News Category: Lumbar Spine

Chronic low back pain may require surgery to remove a herniated disc or fuse an unstable spine. Removing the disc is called a discectomy or decompression. The hope is to avoid any further operations.

In this study, researchers from the University of Washington review the records of patients who had decompressive or fusion surgery from 1990 to 1993. Data was gathered for the next 11 years. The number of reoperations needed was added up and compared for these two groups.

They found nearly a 20 per cent rate of reoperation for both groups combined. Some conditions were more likely than others to develop complications requiring another operation. For example patients with spondylolisthesis had better outcomes after a fusion compared to decompression alone. Spondylolisthesis occurs when a fracture in the vertebral structure allows the main body of the bone to slide forward over the vertebra below it.

And for other conditions such as herniated discs, spinal stenosis, or a degenerative disc disease, decompression had better results with fewer reoperations compared to spinal fusion.

There were some factors that predicted a greater chance of reoperation. For example, patients with workers’ compensation were more likely to have a reoperation compared to patients covered by private health insurance. Older patients (60 years old and older) were less likely to have a second operation.

The authors conclude that in general, the number of reoperations after lumbar spine surgery was significant. They suggest the lower reoperation rate after fusion was due to the surgeon giving the bone graft a longer time to heal before considering a second operation.

More than half of the reoperations after fusion were required because of problems with hardware used to stabilize the spine or because movement occurred where the fusion was supposed to prevent motion.

In 2005, a group of physical therapists (PTs) published a study outlining the first clinical prediction rule for patients with low back pain (LBP). Using this tool, PTs are able to predict which LBP patients might benefit from a program of lumbar stabilization exercises.

In this study, another group of PTs used digital fluoroscopic video (DFV) to look at movement patterns in back pain patients. These patients were judged by the CPR to be good candidates for stabilization exercises.

Lumbar motion was captured by DFV and analyzed using computer software programs. A full cycle of flexion and extension in the standing position was recorded. Movement patterns were compared between a group of 20 LBP patients and another group of 20 adults without LBP.

The program allowed the researchers to look for differences in speed, sequence, and timing of muscle action and motion. This is called a kinematic analysis. The analysis showed a disordered movement pattern present during the first 15 per cent of lumbar flexion.

The normal group had an even rate and flow of motion across all lumbar segments. The LBP group only had a normal response at the L5-S1 segment. In fact, motion at the upper segments was either absent or went in the opposite direction.

Just the opposite reaction occurred during lumbar extension. There was a delay in the rate and angle of motion at all segments except one. This difference was seen during the last phase of motion as the patients returned to the upright position after bending forward.

The authors describe this pattern of decreased motion as segmental hypomobility. This finding was a surprise because it has been assumed that lumbar instability in LBP patients was a result of hypermobility (too much motion) at one or more lumbar segments, not a decrease in motion.

The results of this study are preliminary but may help therapists understand why some patients would respond better than others to lumbar stabilization exercises.

Low back pain with symptoms down the leg(s) is a common symptom of spinal stenosis in older adults. Spinal stenosis is a narrowing of the space available for the nerve roots and their blood vessels in the spine.

Standing up straight or extending the spine closes these spaces even more causing increased symptoms. This is called positional dependent spinal stenosis. Bending forward has the opposite effect and often reduces painful symptoms. The usual way to diagnose this problem is based on the patient’s report of symptoms and a standard supine (lying down) MRI.

However, a dynamic slip from spondylolisthesis won’t show up in a standard MRI. Spondylolisthesis describes a spinal condition where the body of one vertebra slips forward over the vertebra below it. The traction from this movement pulls on the neural tissue causing worse symptoms.

Patients with spinal stenosis and spondylolisthesis may need surgery to take the pressure off the spinal nerves and spinal fusion to stop the slip. In this study, orthopedic surgeons at Baylor College of Medicine showed that changes in the shape and position of the facet joints of the spine can help show when there is positional dependent spinal stenosis with spondylolisthesis. The surgeon needs this information before planning surgery.

The authors call these facet joint changesthe facet distention sign. Once the physician knows what to look for, this sign can be seen on standard supine CT or MRI images. The presence of the facet distention sign predicts that when the patient is standing upright, the vertebra will slip forward making the stenosis worse. Standing X-rays or a myelogram can then be done to determine the degree of slippage.

