with the SF-36 Health Status Inventory, and physical function with 3 scales: Roland and Morris Questionnaire for assessing self-reported disability related to low back pain, the Short Physical Performance Battery, which measures standing balance, gait, speed, and ability to rise from a chair, and the SF-36 Physical Function Scale.

Drop-outs in the study included 6 subjects in the intervention group and 1 in the control group. When the researchers reviewed the study findings, they found that there was significant improvement in the Chronic Pain Acceptance Questionnaire for the meditation group. There was a deterioration in the control group, both over the 8-week period. In the treatment group, the Activities Engagement subscale of the CPAQ also improved in the treatment group.

Although there was an improvement among the treatment group in the McGill Pain Questionnaire and the SF-36 Pain Scale, as well as in the physical function, the difference was not significant over the control group. The Short Physical Performance Battery was the same in both groups.

The authors conclude that such programs could be beneficial in leading patients to pain acceptance and improved physical function.

Lower back injuries are common in Western society and many workers who develop lower back pain end up on long-term disability. Researchers have looked at the risk factors that may lead to long-term disability from lower back injuries. One small study found that patients who were given opioids for more than seven days after the initial injury, had a higher risk of being off work for longer periods.

Initial treatment recommendations for lower back injuries in the United States and Europe includes the use of acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), with use of opioids only if the pain is severe and only for several days, not for a long term.

Researchers have found that patients who had higher pain and worse functioning also had higher opioid use, so the authors of this study wanted to evaluate if opioid prescriptions within six weeks of injury are associated with one-year disability.

The patients in the study, 1,843, were who had received or who were receiving work disability compensation. There ages ranged from 18 to 77 years, with a mean age of 39.4 years. The researchers assessed the patients with a baseline telephone interview that reviewed questions about their socioeconomic status and tobacco and alcohol use. Patients were asked to rate their pain and whether the pain radiated into a leg. Their ability to function was rated by the Roland-Morris Disability Questionnaire (RDQ) and the injury severity was rated with an instrument developed in a previous study.

Also assessed in the study was the patients’ view of where they would be in six months, whether they would be working. Workers gave answers from not certain at all about returning to work to extremely certain.

The researchers assessed opioid prescriptions through data including billing records. By learning which workers received an opioid prescription at or within six weeks of their injury, they were able to calculate how much of the opioids the patients likely took.

Study findings revealed that of the 1,843 patients, 245 (14 percent) were off work at 1 year after the injury; of the 1,843 patients, 630 received opioid prescriptions within six weeks of the injury and slightly more than half of these patients received the prescriptions during their first doctor visit. The mean number of days for prescriptions was 12.1 days, 5.1 days over the seven-day treatment recommendation.

The authors write that the findings of opioids given for more than seven days within the first six weeks following the injury was associated with a higher risk of the worker being off work for longer periods. The relationship, however, is still unknown.

Weaknesses in the study include the self-assessment of the workers over the phone, during which the use of the opioids may have altered the pain and function and, thus, their responses.

In conclusion, the authors say their “findings suggest consideration of some caution in prescribing opioids early after a work-related back injury.” They continue to say that if opioids are to be used, their use should be limited to that of less than a week.

Chronic lower back pain is one of the most common chronic pains in Western society and results in high economic and social costs. Many studies have been done to assess and improve the quality of life (QoL) of patients with chronic lower back pain.

Among the studies done, researchers have determined that acceptance of back pain can have its drawbacks, including a resigned acceptance that there is nothing that can be done. However, the researchers have also found that patients who accept their back pain and who can move on despite it, have less depression, less physical and psychological disability, and better work status.

The authors of this study were interested in learning if patients with chronic lower back pain who accepted their pain developed a more positive outcome on every day functioning. Their aims were to “explore the relationship between pain acceptance and QoL, and consider its potential clinical implications,” as well as to examine the different ways of measuring the acceptance and the outcome.

