News Category: Lumbar Spine

Conservative (nonsurgical) care or surgery: which is better for patients with degenerative spondylolisthesis? In this condition, one of the vertebrae slips forward over the one below it. Back and leg pain and difficulty walking are common symptoms of this problem.

In the aging adult, spondylolisthesis and spinal stenosis often occur together. Stenosis refers to a narrowing or closing of an opening. When the bone moves forward, the spinal canal narrows and the nearby tissues and nerves become irritated and painful. This is because they are pinched or compressed by the narrowing.

So far, there isn’t one best treatment for everyone with this condition. Conservative care with antiinflammatory drugs or pain relievers is usually tried first. If that doesn’t work, then physical therapy and/or epidural steroid injections are tried. Surgery to relieve the pressure on the nerve tissue may be the final treatment choice.

The results of a recent randomized controlled trial (RCT) were compared to patients who were allowed to chose their own treatment path. RCT refers to the fact that patients were assigned to a treatment group randomly and not based on their symptoms or preferences.

Measures of outcomes included pain, physical function, and general health. Patients in both groups made moderate progress. There were no big differences in results between the surgical and nonsurgical patients.

However, when the data was combined for the RCT group and the self-selected treatment group, then surgery was the better treatment option. Patients who had surgery made more progress in treatment than those who had conservative care.

Surgery was linked with less pain, better function, and decreased disability. Seventy-five per cent of the surgical group said they had major improvement. This was compared with only 25 per cent in the conservative care group.

Some experts who reviewed the findings still question how accurate it is to say that surgery is the preferred treatment. There were many patients in both groups who crossed over to the other group. For example, patients in conservative care decided to have surgery after all. And some patients scheduled for surgery cancelled the operation. They went to physical therapy instead.

Many more questions were raised than were answered by this study. More study is still needed before a final decision can be made. It may be that some patients will do better with one choice over the other. Finding the factors to predict treatment outcome is the next step.

In this study, two different methods of spinal fusion are compared for adults with spondylolisthesis. Spondylolisthesis describes a condition in which one of the lumbar vertebrae slips forward over the vertebra below it.

One group of patients were treated using posterolateral fusion (PLF). For the PLF, bone graft from the patient’s pelvic bone is used to fuse the spine. In some cases, screws are used to help hold the spine until fusion occurs. PLF is considered the gold standard or best way to treat spondylolisthesis.

The second group was treated with a posterior lumbar interbody fusion (PLIF). With the PLIF method, the surgeon removed the disc. This is called decompression and is the main difference between the two methods. The empty space was filled with a wedge-shaped implant called a ramp. Bone graft was placed on either side of the ramp.

PLIF has some advantages over PLF that suggest it may be a better way to fuse patients with spondylolisthesis. Studies to support PLIF over PLF are lacking. Evidence from studies done so far is weak.

The results of this study did not support the use of PLIF as a better fusion method. After two years, patient results were the same between the two groups. Pain levels, disability, and patient satisfaction were used as outcome measures.

The authors note that there were many more complications in patients with PLIF. Reasons for this include longer operating time and greater loss of blood. PLIF is a more demanding, invasive procedure without improved results over PLF.

Orthopedic surgeons are aware of the hip-spine syndrome but no one has ever studied it. The hip-spine syndrome refers to low back pain (LBP) that occurs as a result of hip osteoarthritis (OA). This is the first study to show the positive effect of hip replacement on low back pain.

The authors set out to see if reducing hip pain and improving hip function would change back pain. Patients with severe hip OA who were scheduled to have a total hip replacement were included in the study. All patients in the study also had at least moderate LBP.

Everyone was followed for a minimum of two years. After two years, patients were still reporting continued improvement in pain levels and function of the hip. Improvement in LBP did not change from what was experienced by the end of three months after hip replacement. But relief from back pain was maintained at the two-year follow-up.