As more and more people seek help for disabling low back pain (LBP), researchers are stepping up the number of studies on treatment for this condition. Many patients are trying herbal supplements to control pain.

In this study, the results of 10 trials using herbal medicine for LBP are reported. In each research project, half the patients received a supplement. The other half (control group) did not get a supplement. All subjects were adults over the age of 18 with nonspecific LBP. Nonspecific means there is no known cause for the pain.

The authors describe by name a list of herbal medicines used to treat LBP. Some subtances were taken by mouth (oral). Others were creams used to rub on the skin over the painful area.

They also discuss how these products work biochemically. The dosage of each substance used was recorded and compared to the final results. The major method of measuring success was change in the patient’s pain level. Any adverse effects of the herbs was also noted.

There were two herbal medicines that showed good results in the treatment of acute episodes of chronic nonspecific LBP. Included were H. procumbens andharpagoside (an extract of S. alba). Several others were listed as having moderate evidence of effectiveness.

More study in this area is needed to identify effective herbs with minimal side effects. Dosage and duration of use should also be studied to find the most effective use. It would be helpful if herbal medicines were compared with standard treatment using aspirin or Tylenol.

Lumbar disc herniation can cause serious symptoms of leg weakness, numbness in the groin, and loss of bowel or bladder control. This group of symptoms is called cauda equina syndrome (CES).

CES is rare but when it happens, surgery is required to prevent permanent or irreversible neurologic damage. Decompressive surgery is done to take pressure off the spinal nerves. Part or all of the herniated disc is removed.

Most physicians consider CES a surgical emergency. Surgery is required to prevent serious mental and physical disability. This study investigates the results of surgery based on when (how early) the surgery was done for 42 patients.

Five of the patients were operated on within 24 hours. At least half had surgery between 24 and 48 hours. The rest were delayed 48 hours or more. Age did not seem to affect the outcomes. Men and women had the same symptoms before the operation, but women had more problems with bladder control after the surgery.

Patients were followed for up to two years. In general,it did not appear that the timing of the surgical repair made a difference in the results. Even with treatment, the patients with CES did not return to normal. One-third were unable to return to work.

The authors could not say with absolute certainty that a delay in operation is good or bad. Common sense suggests early surgery to take pressure off the spinal nerves would give a better result, but there is no hard evidence for this.

Despite 20 years of use in Europe, there are very few reports on the long-term results of lumbar artificial disc replacements (ADRs). This is the first study published on ADR failure from wear debris.

ADRs are made of plastic and metal component parts. Tiny pieces of those materials can flake off setting up an inflammatory response. The implant starts breaking down or causing nearby bone to dissolve, a process called osteolysis. The ADR loosens and must be removed and replaced.

In this report, four cases of ADR failure are analyzed and discussed.The patients had severe symptoms of pain and loss of function. Walking was difficult. Standing was impossible and sitting was very limited. Surgery was done to remove the ADRs. All implants showed signs of wear debris. The nearby tissue was tested for an immune response. The bone was checked for osteolysis.

They found inflamed tissue around the old and newly formed bone. There was extra blood supply and nerve fibers in the inflamed area. Many of the plastic (polyethylene or PE) particles were seen in the inflammatory tissue. Scar tissue had formed around the loose implant. PE particles were present in the scar tissue, too.

Once the ADRs were removed, the surgeon could see pitting, cracking, and brittle edges of the rim around the core of the implant. In one case, the core had fractured.

This report shows that long-term wear debris can be a problem with lumbar ADRs. Some, but not all problems were caused by the wrong size and/or position of the implant. Improved surgical technique may help eliminate some of these problems.

The authors suggest all patients receiving a disc replacement should be followed long-term to monitor the status of their implants.

It takes time to get back to work after a long episode of low back pain (LBP). Studies show that a multidisciplinary team may have the best results for chronic LBP. In this report, researchers from the Netherlands report on the long-term results of this approach.

Multidisciplinary treatment involves several health care professionals. The team may include a physician, physical or occupational therapist, social worker, and psychologist or counselor. The training program is intense but graded. This means it takes hours each day but goes at the patient’s own pace.

