News Category: Lumbar Spine

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.

Researchers around the world are studying ways to treat chronic low back pain (LBP). Physical therapy is often prescribed. The patient may be treated with manual therapy, which includes joint manipulation or the more gentle joint mobilization. Sometimes therapists combine manual therapy with exercises, heat, or electrical therapy. But what works best?

In this study the results of spinal stabilization exercises are compared to manual therapy. A control group with minimal treatment was also included. Stabilization exercises consist of movements requiring contraction of the abdominal and trunk muscles at the same time. The goal is to hold the spine steady (or stable) during movement.

Level of back pain, function, and use of pain relievers were used to measure the success of these three treatment methods. Patients were also asked about quality of life (QOL) as an outcome measure.

All patients had less pain in the first three months after treatment. Pain relief was greatest in the manual therapy group. Long-term results showed pain was still less six to 12 months later for stabilization exercises and manual therapy, but not for the education group. The spinal stabilization group had the best reduction in disability at each follow up visit. The same was true for improved quality of life and use of pain relievers.

Overall the results of this study favor the use of spinal stabilization exercises over manual therapy or education for chronic LBP. Manual therapy and spinal stabilization significantly reduced pain. The authors suggest manual therapy should not be used alone to treat chronic LBP. By itself, manual therapy doesn’t reduce disability or improve QOL.

Every year the United States and other western countries lose billions of dollars from work absenteeism due to back pain. Most workers recover quickly and only use sick leave for a short time. The risk of disability increases greatly when back pain doesn’t go away, and workers are off the job for one to two months.

In this study the results of low-intensity back school are compared to usual care or high-intensity back school. Back School is a prevention and education program to help patients understand and care for their spines. Information about anatomy, posture, lifting, and exercise is presented over a period of weeks to months.

Three hundred (300) workers were randomly assigned to one of three groups. Group one (usual care) was told to keep doing their usual daily activities. Group two (low-intensity back school) attended four group classes once a week for four weeks. This group learned coping skills and did exercises at home twice a week.

Group three (high-intensity back school) met twice a week for eight weeks. A physical therapist helped this group increase their activity level. Activities and exercises mimicked the work place. This group also did a program of home exercises.

Results were measured by number of days off work, pain intensity, and level of function. Patients in the low-intensity back school went back to work faster than patients in the usual care group or high-intensity back school. Function and freedom from fear of movement were better in the low-intensity group at the end of both three and six months.

More and more back patients are getting the new CHARITÉ artificial disc replacement (ADR). At least 15,000 CHARITÉ ADRs have been done. In this study, results of 589 patients from 14 spine centers across the U.S. are reported.

Patients needing reoperation for any reason were analyzed carefully. Researchers were looking for any patterns of treatment that could help prevent or treat such cases in the future.

Patients who had to have surgery again were put into one of two groups. The first group had an unacceptable position of the ADR. It had shifted or moved too much and had to be removed. The second group kept their ADR but had a second operation to fuse an unstable spinal segment.

About nine percent of the 589 patients needed a second surgery or reoperation. One-third had the ADR taken out and replaced with a smaller size implant. The rest of the patients were converted to a fusion with bone graft. There were five cases of spine instability after ADR from a vertebral fracture.

The authors conclude proper placement with the new, improved ADRs available today should reduce and even eliminate the need for reoperation after an ADR. CHARITÉ artificial disc should never be used when there is a fracture or unstable spinal segment. Patient selection and preparing the disc space are key factors to success with ADRs.

Low back pain and instability can be managed with surgery. Pressure is taken off the nerves and the spine is fused to regain stability. The posterior lumbar interbody fusion (PLIF) is one of the best methods of fusion. Patients get good results but there can be problems.

In this study the results of 251 patients having a PLIF were reviewed. All patients had degenerative lumbar disorders. All were treated with the same surgery. This makes it easier and more valid to compare the results. Everyone was followed for at least two years. Some were in the study for more than seven years.

Complications were divided into three time periods: during surgery (intraoperative), early postoperative, and late postoperative. Problems that occurred within the first 30 days were put in the early group. Anything that happened after that was considered a late complication.

Intraoperative problems included nerve injury, poor position of a screw, and tearing of the lining around the spinal cord called the dural sheath. Early complications included infection, hardware failure, and nerve damage. Patients with more serious early problems died from heart attacks, stroke, or blood clots.

Late postoperative problems were similar. There was infection, hardware failure, and failed fusion. Breakdown of the spinal segment next to the fusion was the biggest problem. A second (revision) surgery was done to relieve pressure from nerves compressed by a screw. Hardware failure such as a screw breaking was not treated if there were no symptoms.

