News Category: Lumbar Spine

Patients with acute low back pain (LBP) can and often do receive a wide range of medical treatment for the same back problem. To help standardize treatment, the military healthcare system (MHS) developed clinical practice guidelines (CPGs) for LBP. The goal of CPGs is to improve quality of care and outcomes after treatment.

This study looks at two things related to CPGs for LBP. First, do doctors use the CPGs? Second, how do the results compare between patients treated according to the CPGs and those who aren’t treated using CPGs?

With more than nine million members of the MHS, the authors had a large sample for this study. The patients came from a computerized database of patient care records kept by the Department of Defense.

Results of treatment were measured using patient satisfaction, general health, and function. The cost of care was also calculated for each patient. The authors report less than half of the patients (42 per cent) received care for their acute LBP according to the established CPGs.

Younger patients on active duty and in good health were most likely to receive CPG care. Patients receiving CPG care had higher levels of satisfaction and function. The cost of their care was also much lower ($222.00 versus $712.00).

The authors think the evidence-based CPGs aren’t used as they should be. This may be because healthcare providers expect that most patients with LBP will get better without treatment. Doctors may think there are many steps in the CPGs that may not be needed so they don’t use them at all.

The results of this study clearly show that following CPGs for acute LBP is linked with improved outcomes. More efforts should be made to educate health care professionals treating patients with LBP to use these guidelines. Patient costs would be less and there would be better results and greater patient satisfaction.

Total disc replacement (TDR) is becoming a popular treatment method for degenerative disc disease (DDD) of the lumbar spine. There are now four types on the market approved by the Food and Drug Administration (FDA). This study reports the results of 36 patients implanted with the ProDisc II model.

All patients were followed for at least two years. Results were measured by pain levels and work status. Function, disc height, and lumbar spine range of motion were additional factors used to measure outcomes. The use of medication was also recorded.

Patients ranged in age from 25 to 58 years old. Two-thirds of the patients had a single-level TDR. One-third had a double-level TDR. Before surgery, ten of the 36 patients could not work because of back and leg pain. After the operation, seven patients were able to go back to work full-time. Only two of the 36 patients needed any pain medication.

The authors report a 94 per cent success rate. This result is similar to studies using other types of TDRs. Function improved steadily for all patients with the ProDisc II. There were improvements in all areas measured. Patients with a single level surgery had the best outcomes. Age, gender, and body size did not seem to make any difference in results obtained.

The results of this study support the use of a TDR for lumbar spine pain from DDD. The TDR can help patients keep their motion and avoid a spinal fusion. Patients reported a high rate of satisfaction based on reduced pain levels and increased function.

Long-term results of the ProDisc II aren’t available yet. The patients in this study will continue to be followed for the next five to 10 years.

Injection of a numbing agent in the lumbar spine is one way to treat chronic pain from lumbar radiculopathy. Radiculopathy refers to low back pain that travels to the buttocks and/or down the leg. It may be accompanied by other symptoms such as numbness and weakness. The symptoms are caused by irritation of the spinal nerve root.

Nerve root blocks in the lumbar spine can even be used to help patients avoid surgery for this problem. This report is the second part of a previous study. In the first study, a group of patients were given injections of either a local anesthetic (bupivacaine) or bupivacaine combined with a steroid (betamethasone). All patients included in this study had symptoms of lumbar radiculopathy caused by a herniated disc or spinal stenosis.

Five years later, 21 of the 55 patients in the original study had successfully avoided surgery. They all had reduced symptoms of back and leg pain, numbness, and weakness.

The authors report no difference in results between those who had a nerve block with bupivacaine alone and those who had the combined bupivacaine and betamethasone injection. Patients with a herniated disc had greater relief of their back pain compared to the spinal stenosis group.

The results of this study show that for many people, nerve root blocks provide more than just temporary relief from back pain and other symptoms. Injections of a local anesthetic may be all that’s needed for a permanent effect. Lumbar nerve root blocks are therefore advised as a first step before surgery. Patients with lumbar radiculopathy due to a herniated disc or spinal stenosis may be able to avoid surgery with a lumbar nerve block.

This study takes a look at patterns of trunk muscle contraction during sitting. They compare the results for healthy people with no back pain (control group) to adults with chronic low back pain (CLBP). Sitting upright and slumped sitting are both included.

EMG activity of 10 trunk muscles was recorded for both sitting on an unsupported stool and slumped or slouched sitting. Skin electrodes were used to measure abdominal and low back muscles.

