News Category: Lumbar Spine

Studies show over and over that staying active and exercising are the first steps to take in treating low back pain (LBP). But what kind of exercises work best? Are aerobic programs ideal? What about strength training? Perhaps a more specific approach such as the McKenzie exercises should be followed?

In this study, a group of physical therapists compared results for patients treated by the McKenzie method with patients who followed a strength-training program. A second goal of the study was to look back at factors present before treatment and see if any of them were linked with a poor outcome.

Both groups of patients were seen by a physical therapist (PT) for eight weeks. A maximum of 15 sessions was allowed. Everyone was instructed to continue his or her exercise program for two more months after discharge from PT.

Results were measured at the end of 14-months. The data collected included functional status, pain level, and work status. The number of health care visits for back pain during that time period was also recorded.

The authors report that the long-term results weren’t any different between the groups. This seems to support the idea that any type of exercise will benefit patients with LBP. The key finding of this study was that pretreatment factors were more important than type of exercise.

Patients who smoked or who had a longer period of symptoms had poorer outcomes. Patients who were more likely to drop out of the program or to have poor results had higher levels of disability and pain.

Patients on sick leave at the start of the program were more likely to withdraw from the study or still be on sick leave at the end of the study. In addition, patients who had low expectations about work were more likely to have high levels of disability.

The authors conclude that some factors can predict results. But these factors should not exclude patients from treatment. Rather, therapists should provide these patients with specialized care.

Reducing pain and disability in order to return to work may take more than just exercise. Cognitive or behavioral therapy and vocational training may be needed as well.

Studies show that a multidisciplinary approach is best for patients with chronic low back pain (LBP). Multidisciplinary involves physical therapy, behavioral and psychologic counseling, and change in psychosocial factors. A chronic stage is defined as patients with pain lasting three months or more.

But does length of time in the chronic stage matter? Can anyone (no matter how long they have had LBP) benefit from this type of treatment? That’s the question researchers in Germany asked in this study.

They divided 387 patients with chronic LBP into three groups. The groups were based on length of time symptoms were present. All patients had pain for more than three months. They also had all been on sick leave for at least six weeks. Each patient had been treated with conservative (nonoperative) therapy without success.

There were four chronicity grades included. Each grade from I to IV was based on the patient’s level of disability and intensity of pain. Patients in grades I and II were combined together into one group.

Everyone in all three groups received three weeks of multidisciplinary therapy. Sessions lasted eight hours a day, five days a week. Areas of focus included exercises, coping skills, education, and relaxation training. Multidisciplinary treatment also included cognitive behavior therapy, work-related training, and problem solving in stressful situations.

Results were measured at six months. Outcomes were assessed using work status, health status, pain intensity, and functional capacity. Patient satisfaction with therapy was also tested.

The authors found that patients in every stage of chronicity benefitted from therapy. In other words, it’s never too late to treat chronic LBP with a multidisciplinary approach.

Even patients in higher stages of chronicity had decreased pain and improved function. Patients who had been unable to return to work before were able to end their sick leave and get back to work.

Future studies must determine what kind of multidisciplinary therapy and how many sessions are needed. This will help reduce costs of therapy and money lost from reduced work productivity.

Back pain, the fifth leading cause of hospital admissions in the United States, is the third most common reason for undergoing surgery with the incidence rising from 147,500 in 1979 to 279,000 in 1990 – an increase of 55 percent. Lumbar fusions, surgery that fuses bones together in the lower back, increased 100 percent during this same period. Surgery is done after conservative, non-surgical treatments, such as physical therapy, fail.

Fusion surgery complications include problems developing in neighboring areas above and below the surgical site, long postoperative recovery, pain, disability, and reduced movement, in some patients. As a result, researchers developed disc replacements, or total disc arthroplasty (TDA). Although the differences between the two surgeries are not significant in terms of outcome (60 percent to 90 percent success rates), quicker short-term recovery and return to work with TDA result in reduced cost for the surgical and medical care.

The authors of this article studied 53 patients with disabling back pain and lumbar disc degeneration. Among the group, 36 received an implant called the Synthes Prodisc TDR and 17 underwent a fusion procedure called circumferential fusion. The patients had level 1 or level 2 degeneration disc disease. The researchers evaluated operating room charges, inpatient hospital charges, and implant charges, to determine the cost of the surgeries. The researchers did not evaluate the cost for equipment after surgery, physical therapy, care by attendants, or lost wages and productivity.