This study documented improvement in back pain and function after hip replacement. The results validate the theory that hip-spine syndrome is a real condition.

The exact cause remains unknown. Change in posture because of pain may be a factor. The authors were unable to show that it was from a true change in the spinal or sacral alignment. Future studies may be able to identify the link between these two sets of symptoms.

Scoliosis or curvature of the spine is often thought of as a childhood problem. But more and more, older adults are experiencing this condition, too. Studies show that bone spurs and degenerative disc disease probably start the process that leads to scoliosis.

As these changes alter the biomechanics of the spine, the vertebrae can actually start slipping sideways. The bones start to rotate resulting in lumbar scoliosis. In this article, surgeons from the Twin Cities Spine Center in Minneapolis, Minnesota review the causes, symptoms, and treatment of this type of degenerative scoliosis.

It’s likely that degenerative scoliosis is more common than previously thought. Studies show that more than half of older adults have this condition. And with the aging of America, it’s probably going to increase even more.

The changes that occur with degenerative lumbar scoliosis also result in a narrowing of the spinal canal called spinal stenosis. Symptoms of both conditions include low back pain. Pressure on the spinal nerves can cause pain down the leg as well. Bending forward or sitting relieves the pain. This is called neurogenic claudication.

Treatment is with conservative care to manage the pain. Antiinflammatory drugs, exercises, bracing, and steroid injections are the most common methods used. No more than four injections are used within a six to 12 month period.

Surgery is considered only after every other option has failed. The goals of surgery are to take the pressure off the nerves and stabilize the spine. Most patients are elderly and have many other health issues making surgery risky. Patients should be warned that the procedure doesn’t always change their symptoms. Pain relief and improved walking are the hoped for results.

The authors suggest only doing what is absolutely necessary during surgery. Most often decompression and fusion are done. However, they do advise that all surgical steps needed should be performed at one time. When fusion is considered, bone quality should be checked first. The types of fusion possible are also reviewed.

When doctors want to know whether or not a specific treatment is effective, they look at a collection of studies and compare the results. The most reliable data comes from a specific type of study called random controlled trials (RCTs).

In a RCT, patients are assigned to groups randomly. This may be done by putting everyone in one group whose birthday was in an odd year. Everyone born in an even year is assigned to another group. Or a computer program can do it randomly.

Each group is treated differently and the final outcomes are compared. In this news report, six RCTs comparing discectomy to nonsurgical care for painful disc herniation are reviewed. The trials were conducted over a period of 25 years. So they were very different in design and approach.

Although there were many things that couldn’t be compared in these six studies, they did agree on the following points:

Artificial disc replacement (ADR) has become a way to replace a degenerated disc without losing motion. Young patients need an implant that will hold up under constant loads for many years. In this study, two ADR designs are compared. The fixed-core and the mobile-core lumbar ADR.

Forces through the vertebrae and the discs between the vertebrae affect the load placed on the face joints of the spine. The facet joints can generate pain in the lumbar spine so increased loads there are important. Surgeons want to find the best placement of the ADR to avoid shear force and stress on the facet joints.

The fixed-core implant is a ball and socket design. The vertebral body moves around a fixed center of rotation (the ball). A mobile-core implant has a moving center of rotation. This is created by two plates that move around a central core.

It appears that the type of ADR and where it’s placed inside the disc space may effect motion and loading at that segment. A 3-D computer model was created to test this theory and find out more about the best placement for ADRs. The model was of the L45 lumbar spinal segment.

The geometric center of the disc nucleus (center part) was used for all implant placements. Viewed from the side, this is located two millimeters (2 mm) behind the center of the vertebral body. The load placed on the facet during motion using this placement with both types of ADRs was calculated. All tests were repeated with the implant misplaced (four mm behind the center instead of two mm).