Ten studies utilizing a multidisciplinary approach for chronic LBP were reviewed. Some had two elements (physical and educational or psychological). Others included up to four components such as physical, educational, social, psychological). Follow-up varied from six months to five years.

Results were measured in terms of work participation and perceived quality of life (QOL). There was a positive effect of multidisciplinary back training (MBT) on work participation. Evidence was limited for a similar positive effect on QOL. MBT did not change pain levels or function.

The authors conclude MBT does help peole get back to work, which may improve QOL as well.

Magnetic resonance imaging (MRI) is often used to look for tumors, infection, or disc herniation as a cause of low back pain. Vertebral marrow and endplate changes are used to classify the spine as stable or unstable. Marrow is the soft tissue found in the hollow center of bones. The endplate is a piece of cartilage between the disc and the vertebral bone.

Modic Type 1 (MT1) changes seen on an MRI of the spine are considered unstable. Modic Type 2 (MT2) changes indicate a stable spine with no sign of ongoing changes occurring. MT0 is used to describe normal disc and vertebral bone. This method for classifying vertebral marrow and endplate changes was devised by Dr. M. T. Modic in 1988 and used ever since.

In this report, two cases of Modic changes called conversion are discussed. Both patients had degenerating discs in the low back at the L5-S1 level. Repeated MRIs showed MT2 (stable) changes transformed or converted into MT1 (unstable) changes. The patients did not report any change or increase in back pain or other symptoms during the conversion.

Both patients had surgery to remove the disc. An artificial disc replacement was inserted with complete relief of painful symptoms. Relief from chronic back pain was still sustained three years later in both cases.

The authors use this study to point out that MT1 and 2 changes may not really reflect the true situation. MT2 changes may not be as stable or unchanging as previously thought. When it comes to patient symptoms, MT1 and MT2 changes can be equally painful and disabling.

The authors also report the results of other studies that found MT changes can convert from MT1 to MT2 (unstable to stable). Less often conversion occurs from MT1 to MT0 (unstable to normal). Rarely, MT2 converts to MT1 (stable to unstable).

Research has shown that psychosocial factors play a role in low back pain (LBP). Work load, limited control over work, and job satisfaction are some of these factors. But the results of these studies don’t all agree or show consistent patterns.

In this study, researchers from Belgium used information from a survey already completed by 2,556 middle-aged workers (men and women). The goal was to assess psychosocial factors about job stress.

Some questions measured job control, perception of job insecurity, and feelings of stress at work. Other items assessed support from supervisors, coworkers, friends, and family. Workers were asked about back pain and physical demands of the job (lifting, awkward body positions, rapid movements).

Almost half of all workers surveyed reported having LBP. Back pain was defined as LBP for a total of eight days or more during the last 12 months. The number of women affected was higher than men. Older workers who smoked or were overweight were more likely to report back pain. LBP was more common among workers with high physical job demands.

Men with little control over their job decisions were more likely to have LBP. Other significant factors included low social support at work, low wage satisfaction, and high stress at work. Women were not significantly affected by these factors. They were more influenced by high job insecurity. There was no clear link between psychological demands and LBP for men or women.

The results of this study support previous reports that LBP is linked with psychosocial risk factors. Follow-up over 6.6 years showed a high rate of retirement, resignation, or dismissal.

Company reorganizations and restructuring eliminated 73 per cent of the workers in the study. The authors suggest their reported results may be underestimates of the long-term drop-out effect of low job control.

A new tool in rehab called the Bodyblade has been tested recently with good results. The Bodyblade is a long, thin foil that oscillates (moves back and forth) at a natural frequency of 4.5 Hz. A foil is the thin sword used in fencing or sword fighting.

The speed of the oscillation combined with the position of the user activates trunk and abdominal muscles. The orientation of the blade is also important when using this tool in rehab.

Fourteen (14) healthy athletes were tested using the Bodyblade. Four different exercises were performed to challenge the core trunk muscles. Surface electrodes attached to the skin recorded muscle activation during each exercise. Position of the spine was also tracked using a special electromagnetic device.

Compressive force through the spine and spinal stability were measured using well-known math and computer models. Patterns of muscle activation were identified and analyzed.