Patients with CLBP showed no difference in muscle activity in the two postures. The healthy controls showed a clear difference in muscle activity between the two positions. The authors suggest the difference is a relaxation response seen normally in the slumped posture.

When the researchers divided the CLBP group into subgroups based on pattern of symptoms, there was a difference. Patients with pain during flexion had less muscle activity during usual sitting compared to the control group. It may be that the lack of muscular activity causes mechanical stress on the spine resulting in pain.

On the other hand, patients with pain during extension movements had hyperactive back muscles when sitting upright. They also did not relax during the slumped position.

The authors conclude that abnormal postural patterns in patients with CLBP can provoke strain and pain. Subgrouping or classifying patients helped bring this to light. CLBP patients who report increased pain during sitting should be classified as a flexion or extension pattern. A specific rehab approach can be used to improve or normalize muscular control and relaxation.

Artificial disc replacements (ADRs) were first sold on the market in 1987. The Charité ADR was the first one approved for use in the United States. Research is ongoing to test the long-term results of this device.

In this study, engineers from DePuy Spine (Johnson & Johnson) test how well the Charité ADR holds up with repeated cycles of movement. The moveable parts of this ADR increase the risk of tiny particles of metal debris. When the debris comes in contact with the bone, changes in the bone can lead to loosening of the implant.

All testing was done mechanically in a lab. Machines were used to simulate motion. Six disc devices were subjected to 10 million test cycles. Normal motion was mimicked as much as possible. But the authors say there may be many combinations of spinal motion that weren’t tested.

After testing, implants were weighed and measurements were taken of the height. Type and size of wear particles were also measured and studied every one-million test cycles. The results showed a very small wear rate. This is consistent with clinical reports. Symptoms from wear are not a problem typically reported by patients who have this type of ADR.

Joint wear and fatigue failure are two important safety issues with any implant. The amount of wear and debris produced by the Charité ADR is equal to (or less than) other ADRs. Wear rates were much lower than with other joint implants (for example, hip or knee replacements). Future tests will be done on the Charité device under different amounts of load and speed during movement.

Artificial disc replacements (ADRs) are new enough that surgeons aren’t sure which patients are the best candidates for this procedure. Until enough studies are done to identify the ideal patient, ADRs will be used for a variety of patients with different spine conditions.

The authors of this study present the three-year results of 92 patients using the ProDisc II ADR. Results reported are for a follow up period of at least two years. Patients were divided into four groups based on their diagnosis. All patients included did not respond to intensive conservative care before surgery.

The four groups included: 1) degenerative disc disease (DDD), 2) DDD and disc herniation, 3) discectomy (disc removal), and 4) DDD with Modic changes. Modic changes refer to bone marrow and endplate changes seen on MRI. The endplate is the fibrocartilage layer between the outer covering of the disc and the vertebral bone.

Results were measured on the basis of patient satisfaction and function. Return to work was also assessed. Previous surgery (discectomy) did not have a negative effect on the results. Patients who had more than one disc replaced had more problems with poorer results compared to patients with a single level replacement.

The results of this study show the best candidates for ADR include:

People who collect data about health care patterns are called epidemiologists. Information of this kind can help doctors, hospitals, and clinics plan ahead to provide needed services. In this study, figures on lumbar spine surgery are reported from the National Hospital Discharge Survey (NHDS).

Some change in trends was observed. Rates of inpatient spine surgery are steady now after 20 years of annual increases. Outpatient surgery for disc problems is very common. When a patient has surgery and goes home on the same day, it’s called outpatient or ambulatory surgery.

Most of the outpatient lumbar spine procedures done were discectomies (removal of the disc). A small number of ambulatory spinal fusions and laminectomies were also done but the rate of these operations doubled from 1997 to 2000. A laminectomy is the removal of bone from the vertebral ring around the spinal cord.

The recent change in outpatient surgery patterns impacts the delivery of health care. A shorter hospital or clinic stay means more care at home. Patient and families will be required to monitor for infection, blood clots, nerve damage, and other complications.

Costs may shift from insurance to the patient. Hospital income may go down while outpatient services such as home health will increase. Changing trends in health care driven by advancing technology and the need to reduce costs may really only shift (not decrease) costs.

Finally, the collection of data may need to be changed. Research including both inpatient and outpatient trends is advised. Studies are also needed to focus on quality of care and patient safety with ambulatory procedures.