The researchers found that patients who had level 1 degeneration had significant differences between the two groups ($12,000 for the replacement group vs. $18,950 for the fusion group) for the operating room charges. Blood loss was higher in the fusion group (794 milliliters) compared with the implant group (412 milliliters). Average time in the operating room for the fusion group was 344 minutes compared with 185 minutes for the implant group. Comparing the time in the hospital, patients in the fusion group stayed a mean of 4.78 days and the implant group a mean of 4.32 days.

The groups with patients who had level 2 degeneration were more similar between the two. The implant group had a average cost of the operating room of $15,340 compared with the fusion group at $20,560 but the overall average cost was $55,524 for the implant group compared with $56,823 for the fusion group. Estimated blood loss was the same between the two groups as was the length of hospital stay. Operating time was an average of 387 minutes in the fusion group and 242 minutes in the implant group.

The authors concluded that the patients who had the implant, regardless of degeneration level, spent significantly less time in the operating room, decreasing those costs.

Up to now, little has been known about the incidence of different types of tears found in degenerated discs. The authors of this study developed a method for recording the types of tears in each disc and reviewed them to find patterns of incidence.

Using freshly removed, intact, lumbar discs from 70 patients, aged from 13 to 79 years, the researchers divided the discs into three groups: those from patients aged 10 to 13 years (19), 31 to 50 years (21), and 51 to 80 years (30). These groups were chosen because of the degree of enlargement or swelling that can exist on the discs before they begin to dry out, around the age of 30 years. Then, at age 50 years, the discs can begin to break down.

The researchers found that posterior (from the back) concentric (central) tears were consistently the first ones to appear in the discs. This corresponds with a study done earlier that found similar “cracks” in patients as young as 15 years and were almost always present in patients over 30 years. Other tears, called rim lesions and transdiscal tears, appeared more often as the patients were older. In the even older group, many of the discs had tears that had blood vessels, which had nerves that transmitted pain.

The authors concluded that there is a change in the type of tears that appear in the lumbar discs from early on in life (13 years) to the elderly.

Neurosurgeons from 14 different spinal centers around the United States participated in this study. They compared spinal motion in three groups of spines. One group of patients had an ADR at one level (L45). The second group had a fusion at one level (L45).

And the third group was a series of eight human cadavers divided into four groups. Four different types of of spinal reconstructions were applied and compared: 1) the control group: nothing was done to the spine, 2) CHARITÉ disc prosthesis was inserted at L45, 3) BAK cage was inserted into the L45 disc space after the disc was removed, and 4) BAK cage with a fixation (fusion) rod at L45.

A special device called a six-degree-of-freedom spine stimulator was used to measure range of motion. Six movements were measured including flexion, extension, left and right sidebending, and left and right rotation.

Motion was measured at the operative level and the adjacent levels (above and below L45). Measurements and X-rays were taken before the operation and again two years later.

The results showed that a one-level ADR does the best job of relieving pain and restoring normal spinal motion. This was true for the operated level and the adjacent levels. In the case of spinal fusion, motion was decreased at that level as expected. It was also increased at both the adjacent levels (L34 and L5S1).

Using the cadavers, the researchers were able to show that the spine stimulator accurately measures spinal motion in all groups. This was true no matter what type of surgery was done. The authors also point out that voluntary motion increased with greater pain relief with the ADRs.

Over the years, the treatment of acute low back pain (LBP) has changed from bed rest to activity. This advice may help prevent acute pain from becoming chronic pain.

But when chronic LBP does occur, what’s the best way to manage it? In this article, Dr. B. H. McCarberg, the founder of Kaiser Permanente’s chronic pain program summarizes what is the current evidence on this topic.

Treatment begins with medications such as analgesics (pain relievers) or antiinflammatories. Topical creams such as capsaicin may be used along with ice and/or heat. Some patients choose to see a chiropractor and seem very satisfied with the results.

Evidence from research supports exercise therapy, behavioral therapy, and acupuncture. Combining several treatment options through a multidisciplinary approach may be best. Some patients don’t have health coverage for outside help. Exercise remains the best and least costly tool.