The authors report that the mobile-core ADR can be put anywhere in the disc space and still decrease the load on the facet by at least 50 per cent. The same was not true for the fixed-core implant. When placed in the center, the fixed-core ADR increased the load by 10 per cent. A misplaced fixed-core implant increased the load by 40 per cent.

The results of this study suggest that the mobile-core implant may be more forgiving than the fixed-core when misplaced. In other words, errors in placement may not be such a problem with the mobile-core ADR compared to the fixed-core model. Long-term studies must be done to confirm what happens over time. When it comes to reducing load on the facet joints, this study shows an advantage of the mobile-core ADR.

The best material to use for spinal fusion is autologous bone from the iliac crest. Autologous means it is harvested from the person who needs it. Using your own bone chips is safer and costs less than getting donor bone from a bone bank. Bone from the iliac crest is easy to harvest.

The major downfall with this type of bone graft material is the pain some patients experience at the donor site. It can be a bigger problem than the spinal fusion operation.

In this study, researchers from the Netherlands take a closer look at pain levels in patients who use their own bone grafts. They compared pain after the operation for patients who had a high fusion with patients who had a low fusion.

High fusion included patients with spinal fusion anywhere between T2 and L2. Low fusion was done anywhere from L3 down. Fusion was done in all patients for traumatic spinal fractures that were treated surgically.

The graft was taken from the posterior iliac crest. The iliac crest is the top, curved part of the pelvic bone. Taking the graft from the posterior part of the crest means it comes from the back instead of the front of the bone. This is located close to the vertebrae of the spine.

They found that the patients who had the spinal fusion close to the site of the donor site were the most likely to report pain up to two years later. Almost 41 per cent of this group reported chronic pain at the donor site. They also had the most severe pain. Patients who had a spinal fusion in the high fusion group had the lowest incidence (14 per cent) of chronic pain from the donor site.

The authors suggest that it may be difficult to tell the difference between donor site pain and pain from the spinal fusion. This is especially true when they are close together in the low back area. Reports from previous studies of donor site pain may be overestimated. The fusion level and its relation to the donor site must be taken into account for a more accurate picture.

This report is from physicians at the Department of Neurosurgery, Stanford University School of Medicine. They studied national trends related to pathological vertebral fractures (PVFs).

PVF refers to a fracture in a bone weakened by some other condition. Osteoporosis (brittle bones) and cancer that has spread to the bone are the most common causes of PVFs.

The authors collected patient data over a period of 12 years (1993-2004). They were able to see trends in treatment and outcomes. The following key findings were reported:

Over 20 years ago, a group of researchers led by T. G. Mayer, M.D. proposed a new approach to chronic low back pain (LBP). The focus moved away from bedrest to a more active treatment approach. The new program was called a functional restoration program.

Instead of avoiding activities, patients were advised to follow a program of exercise to restore function. The goal was to return to work by overcoming deconditioning from inactivity. Workers participated in a program 57 hours each week.

Psychologic needs of the patients were also included in the functional restoration program. Personal and family counseling was provided. Pain management using relaxation and guided imagery was also included.

The results of this work were published and received the 1985 Volvo Award for Research in Back Pain. In this current article by James Rainville, M.D., the work by Mayer and associates is reviewed.

The authors reflect on changes that have taken place in the care of chronic LBP patients as a result of the original Mayer article. The Mayer group clearly changed the way chronic LBP was managed. Better health was reported and more workers returned to work than ever before.

Our current health care system includes a work disability program that does not support the functional restoration program. Even so, when used with chronic LBP patients, the number of sick days is reduced.

Working through the pain can reduce back pain. But even if it doesn’t, physical function is improved. Disability is reduced. Mayers’ group showed that vigorous exercise does not make chronic LBP worse.

Helping patients overcome their ideas about what they can and can’t do was a new approach 20 years ago. Today, it is a core value in the care of LBP.

There’s no doubt that seatbelts save lives. They also reduce neck injuries. But do they protect the lower spine from trauma? That is the focus of this study comparing two groups of patients.