The authors report the key to successful use of the Bodyblade literally lies in the hands of the user. It seems only some people are able to master the coordination needed to achieve resonance. Others can not do so no matter how much they practice.

For those who could use the Bodyblade easily, horizontal use resulted in the highest activation levels of trunk and abdominal muscles. Diagonal use resulted in moderate amounts of muscle cocontraction. Cocontraction is the use of muscles on both sides of a joint at the same time.

Patients who could not oscillate the Bodyblade at lower levels of amplitude had greater spinal compression. For this reason, safety may be an issue for some patients.

Low back pain with leg pain (sciatica) is a common feature with herniated discs. The disc material presses against the spinal nerve causing painful symptoms. The recent trend toward minimizing spinal surgery has led to new techniques. These advances are designed to relieve pressure on the nerve by taking out part (or all) of the disc.

In this study, researchers from Turkey report on the results of percutaneous nucleoplasty (PN) for sciatica caused by disc protrusion. PN uses radiofrequency (RF) energy to destroy the center of the disc called the nucleus pulposus.

This procedure is minimally invasive and only requires a short stay in the clinic or hospital. Patients usually go home the same day. A local anesthetic is used. A RF probe goes in and out of the nucleus creating tunnels or channels in the disc. There is less scarring linked with PN, so fewer cases of pain recurrence.

The results of 52 patients treated with RF nucleoplasty are reported. Thirty-four (34) patients had one disc treated. Eighteen (18) others had two discs treated with this method. Testing done before the PN showed all discs had an intact covering around the disc. This portion of the disc is called the annulus.

Patients were followed for one-year after the procedure. During that time, there were no complications reported. Three-fourths of the patients had complete pain relief at six months. By the end of the year, 84 per cent were symptom-free. Two patients had a second operation within a week of the first procedure due to unrelenting pain.

Although the authors recommend using this treatment method for sciatica caused by contained disc protrusion, an independent researcher questioned the results. Dr. E. J. Carragee from Stanford University School of Medicine pointed out that many patients with sciatica get better without treatment.

Measuring the results after one-year won’t sort out who got better with or without treatment. Likewise, a study this small cannot confirm the safety of the procedure. Until further study is done, Dr. Carraggee does not advise using this treatment method just yet.

Health care is taking a closer look these days at the results of treatment for all kinds of conditions. Patients, physicians, and insurance companies want to know that the treatment chosen is effective for the problem. Toward this end, researchers have developed a new tool to assess treatment outcomes for low back pain (LBP) patients.

The Lumbar Spine Outcomes Questionnaire (LSOQ) is a comprehensive survey to evaluate treatment results. Six measures are included: 1) severity of back pain, 2) severity of leg pain, 3)function/disability, 4) psychological distress, 5) physical symptoms, and 6) use of health care services.

A group of 40 orthopedic surgeons, physiatrists, and psychologists decided and agreed on which test items to include. The survey was tested on 150 LBP patients at eight spine clinics throughout the U.S. Everyone filled out the survey before and after treatment. Once the questionnaire was ready, it was given to over 2,000 LBP patients (before and after treatment).

Most of the patients could fill out the survey in 10 to 12 minutes without any help. It can be used in an over-the-phone interview, face-to-face interview, or the patient can fill it out him or herself. There is an instruction manual and scoring can be done on a computer.

There are many different survey tools available to measure results of treatment for LBP. Often more than one must be used to get all the important data collected. The LSOQ is the first all-in-one questionnaire for this group of patients. It is easy to use, reliable, and valid. The authors suggest using it in both clinical and research settings.

In this study, patients with sciatica due to disc herniation were observed over a 10-year period of time. The goal of the study was to compare long-term outcomes between workers who received worker’s compensation (WC) and those who didn’t.

Health-related quality of life was also measured. The authors looked for ways to predict the final results for patients receiving WC. Some of the patients were treated with surgery to remove the disc. Others had a wide range of nonsurgical treatment.

Work status and disability status were measured by survey (questionnaires mailed to the participants). Subjects completed the same survery every year for 10 years. Questions were asked to see if the person was working or receiving any compensation for back problems or sciatica. Everyone was asked if they had hired a lawyer because of their current back problems.