There are still many treatments used by patients that haven’t been fully investigated. These include trigger point, facet joint, or epidural injections. There is also a lack of evidence for the use of lumbar supports, antidepressants, and muscle relaxants.

There are some test measures that can help identify the source of the pain. This makes it more likely that the cause of the pain can be treated directly. Sometimes there is more than one problem generating pain signals.

In these cases, injections of the facet (spinal) joints or sacroiliac joint may pinpoint the exact location of the pain source. X-rays, MRIs, and CT scans can be used to look for arthritis, fractures, or tumors. Once the pain is under control, physical therapy can be helpful to restore normal motion, posture, strength, and gait (walking) pattern.

Sometimes conservative care is unable to relieve pain and restore sleep, function, and motion. At this point, surgery may be considered. Patient education is the key to avoiding unnecessary surgery. Weight loss, smoking cessation, exercising, and cognitive changes (the way the patient thinks about his or her pain) must be incorporated into the management first.

In this study, neurosurgeons from Italy evaluate the results of unilateral spinal decompression. Unilateral means the operation was done from one side.

The patients all had spinal stenosis with back and leg pain that limited walking. Stenosis is a narrowing of the spinal canal. Pressure on the spinal cord and spinal nerves is the cause of the painful symptoms and limited function.

Everyone in the study had conservative care without surgery first. The results were not satisfactory and surgery was needed. The operation was described in detail in this report. Only one surgeon did the surgeries. A special surgical microscope was used. The surgeon had a clear view of all the anatomic structures.

First, part of the lamina (bone around the spinal canal) was removed to take pressure off the neural structures. The procedure is called a laminotomy. A special microdrill was used to thin the laminae into a V-shape.

This made it possible to remove the right amount of bone without causing a collapse of the remaining bone. Since the surgeon used a microscope, the procedure is also referred to as a microdecompression.

A thickened ligament called the ligamentum flavum (LF) was removed at the level of the stenosis. The rest of the LF was left in place to help protect the sac around the spinal cord. Any overgrowth of bone or bone spurs around the facet (spinal) joints was shaved away. Some patients only had one level decompressed. Others had microdecompression of two or three levels.

The surgeons were able to repeat these steps on the other side of the spine. This was done from the original side and without making a second incision. They were able to reach the opposite side of the spine by raising and tilting the table. This made it possible to change the angle of the microscope to reach across.

The authors note that the posterior facet joints, ligaments, and other structures are not affected. This means the patients didn’t need a spinal fusion at the same time the decompression was done.

Results were measured by pain levels, change in function, and imaging studies (X-rays and CT scans). Almost 90 per cent had improvement in pain and walking. Some patients reported still having sensory or motor loss. The stenosis did not return in any of the patients.

The authors conclude that unilateral microdecompression of spinal stenosis is safe and effective for all ages. It can be used to achieve bilateral (both sides) decompression. It is especially useful when there are natural anatomic changes in the shape of the bone that contribute to the stenosis.

For years, scientists have tried to figure out what treatment works best for patients with low back pain (LBP). Physical therapists have joined that effort by studying various types of exercises that might help.

In this study, the results of two types of exercises are compared in similar kinds of patients. Group one received the extension-oriented treatment approach (EOTA). Group two followed a strengthening exercise program.

The important difference in this study was the fact that all patients with LBP were part of a subgroup. Each one tested positive for the presence of centralization. Centralization means that pain in the buttock or leg went away or moved up closer to the midline of the lumbar spine. This response occurred during extension movement testing.

The new idea in back pain research is to identify LBP patients who are likely to respond to a particular type of exercise program. Matching patients this way will help create a system of treatment based on classification.

Patients in both groups saw a physical therapist a total of six sessions during a 30-day period. The type of extension and strengthening exercises for each group were described. Everyone was given a home program to carry out on the days they didn’t come to therapy.

Patients were re-examined after one and four weeks. A survey of questions was sent to each one at the end of six months. The results showed that patients in the EOTA group had less pain at the end of the first week compared to the strengthening group. No other differences were observed between the two groups throughout the rest of the study.

Treating all LBP patients alike may be why no specific treatment has been found to help the majority of the group. Efforts to match treatment to subgroups of LBP patients are ongoing.