All patients in the study had a motor vehicle crash (MVC). They were riding in the front seat of a four-wheeled vehicle. The impact was from the front of the auto.

Injury occurred at the thoracolumbar junction (TLJ). This is the place in the spine where the thoracic vertebrae end (T12) and the lumbar vertebrae begin (L1). The first group of patients was restrained by a three-point seatbelt (lap-shoulder). The second group was not wearing a seatbelt when the accident occurred.

Two major types of injuries (fracture and dislocation) were compared between these two groups. The restrained group did not have any cases of dislocation. They had a 5.6 per cent incidence of neurologic deficits. This was compared with 33.3 per cent in the unrestrained group who had a neurologic problem as a result of fracture/dislocation.

The authors conclude that nonrestrained front seat occupants in MVCs have more severe TLJ injuries. This is likely the result of a more violent, traumatic force at the time of the impact. The unrestrained group was mostly male and much younger than the restrained group.

The results of this study support the idea that seatbelts protect the spine. However, it should be noted that restrained front-seat passengers still experience compression/burst fractures. The exact mechanism for this injury is unknown at this time.

Sciatica, also known as the lumbrosacral radicular syndrome (LRS) can be a painful and disabling problem. Pressure on the nerve as it leaves the spinal cord can lead to the back and leg pain common with sciatica.

A herniated disc is the most likely cause of LRS. But other problems such as tumors or stenosis (narrowing of the spinal canal) can also cause LRS.

In this study, researchers from the Netherlands examine the cost-effectiveness of physical therapy treatment for sciatica. They compare two groups of patients. All patients had LRS but were divided by treatment.

One group had care with their general practitioner. They were given information and advice. Pain relievers were also prescribed when needed. The second group received physical therapy. The patients in both groups were treated for up to nine sessions over a period of six weeks.

Results were measured by patient survey. Follow-up took place one year after treatment. Questions about symptoms, cost, and perceived benefits were asked and analyzed. The results showed a significant difference between the two groups.

More patients in the physical therapy group reported improvement and satisfaction with the results. The extra direct costs of physical therapy were calculated. The authors concluded that physical therapy added to general care was not more cost-effective when compared with general care alone.

Factors that were not evaluated in this study included time away from work or change in productivity for each group. Further study is needed to assess if the cost of added treatment is valuable from a productivity point-of-view.

Low back pain can shoot down the leg, a symptom called sciatica. The cause of the leg pain is pressure on (or irritation of) the spinal nerve. The pressure usually comes from a protruding disc, bone spur, or other degenerative changes in the spine.

Any time a nerve is damaged or irritated in this way, the condition is called lumbar radiculopathy. Besides sciatica, radiculopathy can also be accompanied by numbness and tingling down the leg. Weakness and loss of sensation can occur. Deep tendon reflexes such as the patellar tendon reflex and the ankle jerk may be changed (increased, decreased, or absent).

One test used most often to test for lumbar radiculopathy is called the straight raise leg (SLR). This test can be done in the sitting position or with the patient lying down (supine). The examiner lifts the patient’s leg to 90 degrees while keeping the knee straight.

Normally, the test movement causes the nerve to glide. A positive test occurs when the test causes or reproduces the patient’s pain and other symptoms. The gliding nerve is pressed and pulled against the disc causing pain.

In this study, both test positions (sitting and supine) were compared for sensitivity and accuracy. How likely is it that the patient has a disc problem based on the SLR test? Does it matter if the patient is sitting up or lying down when the test is done?

All patients included had a positive MRI for lumbar disc herniation. The imaging was done before the two SLR tests were done. The results of testing showed that the supine SLR was a much better test of lumbar radiculopathy compared to the sitting test.

The authors caution anyone conducting SLR tests to be aware that the seated test may not detect the presence of lumbar radiculopathy when it’s present. More studies are needed to compare these two test positions before suggesting we disband the seated test.