The authors reported an overall complication rate of 25 percent. They suggest several ways to reduce problems. Computer navigational systems may be able to help reduce screw malposition. Removing the joint (total facetectomy) is advised as this method gives the nerves more space. Neurologic problems should be treated right away to prevent permanent nerve damage.

Researchers keep trying to sort out back pain patients. What treatment would work best for each problem? What factors predict the outcome? Do patients on sick leave, retirement, or disability have different results from patients who aren’t on any of these? Swedish scientists report the results of an ongoing study trying to answer these questions.

Patients in a previous study on back pain were included in this research project. They were contacted one year and five years after treatment. Data was collected on age, gender, smoking habits, and exercise and activity levels. Patients were asked if they were happy at work and how long their symptoms had lasted. They were also asked what they expected from treatment.

The authors report the following findings:

What’s the best treatment for patients who still have back pain a year or more after the disc is removed? In this study two treatment methods were compared. Patients in the first group had spinal fusion. Screws and bone graft were used to fuse one segment in the lumbar spine. All patients in the study had the disc removed (called a discectomy) for disc herniation.

The second group was given advice and exercises. Patients in this group received education and advice about their condition. They were told about the importance of movement and activity. They were advised that they could not hurt their back by doing every day activities. Three types of exercises were included: aerobic or outdoor activities, pool therapy, and individual exercises.

Results were measured by pain intensity, use of daily drugs for pain, and general function. Patients also rated their emotional distress and answered questions about work status. X-rays were taken of the patients who had a fusion to see if the fusion was successful. Everyone was followed for one year.

The authors report that more people in the study believed surgery was better than non-operative treatment. Even so the results showed no difference between the two groups. The success rate was about 50 percent in both groups. Two men in the exercise group had surgery later and still did not improve. There was major improvement in function in both groups.

The authors conclude spinal fusion surgery is being done for many low back pain patients. More studies are needed to identify which patients can benefit the most from this type of treatment. The results of this study suggest that fusion is not advised for patients with chronic low back pain after discectomy.

Two phrases always catch the eye of research scientists: meta-analysis and random controlled trial (RCT). This study on the McKenzie Method for low back pain is a meta-analysis of RCTs.

Meta-analysis means that the authors reviewed a large number of trials and combined the data. This gives the highest level of evidence possible in research. In this study every RCT study published on the topic was included for the period of time listed. Four major databases were searched up to the year 2003.

RCT means the subjects were placed in each group by chance. Neither the patients nor the researchers knew who was in each group. In other words, patients were randomly assigned to a group. And there’s always a control group — subjects who don’t get the treatment being studied. In a blinded RCT, the subjects or patients don’t know if he or she is or isn’t getting the treatment. In a double-blind RCT, the researchers don’t know who is assigned to each group. RCTs allow scientists to test directly for the effect of a specific treatment.

The McKenzie Method is a way of treating low back pain (LBP) based on how the pain and/or symptoms respond to changes in movement in a specific direction. Patients are grouped or classifed for treatment based on the results of movement testing. For example, if the patient feels better when the spine moves in one direction, then treatment begins with that position. Over time the patient is taught how to move from a the comfortable position to all other positions without pain.

Does the McKenzie Method really work? Is it effective in treating LBP? By comparing the results of many studies the authors try to answer this question. They reviewed how well McKenzie treatment worked compared to passive therapy (pamphlets, brochures), advice to stay active, spinal manipulation, and back school.

The authors report that the McKenzie method works a little better than passive therapy, ice packs, or massage. They aren’t sure that the small amount of difference really means anything. More studies are needed in which patients are classified according to the McKenzie Method before treatment is started.

About 10 years ago new knowledge about low back pain (LBP) came to light. Researchers wrote about the fear of movement/reinjurymodel of chronic LBP. They discovered some people had chronic LBP because they stopped moving for fear of pain or reinjury. This concept has come to be known as fear avoidance beliefs (FAB).

In this study scientists in Norway compared FAB in acute versus chronic LBP patients. Three tests were given: FAB for work, FAB for physical activity, and a third one for emotional distress. Patients with acute LBP (lasting less than three weeks) were rechecked after four weeks. Patients with acute LBP (lasting more than three months) were rechecked after three months. Everyone was followed for one full year.

The results showed that pain at the end of 12 months was linked to FAB-work and distress for patients in both groups. Distress was the strongest predictor of pain in the acute group. FAB-physical activity showed rapid improvement in the first four weeks after acute injury. The chronic group showed no change in FAB during the entire year.