In this study, physical therapists assess the benefit of neutral zone (NZ) exercises to prevent low back pain. Exercises to preserve the NZ of lumbar motion keep the natural low back curve during movement and function. The natural curve is similar to the spine’s position when in the upright or standing position.

Two groups of middle-aged, working men were included. All men had a recent episode of low back pain (LBP). The men were divided into two groups. One group (the training group or TG) did 10 exercises twice a week for 12 months. The exercises were designed to improve movement patterns of the spine. The goal was to get better control of the NZ and improve spinal stability.

The men in the second (control) group were told to continue with their usual activities. They did this for 12 months. Afterwards, they were invited to do the training exercises, too.

Results from both groups at the end of one-year were measured by any change in their level of pain and fitness. Potential for return to work (RTW) and level of disability were also measured.

The authors report pain intensity decreased much more for men in the TG. Negative thinking about RTW decreased in both groups. More men in the TG improved in this area compared to the control group. Most of the men in the TG did the exercises for the first six months. After that, compliance was much less.

The authors conclude that NZ exercises decrease pain intensity by unloading the spine. Controlling the lumbar spine in the NZ during daily activities is a valuable tool in preventing future episodes of LBP.

Bone fusion usually requires the use of bone graft material along with screws to hold the bone in place until healing occurs. There are many problems with bone from a bone bank called an allograft. Bone donated by the patient for his or her own use called autograft isn’t always possible.

In this study Dr. Nancy Epstein from The Albert Einstein College of Medicine in New York studied the use of a new artificial bone substitute. The product is called Vitoss/Beta Tricalcium Phosphate (B-TCP).

B-TCP was mixed 50-50 with bone removed from the patient’s spine as part of the procedure. All patients had a spinal fusion with the B-TCP and screws. Some had one lumbar level fused. Others had two levels fused.

The results were measured by X-rays, CT scans, and two patient surveys of general health. Two neuroradiologists reviewed the images taken at three, six, and 12 months. They did not see the patients or compare the results with each other. This is called a blinded study.

Two different scales were used to assess pain, general health, and function. The two scales commonly used were the SF-36 and the Odom Criteria. The SF-36 showed a decline in health and function in the first months after surgery.

Improvement was seen in some areas between three and six months post-op. Scores were better in all areas by the end of 12 months. The Odom Criteria showed everyone had good to excellent results by the end of the first year. The author suggested that the Odom scale may overestimate the quality of results in this patient group.

Results show that B-TCP is a good bone substitute to use in posterolateral lumbar spinal fusions. The 50-50 mix of B-TCP with patient autograft worked just as well as using an autograft without mixing it. Only one patient needed a second fusion because of nonunion in this study.

Researchers have not been able to show a link between low back pain (LBP) in women and hormonal factors. Pregnancy, menstrual cycle, birth control pills, and menopause are just a few of these possible factors. Women also tend to report upper extremity pain (UEP) more often than men. Perhaps there’s a hormonal link for arm pain, too.

To help answer these questions, data from a study of 11,428 women was analyzed. All women in the study were between 20 and 59 years old. Back pain and arm pain were assessed to see if there is some biologic reason for women to have these problems.

Data analysis showed the following findings:

In this study three methods of posterior spinal fusion were compared. Fusion is designed to restore spinal stability or rigidity after bone has been removed in an operation called decompression. Decompression takes pressure off the nerves as they leave the spinal canal. The goal is to relieve back and leg pain.

The authors describe each operation and mention advantages of each one. The three operations included:
1) Posterolateral fusion (PLF)
2) Posterior Lumbar Interbody Fusion (PLIF)
3) PLF combined with PLIF (PLF + PLIF)

Patients with degenerative lumbar disease were randomly placed in one of these three groups. A total of 167 patients were fused at one or two levels. Patients were followed for at least three years.

The authors report there was no difference in results among the three groups. At least 80 per cent and as many as 88 per cent of the patients reported good or excellent results. Success was measured based on improvement in symptoms, function, and disability. X-rays were taken to show the disc heights and fusion sites.

Problems such as nonunion, infection, and nerve damage occurred in all three groups at about the same rate (four to eight per cent). The three methods compared have equal results but slightly different advantages and disadvantages. PLF + PLIF gives a solid fusion. Fusion rates were slightly less with PLF alone. PLIF alone has the advantage of a shorter operation, less blood loss, and no bone graft donor site pain.