Sometimes researchers come to conclusions that may not really be supported by the data. Results may be overstated in a positive way. This problem is called over-reporting.

Staff from the Institute for Research in Extramural Medicine in the Netherlands took a second look at 43 randomized controlled trials (RCTs). These studies involved exercise for chronic low back pain (LBP). Almost half reported very positive results for exercise therapy.

In fact, only six of the studies really showed that exercise was statistically and clinically important. And that’s the problem. Statistics can show one thing on paper. But the clinical results (how the patients are doing) are a separate issue.

The authors point to one concept that researchers should pay more attention to. And that’s the minimally clinically important difference (MCID). Measures of results such as pain, function, health status, or disability are often used to show results.

But how much change in each of these factors before and after the treatment is considered significant? That’s what needs to be addressed for future studies. The authors say it would be good if a common base of information and MCID were used in all studies. This would help advance LBP research.

Exercise has been touted as one of the few treatment methods that actually works. But the results of this review suggest that these studies have overestimated the treatment effects of exercise. A closer look at studies reporting on other interventions for chronic LBP (advice, behavioral therapy, medications) may have the same problem of over-reporting.

To avoid exaggerating results of studies, the authors offer other researchers seven suggestions. First, choose one main measure of results. Make it clinically relevant. Do a sample size calculation. This tells the researcher how many people have to be in the study to get results that are statistically significant. They also review important statistics to use and how to analyze them.

Finally, the authors suggest that studies should not report success with their treatment unless the results have clinical importance.

Many studies are published each year on the results of treatment for low back pain. Surgery for lumbar disc prolapse is one of these operations. In this review, two well-known back experts review current data on this treatment. They analyzed and compiled the results of 40 randomized controlled trials (RCTs) and two other semi-RCT studies.

Patients were grouped according to how long they had their symptoms. There were three groups included. Group one had symptoms less than six weeks. Group two had symptoms six weeks to six months. Group three had symptoms longer than six months.

Results from disc removal by any method were measured by recovery, pain level, and function. Function was measured using various scales of disability or quality of life. Return to work and number of further operations were also recorded.

Comparing results was limited because many studies did not include the same information. For this reason, results had to be interpreted carefully. Whenever possible, the authors compared surgery with conservative (nonoperative) care. Various methods of disc removal (discectomy) were compared.

The different types of discectomy included laser, microendoscopic, open, and percutaneous. The use of chymopapain is no longer available so the studies available were presented as a historical summary.

The authors report that all things considered, most lumbar disc prolapses resolve on their own without any treatment. For patients with severe sciatica, discectomy provides rapid relief of symptoms. It’s still unknown when is the best time to have surgery.

Whether a microdiscectomy or standard disc removal is better may depend on the surgeons’ expertise. Overall it appears the results are about the same. Laser discectomy and coblation therapy are still viewed as research tools. Despite the large number of studies on the topic, more studies with a specific focus on treatment of disc herniation are needed.

The authors suggest the quality of studies needs to be improved. Longer follow-up of patients is advised. There should be a comparison of patients who have surgery with those who don’t have surgery.

Records should be kept to measure the cost of the procedure and compare it to the benefit obtained. Different operations could then be compared against each other both in terms of cost and effectiveness.

It’s been assumed for years that a decline in physical activity leads to deconditioning and that deconditioning can result in chronic low back pain (CLBP). But studies have not been able to prove this point right or wrong. However, research does show that declining physical fitness is more likely to be related to disability.

This study of the relationship between physical fitness and CLBP included patients with subacute LBP. Subacute means the pain has been present between four and seven weeks.

Physical activity level (PAL) was measured for each person. A special device was used that recorded how much the person moved. They wore the accelerometer for seven days during their waking hours. Their PAL was measured twice: once at the beginning of the study and again at the end of one year. Decline in PAL was referred to as disuse.