Eighty-six patients (ages ranging from 17 to 92 years) participated in the study. They completed questionnaires that assessed their QoL (the World Health Organization Quality of Life Assessment, or WHOQOL) and their acceptance of pain (the short-form Chronic Pain Acceptance Questionnaire, or SF-CPAQ). The WHOQOL measured 6 domains: physical, psychologic, level of independence, environment, social relationship,and spirituality, religion and personal beliefs. An extra module in the WHOQOL, the pain and discomfort module, or PDM, addressed pain relief, anger and frustration, vulnerability/fear and worry, and uncertainty. The SF-CPAQ measured emotional distress and daily function.

The results of the questionnaires were not surprising to the authors. The findings were that the QoL was positively associated with the overall acceptance of pain, with engaging of activities, and willingness to accept pain. The acceptance was linked with feelings of independence, being mobile and being able to work. Patients who were aware that trying to avoid pain would not be helpful were less prone to anger, frustration and uncertainty – and also had a better QoL.

The authors conclude that further studies are needed, including research into whether changes in acceptance alters QoL or whether better QoL affects acceptance.

People with back pain don’t always agree on what improvements suggest they are better. Is a 10 per cent decrease in pain enough to say, I’m better now? How much improvement in function suggests that treatment is working well?

In this study, researchers attempt to find the minimal important change (MIC) for five commonly used questionnaires for back pain patients. The Visual Analogue Scale, Numerical Rating Scale, Roland Disability Questionnaire, Oswestry Disability Index, and the Quebec Back Pain Disability Questionnaire were included.

These surveys measure pain, function, work disability, health status, and patient satisfaction. Two outcomes of particular interest in this study were pain and back specific function.

The researchers asked a panel of experts two questions: How much change in the scores for these tests before and after treatment is meaningful? If the outcomes are statistically significant, are they also clinically meaningful? In other words, if the improvement in test scores signifies an important change, does this match up with the patient’s level of pain and function?

After much discussion, a consensus of opinion was reached. The panel agreed that the MIC for the questionnaires included in this study was a 30 per cent improvement. The same measure was used for all patients whether in the acute, subacute, or chronic phase of back pain.

Doctors and therapists working with back pain patients can use this 30 per cent figure as a baseline for judging outcomes. MIC values can still depend on each patient’s circumstances.

Each case should be judged carefully for evidence that the MIC value fits the patient. For example, a different MIC may be needed for children versus adults. Likewise, surgical versus nonsurgical cases may require different percentages.

The authors report that the proposed 30 per cent MIC is a guideline, not a standard for failure or success of treatment. If all researchers have a common starting point, then the results of their research can be compared and contrasted to other studies using the same test measures.

For now, this value is suggested for use with individuals, not groups of people. Further research is needed to verify this figure for the baseline. Changes may be needed based on future study results.

Experts are working hard to help sort out types and causes of low back pain (LBP). Around the world, different groups have published clinical decision rules (CDRs). CDRs help doctors diagnose and treat patients with LBP.

In this article, specific attention is paid to LBP from neurologic disease. Three sites were searched for clinical guidelines that included neurologic syndromes. These sites included Medline, the Internet, and published health science journals. Medline is an on-line medical library provided by the National Institutes of Health (NIH).

To be included, the guidelines had to be written in English. They also had to have recommendations for management by primary health care providers. Seven guidelines were found that met the required criteria.

Three groups or categories of LBP with neurologic disease were identified. These included cauda equina syndrome, nerve root syndrome, and spinal stenosis. The authors provide two tables comparing these syndromes as they are presented in each guideline.

In general, there was not agreement among the guidelines. Various opinions were offered about decision factors for diagnosis. There was some agreement and some disagreement about the timing of assessment and predictive value of the diagnostic factors. The greatest amount of agreement was observed in the diagnosis of cauda equina syndrome.

LBP with a neurologic syndrome is less common than LBP from nonspecific causes. But it is also more serious with an increased risk of permanent damage. For this reason, it is important to identify these syndromes as soon as possible.

The authors suggest that a clinical guideline that includes all three of these syndromes is needed. Whenever possible, the specific guidelines need to be based on evidence. Significant predictors of neurologic involvement for each syndrome should be included.

When there is no evidence to support decision making, then group consensus is used. And studies must be done to show if the guidelines are resulting in improved outcomes. The guidelines should also be shown to reduce costs of care for patients with LBP.