The authors conclude it looks like emotional distress is a stronger predictor of long-term pain and disability compared to FABs. They suggest that emotional distress includes overall anxiety and depression. FAB may only include anxiety related to back pain. It’s possible that emotional distress and FAB are related and not really two separate factors. More study is needed to test this theory.

Studies show that low back pain is a common problem in the United States. Lumbar spine disorders can be as disabling as chronic medical diseases. In this report doctors look at the impact of four lumbar spine disorders on the health status of adults ages 30 to 56 years old.

Patients had one of these four common lumbar spine disorders. The authors described cause and effect of each one:

Every study has a who, what, where, and why. In this report researchers assess the lumbar strength and motion (what) of 61 healthy adults (who). All subjects were students or employees of a university hospital in Belgium (where). The goal was to use commercially available equipment to check the reliability compared to other testing devices (why).

Knowing normal lumbar range of motion (ROM) and strength values helps physical therapists evaluate patients with back pain. It allows monitoring of response after treatment. It may even help identify people who are at risk for low back pain (LBP).

The Tergumed equipment was tested because it is often used in Europe to assess and train patients with LBP. It’s also used for physical training with healthy adults who don’t have LBP. Each person did two sets of exercise trials on the same machine. They were supervised by a different therapist each time.

Test results showed decreased motion and strength with age. Tall men have greater spine extension compared to others. In general, men have greater strength than women. Everyone had better test results for the second test trial. This finding indicates there was a learning effect. Therefore it’s better to use the best results out of three trials rather than using the first test results (or only testing one time).

Before testing normal adults for back strength and motion it’s important to make sure the testing devices are accurate and reliable. Tergumed equipment is reliable in its measurements. However, ROM is measured in centimeters instead of the more standard degrees. For this reason it will be difficult to compare the results of testing from Tergumed equipment with other devices.

Back pain that goes down the leg is called lumbar radiculopathy. It’s caused by chemical irritation or mechanical stress on one or more of the spinal nerves. Selective lumbar nerve blocks (SLNBs) may help the patient avoid surgery. A steroid and a numbing agent are injected into the area around the nerve root.

This study looks at the overall number of immediate problems (small or large) with SLNBs in 1,777 patients. Some patients had a single level SLNBs. Others had an injection at more than one level. The position of the needle tip during the injection was compared for patients with and without complications.

The authors report an overall complication rate of five percent. Problems reported were minor and didn’t last. These included feeling lightheaded, new pain, leg numbness, and leg weakness. Increase in the usual back or leg pain was a sign that the right nerve root was being blocked and didn’t count as a complication.

Needle-tip position did not seem to matter. The number of injections was more important. The number of problems doubled in patients who had multiple injections at the same time. Long-term results aren’t available but from this study it seems that SLNBs are safe and effective.

If you are an industrial worker and hurt your back while on the job, there’s a one in four chance of reinjury. The rate of recurrent work-related low back injuries and risk factors are the subject of this study. Recognizing risk factors may help reduce or prevent future episodes of low back pain (LBP).

After studying 352 hourly union workers, researchers report the following risk factors that can trigger a recurrence:

Many patients report ongoing pain after fusion surgery for low back pain. In this study researchers at New York Upstate Medical University identified poor emotional health as a risk factor for back and leg pain after surgery.

In a previous study, the same authors found better results in patients with lower anxiety, depression, and hostility. The lumbar fusion patients were able to return to work with less pain and more function.

In this study 160 patients had an anterior fusion with cages. The same surgeon performed all the operations. All patients were followed for at least one year. Most stayed in the study for two years. Health-related quality of life was measured before and after surgery. Pain and function were also measured.

Smoking and worker’s comp were linked with poorer operative results. Scores on the mental part of tests given were also negatively linked with outcomes. Patients with poor emotional status before fusion had more pain and less function at one and two yeas after the operation.

The authors aren’t sure if improving mental health before surgery will decrease pain and increase function after surgery. Future studies are suggested to look at pre-treatment to improve emotional and mental health before lumbar fusion. The authors suggest it would be better to help these patients rather than withhold surgery for fear of poor results.

Anesthetic and steroid injections to block nerve pain in the low back can bring patients immediate pain relief. Does the needle tip position at the time of the injection make a difference? That’s the question this study answers for surgeons.

Over 1200 patients were included in this study. Injections were made using X-ray imaging to guide the needle into the radicular space. The radicular space is the area where the spinal nerve exits the spinal canal and then travels down the spine.