Finding subgroups of LBP patients most likely to benefit from exercise is a start. The results of this study suggest the need to narrow the groups even more. Further study is needed to identify LBP who can benefit the most from EOTA.

Patients who are older who have degenerative spine disorder may benefit from a dynamic stabilization of the spine rather than a rigid system.

Rigid instrumentation is often used to fuse the spines of patients with degenerative spinal disorders. However, surgeons have found that patients who undergo such fusion often experience worsening of lumbar lordosis (swayback), increased lower back pain, fractures of the vertebrae, loosening of the hardware (screws), or degeneration of the spinal segments next to the fusion.

The authors of this study compared the results following a rigid stabilization to a dynamic system, one that allows the spine to have more movement and ability to bear weight. The Dynesys system is believed to avoid some of the issues resulting from the rigid fusions.

Fifty patients (33 females) participated in the study. Twenty-five patients, aged 23 to 74 years, were in Group R (Rigid fixation) and 25, aged 24 to 70 years, in group D (Dynesys system). All patients were evaluated clinically with physical examinations, neurological examinations, and x-rays. They were also evaluated through the Visual Analog Scale (VAS) for pain and the Oswestry Disability Index (ODI) for disability. They were evaluated before surgery, and then again at six weeks, six months, one year, and two years following surgery.

The researchers found that the patients in group D had an average VAS scale (on 1 to 10, with 10 being the worst ever pain and 0 being no pain) of 6.9 for lower back pain before the surgery, which decreased to 3.4 two years after surgery. In group R, the VAS score was 7.6 before surgery and 3.7 at two years after. When evaluating VAS for leg pain, group D reported a decrease from 6.2 before surgery to 2.1 at two years; group R reported a decrease from 6.9 before surgery to 3.0 at two years.

When evaluating the ODI, which is out of 100 and the lower the number, the better the score, group D reported an ODI score of 29 at two years after surgery compared with 54 before; group R reported 39 at two years, down from 56 before surgery.

Some patients received more than one fusion in the spine; they reported an ODI score of 35 at two years, compared with 52 before surgery.

The researchers broke down the groups according to age over 50 years and under. Among those over 50 years, group D patients reported an ODI of 25 at two years compared with 50 before. The group R patients reported an ODI of 39 at two years, compared with 62 before surgery. This is interpreted as a greater than 50 percent improvement for those in group D but only more than 25 percent for those in group R. Among the patients who were under 50 years, ODI was 39 at two years for group R, down from 62 before surgery; ODI was 39 at two years for group D, down from 60 before surgery.

Complications were found among 10 patients: three patients experience infections (one in group R, two in group D), one had seroma, or fluid under the skin (group not reported), four had technical errors (three in group R, one in group D), and two had nerve root irritation, both in group R.

The authors conclude that their study indicates use of rigid instrumentation can help patients if this is over a short area, however, use of a dynamic system is helpful for larger areas. They do point out, as well, that the dynamic system does not require donor grafting, eliminating any issues that may arise from taking grafts.

When patients present with leg pain, it can be difficult for doctors to learn if the pain is coming from hip or lumbar spine arthritis. X-rays, while indicating arthritis in both, cannot show which is causing the problems.

The authors of this study examined the records of 83 patients who underwent a fluoroscopically guided intra-articular injection in order to determine if the procedure helped locate the basis of the pain.

All patients had a diagnosis of hip and spine arthritis and had pain around the hip joint and/or gluteal area. All patients were followed for a minimum of 24 months after the procedure.

The injection into the hip joint was done in an operating room and the patients were all discharged one hour after the procedure. They returned for a follow up two weeks, six months, and 12 months after the injection, and then once a year after. If a patient had a later hip replacement, they were assessed at six weeks after the surgery as well.

Pain assessments were done with the visual analog scale (VAS), which rates the pain on a scale from zero to 10, with zero being no pain and 10 being the worst pain. The severity of the arthritis in the hip was measured using the Harris hip scores (HHS), a score out of 100, with 100 being the best possible score.

The 83 patients had a mean HHS score of 54.3 before the procedure. At two weeks after, 74 patients reported an improvement in pain from 7.4 to 2.7, on average, and an HHS improvement to 80.4. Nine patients did not report pain relief or improvement in HHS.