At the same time, three measures of physical fitness were taken. These included body weight, body fat, and muscle strength. The data was analyzed for two groups: patients who recovered during the year and those who developed chronic LBP.

PAL increased for both groups. Strength and percentage of fat remained the same in both groups. Disuse was reported in less than half the patients. All patients with chronic LBP actually had an increase in activity levels. This showed that patients with chronic pain could cope in such a way as to maintain their daily activity at a normal level.

This study over a year period of time failed to show that deconditioning occurs as a result of chronic pain. Patients may have felt disabled, but they didn’t stop doing their daily activities. Consequently, their level of physical fitness didn’t change.

The search continues for a way to predict and prevent chronic low back pain (CLBP). One theory is that CLBP leads to physical deconditioning. Deconditioning means loss of strength, endurance, and aerobic capacity. Deconditioning is likely to result in more pain. But this theory has never been proven.

In this editorial, the authors comment on the first longitudinal study of patients with LBP. Longitudinal means they followed the patients over a longer period of time to see if deconditioning is really the end product of pain. In this case, the time period was a full year.

The study did not show that deconditioning occurs as a result of CLBP. But the editorial authors point out some ideas to consider before throwing the deconditioning theory out the window.

First, some of the patients might have received treatment during the year long study. They weren’t told not to and they weren’t asked what, if any, treatment they had. Treatment might have prevented deconditioning.

Second, it’s hard to really get an accurate measurement of people’s activity level. They don’t always remember what they did. Sometimes they become more active when they know they are being monitored.

It is possible the variables used to measure fitness aren’t good tools for assessing deconditioning. Things like body weight, amount of body fat, and muscle strength may not really measure conditioning or deconditioning.

Previous studies have shown that reconditioning isn’t as important as other interventions. Reducing fear and worry that comes with pain for some people is more effective in increasing physical activity. This study was a good first start. More research is needed about the role of activity level in CLBP.

When it comes to surgery to stabilize the spine for degenerative spondylolisthesis, what’s the best operation? Just decompression (removal of bone)? Fusion with instrumentation (screws, metal plates)? Fusion without instrumentation?

Degenerative spondylolisthesis occurs when arthritis is combined with aging discs and degenerating spinal joints. Spondylolisthesis refers to the forward movement or displacement of the vertebra. The spine is unstable and neurologic problems can occur.

Slipping of the vertebra results in stretching and/or compression of the spinal cord and spinal nerves. The patient has back and/or pain, numbness,and weakness. Sometimes there are bowel and bladder problems. Surgery is the usual treatment for this problem.

In this report, researchers from the University of Ottawa (Canada) review studies on the topic from 1966 to 2005. They compared results of the three types of surgery to see if one had better results than the others.

They found 13 studies that qualified and could be included. There were a total of 578 patients with degenerative lumbar spondylolisthesis included. This type of review and analysis is called a systematic review. Instead of relying on the results of one study, the data can be pooled to show patterns of results more clearly.

The authors report a general trend of better results obtaining a solid fusion with an instrumented surgery. There was also a greater chance of repeat surgery with instrumented fusion. Both types of fusion surgeries had a lower reoperation rate compared with decompression.

Overall results were better with fusion surgery when compared with decompression alone. Achieving a solid fusion is more likely with instrumentation but the clinical outcomes (patient results) isn’t better with one type of fusion over the other. More research is needed with better designed studies.

Total disc replacement (TDR) has become a new option for patients with degenerative disc disease (DDD). It may replace spinal fusion. The obvious advantage is maintaining range of motion (ROM). There’s still some concern about what happens to motion in the spine below the level of the TDR.

In this study, surgeons from Korea study X-rays to see what affect TDR has on the lumbar spine. They also looked for any factors that might influence the results of surgery. Patients having the TDR were followed for at least two years.