Researchers used the images to record exact locations of the needle tip at the time of the injection. Three dimensional (3-D) views were taken. They compared the results with how quickly patients got pain relief.

The authors report that exact needle tip position doesn’t affect pain outcome. These results give surgeons more freedom when doing nerve block injections. Safety, anatomy, and patient comfort can be used to guide this procedure. The surgeon can avoid getting too close to the nerve root thereby preventing even more pain for patients.

This study points out the fact that surgeons can’t agree on when lumbar fusion should be used. The study was set up so that 19 spine surgeons were given a proposed classification system to choose patients for lumbar fusion. Each surgeon looked at 32 cases. Each patient had some degree of lumbar degenerative disease.

A classification system helps define which patients would benefit from a spinal fusion. Once patients are selected for fusion, surgeons could decide which method would work best for each person. And a classification system would allow researchers to compare results of each group.

Patients were divided first into two groups based on whether or not they had a previous spinal surgery. The group with no prior surgery was called the primary surgery group. Patients who had a previous surgery were put in the revision group.

Reasons or indications for fusion included deformity, instability, and bone or joint disease. Disc collapse or disc pain was also included. Surgeons were given descriptions for each of these classifications.

The spine surgeons’ task was to select the reason for fusion using this classification system. Results of the clinical exam, X-rays, and other studies were used to make the decision. The surgeons’ responses were analyzed for consistency.

The authors report the level of agreement among the 19 surgeons was ‘only moderate.’ Surgeons were unable to agree on why each patient was chosen for spinal fusion. Decisions are difficult to make because patients often have more than one spinal level involved. Some have X-rays that look worse than the clinical picture and vice versa.

The authors say this classification system isn’t reliable for use with all patients. Degeneration at multiple levels makes the decision more difficult. More study is needed to improve the system.

Increased abdominal fat is common in the aging adult. Along with it comes an increased risk of low back pain (LBP). According to the results of this study, isolated strength training may help slow the effects of aging on the low back.

Studies show that obese adults are more likely to have LBP. Obese adults with LBP are less likely to remain active and seem to walk less than obese adults who don’t have back pain. The goal of this study was to see if lumbar strength training could prevent some of these back problems.

Eighty-four (84) healthy adults were divided into two groups based on their body mass index (BMI). BMI is a measure of obesity based on height and weight. Only overweight (not obese) adults and adults without back pain were selected for the study. The two groups were further divided into two groups each.

One group followed an exercise program three times a week for six months. Exercises were done for the abdominal muscles, calves, legs, and arms. Extension exercises for the low back were done once a week. Based on the results of other studies, once a week is all that’s needed for lumbar extension exercises. The other group had no further training. They were told to keep up their regular activities but not to start any new exercises.

Baseline measurements of strength were taken before the study started. The overweight (OVW) group had greater overall strength than the non-overweight (NOVW) group. When the two groups were compared by muscle mass only, then overall strength was equal between the two groups. At the end of the study, low back strength was improved in both the OVW and NOVW groups. There was no change in the nontraining (control) groups.

The authors conclude lumbar extensor strength can be improved in all older adults regardless of weight. Such exercises should be done to reduce the chances of LBP.

Discography to test for painful discs doesn’t always work. Sometimes there are false-positives leading to unnecessary surgery. A false-positive means the patient’s test suggests a painful disc when there’s nothing wrong with that disc. Discography is done by injecting a dye into the disc. Damaged discs are chemically sensitive and react to the dye. The test causes back pain right away.

In this study researchers check to see if using low-pressure as a positive test would reduce the number of false-positives. When pain was caused by pressure less than 22 psi, the test was considered positive.

The results from discography in two groups were compared using this definition of a positive test. One group didn’t have low back pain (LBP). This group included people with no pain, other types of chronic pain, and previous back pain. The second group had persistent back pain and was considering surgery. Everyone in both groups was also given psychologic tests to assess levels of distress and depression.

The authors report about 25 percent of the subjects currently without back pain had a positive discography at 22 psi. By studying the group closely they found three subgroups most likely to have these results. They included subjects with abnormal psychologic tests, people with chronic pain problems, and those with true disc damage but no back pain. Only the subjects with no LBP, no history of LBP, and no chronic pain had no pain with low-pressure injection.

The authors conclude that using a low-pressure psi as a positive discography won’t eliminate false-positive tests. There are too many other factors responsible for a painful response to low-pressure discography. Newer and better diagnostic tests are needed.