Among the 74 patients who experienced significant pain relief, 50 had a hip replacement later on; their HHS had dropped from the 80.4 at two weeks post-injection to 60.3 three months later; their pain score rose from 2.7 to 6.6. Only two patients who had a replacement did not report significant pain relief and their HHS was 61.3 after one year following the surgery.

Of the 74 patients who had pain relief and did not go on to have a hip replacement, 17 had a second injection when their pain returned, about six months after the first one. The nine patients who did not obtain relief and two others who did but still had pain after their hip replacement were referred to see spinal specialists.

Of these 11 patients, eight had injections or surgery on their spine while the remaining three managed their pain with medications.

The authors write that both hip and spinal arthritis can and do present with similar symptoms. They found, however, that those patients who had a limp were seven times more likely to have pain from the hip alone or from both the spine and the hip. The same was found among those with groin or limited internal rotation of the hips – they were 14 times more likely to have this problem.

Earlier studies have shown that treatment of the spine does not help if the problem originates from the hip, and the other way around. Therefore, it is important for the physicians to understand from where the pain is originating.

The authors conclude that their study shows the use of the injection can be an excellent aid in determining the origin of the pain.

Back pain that travels down the leg is called radiculopathy. It is caused by pressure on the spinal nerve from a herniated disc. Chemicals released from the damaged disc can also irritate the nerve causing radiculopathy.

A common treatment for this problem is an epidural steroid injection. The surgeon applies the numbing agent and antiinflammatory directly on the inflamed nerve (or as close as possible).

In this study, surgeons show that fluoroscopy can be used to guide the needle for better accuracy. Fluoroscopy is a form of X-ray that allows the surgeon to view what’s inside the body. The images are downloaded to a computer and viewed on the computer screen.

Without imaging, there is a 25 to 30 per cent incidence of incorrect needle placement. In the lumbar spine, there is an increased risk of injecting a blood vessel without imaging. But with imaging, there is a risk of exposure to radiation.

In this study, surgeons perform L5 and S1 ESIs at the same time. Although they use fluoroscopy to guide both needles into the foramen, there is less radiation exposure. The foramen is the opening in the vertebral bone for the spinal cord or spinal nerves.

MRIs of the procedure are shown. The surgeons use a view and contrast dye that shows the Scotty dog formation. This is the outline of a Scotty dog formed (in part) by the pedicle of the vertebra.

The pedicle is the connecting bridge of bone between the main body of the vertebra and the posterior portion of the bone. The Scotty dog formation can only be seen when images are taken at an oblique angle. The pedicle forms the eye of the dog. Finding this image allows the surgeon to locate the foramen.

The authors conclude using fluoroscopy to view the S1 foramen can improve accuracy and effectiveness of ESI at the L5 and S1 levels. Further studies are needed to measure the actual amount of radiation exposure.

Core training or core stabilization exercises are very popular right now. Many people do these exercises after a back injury or for back pain. Others do them in hopes of preventing a back problem. Do they work? Who should do them?

In this report, two doctors from the University of Washington (Seattle) review the research. They offer an opinion on this topic. A summary of the original studies that led to the development of core stabilization is also included. Using data from current studies, they try to answer the following questions:

With the growing availability of total disc arthroplasty in place of fusion, the authors of the study chose to study the accuracy of xrays as opposed to comupted tomography (CT) scan in estimating placement of the implant. At the time of the study, most were evaluated with xray only.

Correct placement of an implant is critical in optimal long-term function. Malplacement may cause premature implant wear, implant loosening, and stresses on adjacent segments and facet joints.

Thirty-six patients who had undergone lumbar total disc arthroplasty were studied. Imaging is used to assess interpedicular midline placement as well as vertebral body placement. Anteroposterior (AP) and lateral views with plain Xrays were obtained. These were compared to CT scans. The authers found that there was no significant difference between xray and CT scans when evaluating for midline malplacement. However, the authors felt the correlation between xray and CT for vertebral body penetration was poor. Therefore, they recommend early postoperative CT.