Pilates is a form of exercise that has become popular in the United States. Many people are using it to treat their low back pain (LBP). This Canadian/Hong Kong study looks at how well Pilates works with a group of 39 adults who have chronic LBP.

Pilates was named for its founder and inventor, Joseph H. Pilates. As a form of exercise, the Pilates method became very popular with dancers in the early 1930s. It was rediscovered and gained popularity with dancers in the 1980s. Most recently, the Pilates craze has been joined by millions of Americans.

The key features of Pilates exercise are:

Is it possible to predict who will return to work (RTW) after an episode of low back pain (LBP)? Are there specific factors in patients who do RTW that can help show who those patients are? Researchers at the Netherlands Expert Centre for Work Related Musculoskeletal Disorders study these topics and questions.

Other studies have shown that two-thirds of back pain sufferers still have pain one year later. Most patients are back to work but still have pain. Pain level and loss of function are linked with time off from work. The researchers at the Expert Centre wanted to know if the opposite is true. Does RTW help patients recover even more?

Information was collected from LBP patients before treatment and later after three months and six months. Questions were asked about age, gender, level of education, body mass index, and fear of movement. Type of LBP and information about work hours and type of work were also included. Improvement in pain level, function, and quality of life were the main outcome measures.

The authors report strong recovery in the first three months. Improvement continued at a slower rate between three and six months. RTW at three months also had a positive effect on all three outcome measures. A quicker recovery was seen in younger patients, males, and patients engaged in sports activity.

Most patients RTW before fully recovered. This study showed that RTW without complete recovery is not more harmful than staying on sick leave. The study did not answer the question whether patients RTW when they feel better or if they feel better after they RTW.

Studies show that recovery from lumbar disc surgery can be slowed down by behavioral factors. Patients who are afraid to move or who worry about reinjury are more likely to have chronic pain and disability after low back surgery. Researchers are trying to figure out who might be at increased risk for this kind of problem before the surgery is done.

In this study, physical therapists test the role of cognitive-behavioral factors before surgery. They compare the results with patient disability after surgery. They expected that patients who were afraid to move or who expected a bad result would have more pain and disability after surgery.

All 310 patients in the study had low back pain from a disc problem. The diagnosis was lumbosacral radicular syndrome (LRS). Everyone had surgery to remove the damaged disc. Before the operation, pain intensity was measured. Pain-related fear of movement or reinjury was also measured before surgery.

Two other tests were also done. The first measured passive pain coping using a scale of worrying, resting, and retreating items. Resting referred to limiting activities because of pain. Retreating was based on the idea that pain would get worse with activity so sitting or lying down was needed.

The authors report older women who had more intense pain before the operation were more likely to have disability and pain after the surgery. This was true at six weeks and again at six months. Cognitive-behavioral factors were also important. Fear of movement and fear of reinjury were linked with more negative results.

Do you really have to do those exercises after a lumbar discectomy (disc removal)? According to this study, yes — if you want to get back to work sooner, see your doctor less often, and feel better in general.

Patients with a diagnosis of lumbrosacral radicular syndrome (LRS) were included in this study. This means a disc was protruding and causing painful back and leg symptoms. A simple discectomy to remove the disc was done.

The patients were divided into two groups after surgery. One group received a formal exercise program. The patients in this group were supervised by a physical therapist three times a week for six months. The second (control) group was given general advice only. They were told to get back to their normal daily routine as soon as possible.

Results will be reported after a three-year period. This study reports patient results after one year. The one-year outcomes showed no difference between the two groups in terms of function. However the exercise group went back to work a week earlier than the control group. And the control group needed an extra 14 weeks of worker’s compensation.

So although the functional results were the same after a year’s time, the financial savings of the exercise group were significant. The authors suggest future studies to compare exercise programs and find which one works best.

There are many ways to treat low back pain. In this report, doctors from three large medical schools in the United States review the nonsurgical methods. Education, medication, activity and exercise are described and discussed. The use of physical therapy, massage, magnets, and manipulation are also included. Traction, injections, bracing, acupuncture, and behavioral therapy are other conservative treatment choices.

Many studies on the treatment of low back pain have been done. Many of these treatment approaches are moderately helpful. Others have no proven effect. Some have never been scientifically studied. So far, we know that some medications such as muscle relaxants and antiinflammatories work better than placebos (pills with no drug in them).