All patients included in the study had severe pain from DDD that wouldn’t go away with any form of treatment. The lumbar levels affected were between L3 and S1. The disc was replaced with the ProDisc II prosthesis. The same surgeon did all the operations.

Digital X-rays were taken before and after the surgery. A computer program was used to take and analyze various measurements. Several factors were evaluated to see if they might influence ROM. These included age, sex, body mass index, and motion before surgery. The level of the implant was also included as a possible factor affecting the results.

The authors found that ROM at the L5-S1 segment was less than at other levels with this particular implant device. They suspect this difference can be explained by the unique anatomy of the L5-S1 segment. There are many ligaments and an increased stiffness in this zone. This is where the lumbar spine is connected to the sacrum.

Other factors had no value in predicting the results. ROM before surgery did not seem to affect motion afterwards. This result suggests that diseased segments with decreased ROM could benefit from TDR. The authors plan to study and report the outcomes over a much longer period.

Studies show that endurance of back muscles is more important than strength in preventing low back pain (LBP). Physical therapists (PTs) are studying ways to measure back extensor muscle endurance. They will use this information to set up the best exercise program for LBP patients after discectomy. Discectomy is the name of the operation to remove a herniated disc from between two vertebrae in the spine.

In this study, the test used was the Sorensen Test (ST). ST is a tool used to test the endurance of the lumbar extensor muscles. It is measured by the amount of time a patient can keep the upper body horizontal over the edge of a table without any support.

Improving performance on the ST is an important goal for anyone with LPB but especially after back surgery. Not everyone can do the ST. Some patients are too afraid to try it. Others have too much pain. So it was changed so that anyone can do the test safely and at their own level.

In the modified ST, patients start at a much more upright level. They gradually work their way down to an unsupported horizontal position if they can. The test can be done at six different levels and stopped when the patient cannot perform any further levels.

The six levels are from almost straight up (75 degrees) to horizontal (zero degrees). At each level, the position was held for as long as possible before fatigue, fear, or pain forced the patient to stop.

Analysis of the data showed that the ST is a reliable test when used on normal, healthy adults. The modified ST was not reliable for patients with LBP. There may be many reasons for this low reliability but it doesn’t mean the test isn’t useful.

By using this test, PTs will have a good starting point for therapy. Exercises can be prescribed at the right level that the patient isn’t afraid to do. Endurance can increase safely and the intensity can be adjusted properly.

The authors conclude the modified ST is a useful tool for prescribing exercise after low back surgery such as discectomy. The ST is just too intense for most patients during the first four to six weeks after a single-level discectomy. The modified ST allows everyone to be tested at their own level, within the safety of their ability, pain levels, and confidence.

There’s a wide range of patient responses to treatment for low back pain
(LBP). Some people get better while others develop chronic pain. Scientists
are trying to find out why this happens. Studies show that psychosocial
factors may predict the development of chronic LBP. These same factors may also predict the results or outcomes of treatment.

In this study, researchers from Johns Hopkins School of Medicine look for
predictors of pain-related outcomes after treatment for sciatica (leg
pain and numbness). Specifically, they looked to see if psychologic distress
(depression, anxiety) could predict pain and disability.

The goal is to find ways to screen patients ahead of time to identify these
predictive factors. This might help doctors choose the best treatment for each patient.

All patients in the study had a disc herniation causing the sciatica. Each patient took a survey before and after treatment to measure levels of distress. Treatment was different for each patient and included both nonoperative care and surgery.

The authors expected to find that higher levels of distress before treatment
would be linked with greater pain and disability. They did find that psychologic distress is a general risk factor for all patients. The greater
the distress, the more pain and disability present after treatment. This was true for all kinds of treatment and included workers’ compensation patients.

The authors say the results of this study do not suggest patients with depression or anxiety should not be treated. There’s a reason anxiety and
depression strongly predict pain and disability as much as three years after
treatment. It may be because these patients have poor coping strategies but
that’s just a guess. Future studies should take a look at this factor.