Many occupations and daily activities require prolonged sitting. This may be a cause of low back pain and sitting discomfort. The authors studied the use of a fixed lumbar support compared to a Continuous Passive Movement (CPM) lumbar support. The cushions had the same inflation pressure in sitting. Thirty-one male healthy subjects were required to sit in the same chair for a two hour period on three consecutive days. One of the days, there was no support, another a fixed lumbar support, and the remaining day with a device called a CPM lumbar support.

Each rated low back pain, stiffness, fatigue, and buttock numbness on a visual analog scale (VAS). The subjects were encouraged to remain motionless during the two hour period. Whole body motion was measured using the VICON system. Pad Professional System measured maximum pressures of the seat where there was human contact.

The results of the VAS showed that even subjects who did not have a history of back pain reported back pain during prolonged motionless sitting. While the subjects reported significantly less less back pain while using the fixed lumbar support and the CPM lumbar support, there was not a significant difference between the two devices with regards to back pain. The CPM lumbar device did seem superior to fixed lumbar support in reducing buttock numbness.

Surgeons are looking for less invasive ways to surgically treat degenerative lumbar spinal stenosis (DLSS). DLSS is a common problem in older adults. Changes in the soft tissues, discs, and spinal joints lead to compression of the spinal nerves. The result can be back and/or leg pain and loss of function.

When conservative care fails, surgery may be the next step. But poor health and problems with spinal instability after surgical decompression make this a less than favorable option. That’s why finding a minimally invasive operation with better results is so important.

In this study, neurosurgeons from Italy review the results of 374 patients who had surgery for DLSS. A microsurgical decompression technique with a unilateral (from one side) approach was used. Bilateral decompression was possible. This means that pressure was taken off the spinal nerves on both sides using a single-sided approach.

A detailed description of the surgery is provided. Computer-generated drawings and corresponding CT scans help show what was done. The procedure is called a unilateral laminotomy. A surgical microscope was used to give constant clear pictures of the spinal anatomy and nearby soft tissue structures.

The goals were to reduce the amount of time in surgery, bleeding, and other complications. The surgeons hoped to improve results with better long-term pain control and function. Meeting these goals would mean more patients could have this operation with good results.

Analysis of the data show that almost 90 per cent of the patients had improvement in pain levels and function. They had a shorter hospital stay and faster recovery. Only a few patients ended up with spinal instability. They could be treated conservatively. No further surgery was needed.

The authors say they have adopted this approach for their patients with single or multi-level DLSS. The results show the procedure is safe and effective and can be used in both young and elderly patients.

In 1994, the Agency for Health Care Policy and Research (AHCPR) published Acute Low Back Problems in Adults. These clinical guidelines have been used by many doctors in advising patients with low back pain (LBP) to stay active.

A new set of clinical guidelines has been added to the previous AHCPR document. These new guidelines aren’t meant to replace the AHCPR publication. Instead, they focus on primary care and the treatment of pain as the underlying disease.

The American College of Physicians and the American Pain Society developed the new guidelines. They are evidence-based, follow a clear path, and are user-friendly. Seven main recommendations are made and include:

Flatback syndrome, also known as lumbar degenerative kyphosis (LDK) is a common problem after surgery for scoliosis. It is also the most common cause of spinal deformity in the adult Asian population. Changes include narrowing of the discs, collapsed vertebral bones, or wasting of the extensor muscles in the lumbar spine.

In this study, X-rays are used to classify or group patients with LDK. The X-rays were taken of the entire spine from the side with the patients standing. Spinal curves, sacral slope, angles, and the sagittal vertical axis were measured.

Seventy-eight women with LDK were put into two groups based on X-ray findings. The main focus was on the thoraco-lumbar (TL) junction. This is where the thoracic curve of the mid-spine meets the lumbar (lower) spine. Based on the T-L junction angle, the spinal curve deformities were either flat or lordotic.

Group 1 was classified as sagittal thoracic compensated. Compensated refers to the fact that the spine develops a second curve to offset the first one. This is a more flexible type of LDK. Group one was further divided by location and shape of the curve. The three types of lumbar kyphosis were lower lumbar, middle lumbar, and flat type.

Group two was labeled as sagittal thoracic decompensated. Decompensated means the deformity was structural and extended through the entire spine. Decompensated LDK is rigid and more difficult to correct.