Other information was collected about pain, symptoms, function, and quality of life. All data was analyzed to find factors present from the beginning that were linked with better results in the end for patients getting WC.

The following results were reported:

Almost 800 adults participated in this study of low back pain (LBP). There were two goals:

This study presents the results of a telephone survey of the U.S. workforce measuring low back pain (LBP) and work loss. It was part of a larger national telephone survey conducted by the Caremark American Productivity Audit.

The focus of the study was to measure how many adults have LBP at any one time and calculate the cost in lost productive time. Everyone contacted in the main survey was 16 to 65 years old and currently employed.

Subjects included in this study were 40 to 65 years old and reported back pain in the previous two weeks. All were employed during that time. Two groups were compared. The first group had back pain. The second group did not have back pain.

The authors report about 15 per cent of the total group had LBP at any point in time. This is called prevalence. Almost half of those adults (42 per cent) had repeat episodes of back pain called relapses or exacerbations.

Workers with LBP relapses reported much more activity limitation and lost production time compared to workers without LBP or workers with other health problems. The cost of LBP to employers was estimated at 7.4 billion dollars/year. Three-fourths of that cost is directly linked to relapses.

The authors conclude that more efforts to reduce flare-ups of LBP could improve work productivity. More research is needed to find ways to predict workers prone to LBP relapses and treat them to prevent this from happening.

About one-quarter (25 per cent) of back patients who have a disc removed aren’t able to go back to work — even six months later. Who’s at risk for this problem? If doctors can screen patients before surgery, they may be able to reduce this problem. Treatment early on might give patients what they need to avoid work loss.

To test for what are called predictive risk factors, researchers from the Netherlands studied adult workers who had a paid job before back surgery. All the patients had a problem called lumbrosacral radicular syndrome (LRS). This means a bulging disc was causing back and leg pain.

Patients were tested and took a survey one day before the operation. These measures were repeated three days after surgery and again six months later. Work-capacity (WC) was assessed using a self-report questionnaire. WC was calculated as a percentage of previous capacity before surgery. For example, a patient who worked 40 hours/week before the operation who can only work 20 hours now had a 50 per cent work capacity.

Results showed three factors that may predict reduced work capacity after surgery for LRS. The first is fear of movement or reinjury. The patients who are afraid to move because it might hurt or because they might reinjure themselves were less likely to return to work.

Second, patients with passive means of coping with pain had reduced work capacity. This includes patients who worry and avoid activity as their main ways of coping.
The third predictive risk factor for reduced work capacity was a higher physical work-load on the job and lower job satisfaction.

The authors conclude that most patients with LRS do get back to work full-time. Those who don’t have cognitive-behavioral factors that keep them from doing so. These factors may be treatable.

Helping patients overcome their fears, improving fitness, and training them to handle different workloads may be the key. More studies are needed to find out what works best. The first step is the screening process to predict who might have these problems.

Drs. Lin and Wang present a review of the total disc replacement (TDR) from its beginnings in the 1950s until today. Surgeons refer to TDR as a total disc arthroplasty (TDA).

TDA has become an alternative treatment option to spinal fusion. The goals of TDA are to: 1) remove the source of pain, 2) maintain disc height, 3) provide spinal stability, and 4) preserve motion.

The design of the TDA has changed over the years. Studies have shown what works and what doesn’t. Today’s TDAs are a ball and socket style. They must last the lifetime of the patient. The materials must be acceptable to the human body to avoid rejection. The disc must not break down or shed particles called debris.

There are two main lumbar discs available in the United States (Charité III and ProDisc-L). Other implants are being studied. Each design has its own specific unique qualities.

Materials, load-bearing surface, and mobility or constraint are just a few things that must be considered. How and where the implant moves and how it is fixed to the bone are also important. The authors review each type of TDA in detail.

TDAs for the cervical spine are also under investigation. Although cervical fusion is very successful, problems with swallowing and degeneration of the adjacent segment can occur. On the other hand, problems with disc replacements can also occur. Cervical implants are new enough so that only short-term results are available.

The authors pose many questions for the future. Will TDA replace spinal fusion? Can these implants last a lifetime without complications? What is the best design? What are the long-term benefits?