Exercise and activity are much better than bed rest. Researchers haven’t been able to show that one exercise is better than another to speed up recovery. Dealing with negative emotions and thoughts through behavioral therapy has been shown to improve quality of life (QOL). Improved QOL helps patients stop taking pain relievers.

Manual therapy can reduce symptoms if used in the first six weeks. This type of spinal manipulation is usually performed by a chiropractor or physical therapist. No benefit has been found with the use of magnets, prolotherapy, or bracing. Until more research is done, acupuncture is not advised as the first treatment to try. Acupuncture is usually used as part of a whole treatment program for patients with chronic back pain.

Education and activity have been given top billing for the treatment of acute and chronic low back pain. Education includes proper posture, lifting, and ways to reduce painful symptoms. Activities should be monitored to avoid protective postures and protective movement patterns. Patients who are afraid to move because they might hurt themselves can end up in a downward spiral of pain – inactivity – and more pain.

The bottom line is that patients who stay active recover faster with fewer problems.

In this study two physical therapists (PTs) at the University of Wisconsin – Madison review the records of 133 patients treated for low back disorders. There were three goals:

Medical knowledge about effective treatment for low back pain (LBP) is slow to trickle down from researcher to doctor. Clinical practice guidelines (CPGs) written to help the physician treat LBP patients are based on scientific evidence. Getting this information into the hands of doctors is called a Knowledge Transfer.

Frequently these guidelines aren’t read or used by doctors even if the information is useful or helpful for patient care. In this study doctors were given direct information about CPGs for low back pain. The goal was to see if direct transfer of information would increase the use of these CPGs.

Only worker’s compensation patients with acute LBP (symptoms present less than four weeks) were included. Each patient was put into one of three groups. Group one was the control group. No information about the CPGs was given to the patients or their doctors. Doctors of patients in group two got a copy of the CPGs. They also got a letter naming the patient and advising use of the CPGs for that patient.

Group three was the same as group two except the patients also got a pamphlet with the same CPGs in a little easier-to-understand form. Both groups two and three were sent follow-up letters at regular intervals reminding the doctors in group two and both doctors and patients in group three of the guidelines.

The results of this study showed that even with physician-to-physician communication, CPGs for LBP patients weren’t used. There was a trend toward fewer recommendations for bed rest. Patients were also advised to increase aerobic exercise.

Neurogenic intermittent claudication (NIC) is a condition that causes pain in the low back and legs when standing. The symptoms go away or get better when sitting or bending forward. Neurogenic refers to the nerves and spinal cord. Intermittent means it comes and goes. Claudication is the sensation of pain or discomfort that comes with this condition.

In this study, a small device called the X STOP was placed between two spinous processess of the spine. The procedure is called an interspinous process decompression (IPD). This oval spacer is designed to increase the width and diameter of the spinal canal. The spinal canal is the opening in the vertebral bone that allows the spinal cord to pass from the skull down to the bottom of the spine.

Two groups of patients were compared. Patients in both groups had NIC caused by a condition called degenerative spondylolisthesis. In spondylolisthesis, one vertebra moves forward over the vertebra below it. This movement has the effect of closing down the spinal canal. It also puts traction on the spinal cord or spinal nerves.

The first group of patients had an IPD with the X STOP inserted surgically. The second (control) group was treated conservatively without an operation. Conservative care included steroid injection, nonsteroidal antiinflammatory drugs (NSAIDs), pain relievers, and physical therapy as needed.

Results based on symptoms, function, and patient satisfaction was measured over two years. The authors report a 63 percent improvement in the IPD group compared to only 13 percent in the control group. The authors conclude the X STOP is safe and effective in the treatment of NIC caused by spondylolisthesis. Further study is needed to find out which patients are the best candidates for the X STOP.

Five measures are often used in studies to evaluate the results of treatment for low back pain (LBP). These include pain, function, health status, disability, and patient satisfaction. In this study researchers present the results of a new tool to measure these five outcomes.

Finding a short survey that covers all five areas has been difficult. It also has to be reliable and valid. To meet both needs a CORE SET of six questions was tested. One hundred fifty four (154) patients with chronic LBP or osteoporotic fracture were included.

Each patient completed the CORE SET before and after treatment. Some patients were treated conservatively without surgery. Others had surgery to stabilize the spine.

The authors report that the results show the CORE SET is a valid tool to use with chronic LBP patients. With new methods of treatment for LBP doctors need some way to know what works best. When time is limited, this short survey is useful.