They all had trouble walking and standing because of back and buttock pain. A stooped posture was common. Even those patients who compensated by extending the upper back stooped when tired.

Patients with LDK may need surgery. The authors point out that the type of surgery will differ based on whether the patient is in the compensated or decompensated group. Fusion levels are determined based on whether or not there is a compensatory thoracic curve.

There is a wide range of spinal deformities leading to disability in the adult population. In particular, adults with scoliosis are the focus of this study. Scoliosis is an abnormal curvature of the spine.

A classification system was previously developed to group patients with spinal deformities. This adult spinal deformity classification system was used to provide a common language for talking about this condition. Patients were grouped according to the level of their disability, pain, and the impact of the condition.

The researchers were looking for treatment patterns and surgical strategies based on the type and location of spinal deformity. X-rays were used to place patients in groups. The hope was to find treatment guidelines to help doctors manage these complex disorders.

The classification method used has already been proven reliable. Past studies show that the patient classification is linked with disability. The next step is to see what affect classification has on surgical outcomes. For example, can the clinical impact of the condition help guide the surgeon in choosing the best procedure?

The authors found that the rate of surgery increased in patients with the greatest spinal imbalance and deformity. Specific descriptors in the classification were also linked with the type of surgery done.

For example, fusion and surgical approach (from the front, side, back, or combination of directions) could be predicted based on the patient’s classification group. Likewise, patients with decreased lumbar lordosis (natural curve of the lower spine) were more likely to need a more aggressive operation to achieve realignment.

Other patterns were also observed. Patients with no lordosis were the most disabled before surgery. They also had the most improvement and least disability at the end of one-year.

Although the authors found some patterns in the results and effect of surgical approaches, they state that larger studies with further analysis are needed. This study was just the start in understanding what constitutes optimal care for adults with spinal deformity such as scoliosis.

Spinal stenosis (SS) is a narrowing of the spinal canal or the openings for the spinal nerves. It is a common change that occurs with aging. Lumbar spinal stenosis is a frequent cause of low back pain and neurologic changes in the leg(s).

In this study, the size of the spinal canal was measured and compared with patient symptoms. The goal was to see if spinal canal diameter was linked with severity of symptoms.

Pain, perceived function, and walking distance were used as measures of results. MRIs of the lumbar spine showed the spinal canal size and condition of the spinal structures (ligaments, disc, joints).

Patients with the smallest openings were more likely to have bulging discs, thickened ligaments, and joint changes. A small number of patients with spinal stenosis did not have any of these types of changes.

Although patients with the smallest canal diameter had more pain below the knee, this finding was not statistically significant. Almost half of the patients with larger spinal canals also had pain below the knee. It’s likely that some other factor besides canal diameter is the cause.

Pain intensity, walking ability, and function were not different between patients with smaller versus larger spinal canals. Patients with the smallest canal diameters did report more pain-related disability. This has more to do with perception of pain than canal size.

The authors of this study point out that these results support other research that shows the anticipation of pain and not the actual pain felt is most predictive of function. Fear of pain and changing activity levels to avoid pain may be the real issue here, not the size of the spinal canal. Further study is needed to examine this more.

Standing AP and lateral X-rays are often ordered when back and/or leg pain doesn’t go away. The value of X-rays in diagnosing low back pain (LBP) has been questioned in the past. In this study, researchers reviewed the use of flexion-extension (F/E) X-rays for patients with LBP.

FE X-rays are taken with the patient bedning forward or extending backward as far as possible while in the standing position. This allows for a better idea of how the spine looks in a functional position. This type of X-ray is called a dynamic radiograph.

Dynamic F/E X-rays may be taken to look for spinal instability. But should every patient with LBP have this type of X-ray at the initial (first) exam? According to the results of this study, the answer is No.

A series of X-rays were taken and reviewed by three experts. The series included AP, lateral, and dynamic F/E radiographs. The panel included a musculoskeletal radiologist, a spine surgeon, and an orthopedic resident. The films were also measured and analyzed using digital measuring tools and computer software.

Only two patients out of 342 had findings on the dynamic F/E X-ray that weren’t seen in standard X-rays. And neither one of those patients needed surgery. The authors suggest dynamic radiographs of the lumbar spine are only justified in surgical patients. They are not advised for routine screening of LBP.