In time, gene therapy and human growth factors may make it possible to regenerate diseased discs making even TDAs a treatment of the past. Ongoing studies must continue to analyze results. The true place of TDAs in the treatment of back pain is yet to be decided.

In this study, researchers asked the question, Does minor trauma increase the risk of serious low back pain (LBP)? They report the answer is No. This was the case even for people with risk factors for degenerative lumbar disc disease but no previous episodes of LBP.

Two hundred (200) working adults with no history of serious LBP problems were followed for five years. Half the group had chronic pain somewhere else in the body. These patients were included because previous studies have shown an increased risk of disabling LBP in people with chronic nonlumbar pain.

Everyone was tested for structural changes of the spine. Physical exam, X-rays, and MRIs were done of the lumbar spine. Rechecks were done every six months. New MRIs were ordered anytime someone had persistent LBP. MRI results were compared with the baseline studies.

Serious LBP was more likely to occur with daily activity or from no known cause. Minor trauma was not linked with corresponding serious LBP. Subjects in this study with structural changes in the spine were not more likely to have LBP after minor trauma. Structural changes refers to degenerative changes in the spinal segments, especially disc disease.

The results of this study support previous research that points to patient social, behavioral, and psychological factors as being far more predictive of LBP. Psychologic distress, smoking, and previous compensation issues were better predictors of serious LBP and disability than minor trauma — even in the presence of degenerative disc disease.

Doctors continue to search for ways to treat lumbar spinal stenosis (LSS) in older adults. LSS is a narrowing of the spinal canal and the holes where spinal nerves exit the canal. Degenerative changes in the spine that come with aging put pressure on these nerve tissues. The result can be painful symptoms for many adults 65 years old and older.

Nonoperative therapy such as steroid injection, nonsteroidal antiinflammatory drugs (NSAIDs), and physical therapy often help. But when they don’t, then surgery to remove bone from around the nerve may be needed. This procedure is called surgical decompression.

There are many different ways to surgically decompress the spinal nerves. In this study, a new device called the interspinous process decompression (IPD) system was used for this condition. Results were compared to a second group treated with conservative, nonoperative care.

Using local anesthesia and a small incision, the IPD was inserted between the spinous processes of two lumbar vertebrae. The spinous process is a bony projection off the back of the vertebral body. The end of the spinous process is the bump you feel along the back of your spine.

Results of this treatment were measured by having the patients take a survey before and then several times after the operation. Patients receiving nonoperative care filled out the same survey in the same time intervals. Everyone was followed for at least two years.

The final results showed a positive difference for patients with the IPD. Patients reported a much improved quality of life after the implant was put in place. The results were about the same for other methods of decompressive surgery. Future studies comparing IPD with other operative techniques for LSS are needed next.

Surgeons from China describe the use and results of a new treatment method for minimally invasive discectomy. The procedure is called a microendoscopic discectomy (MED). It was done on 873 patients with disc herniation. Results were compared to a control group of patients treated with open discectomy for the same problem. All patients were treated by the same surgeon in the same hospital.

A special endoscopic instrument called the MEDTRx system was used. Detailed drawings and photographs of the equipment and patient position are included. With this system, the surgeon is able to see a high-quality image of the disc and surrounding tissues on a video screen. MED allows the surgeon to use both microsurgical and endoscopic techniques.

The authors report that pain was improved equally in both groups. Recovery time in the MED group was much faster. Patients’ stay in the hospital was shorter. They were able to return to work and to their daily activities faster.

With the smaller incision, there was less bleeding and less tissue trauma. Only a light anesthesia was need so the side effects of general anesthesia were avoided. There is also less trauma to the nerve root because the patient could tell the surgeon if there is any pain or numbness during the procedure. Operative time decreased as the surgeon gained experience with this new technique.

MED isn’t for every patient with disc problems. The best patient for this procedure is someone who has a single-level disc protrusion causing sciatica. Older adults with spinal stenosis (narrowing of the spinal canal) are not good candidates for MED. Patients with spinal instability are also poor candidates.

With time and effort, surgeons can obtain the necessary training and practice to use this new three-dimensional treatment for patients with disc herniation.