News Category: Lumbar Spine

Doctors are concerned about the rising costs of health care. Imaging studies are expensive and not always needed. In this study, research shows when doctors should order CT scans for patients with acute low back pain. In most cases, quality of care and patient safety are still preserved when advanced imaging isn’t ordered.

One-hundred (100) men and women with acute low back pain were included in this study. Each one was examined by two physicians. The exam included range of motion, leg length, and muscle function. Any changes in sensation were recorded. X-rays and CT scans were also done.

There was no link between clinical findings and results of X-rays. CT scans were normal for 28 patients. The rest of the group had one or more changes observed. The findings included disc bulging, narrowing of the spinal canal (stenosis), or bone spurs.

The authors compared the results of X-rays and CT scans with patients’ symptoms and exam findings. Disc bulging was observed on CT scans in one-third of the patients who didn’t have any clinical signs of disc problems. For patients who reported sensory changes, only half had actual signs of disc bulging on CT scan. Of the 100 patients in this study, only six had true neurologic problems linked to disc protrusion seen on CT scans.

The authors suggest that advanced imaging should be saved for patients who don’t get better or get worse with time or treatment. CT scans should be ordered for the patient with significant neurologic problems at the time of the first exam. This approach saves money without sacrificing results.

Who can benefit from treatment for back pain? And when should treatment be given? These are the questions discussed in this article.

There are about 15 million office visits to doctor’s offices each year for back pain. Most get better without specific treatment. Money spent on health care could be saved if only those patients who need care get it. Some treatment can even make patients worse. Targeting those who really need intervention could also save some patients unnecessary suffering.

Doctors must triage or screen patients differently based on how long they’ve had the back pain. In the early or acute phase doctors look for red flags to indicate the need for urgent care. This would include patients who have fracture, infection, or tumors. Imaging isn’t needed in this phase if there are no red flags.

For patients in the subacute phase pain has gone on more than four weeks. Studies show patients in this group are at risk for chronic pain and disability. An exam of psychologic and social factors is important during this phase. Patients who are improving slowly but steadily should be referred to physical therapy for a supervised exercise program.

Results of many studies show a strong link between chronic pain (lasts more than three months) and permanent disability. Only half the patients in this group are able to return to work. Treatment should involve many different members of the health care team. This is called a multidisciplinary approach.

The last group of patients to consider are those who have back pain that comes back two or more times during a 12-month period. This is called recurrent back pain. The doctor must look for both psychosocial factors and specific workplace hazards that could be causing repeated episodes of back pain.

Back pain of unknown cause remains a complex and poorly understood problem. Research has not given doctors all they need to make treatment decisions yet. The authors conclude by saying that triage is important but good judgment and experience are still the physician’s best tools.

In this review article surgeons from the William Beaumont Hospital in Michigan bring us up to date on spondylolisthesis. They discuss the causes, pathology, effects of, and treatment of this condition. They focus closely on recent changes in surgical treatment of spondylolisthesis.

Spondylolisthesis is a slipping of the spine. One vertebrae slips forward of the others. This may not seem like much of a problem but when the bone moves forward, pressure on the spinal cord and nerves increases. Serious problems can occur. Pain, weakness, numbness, and even paralysis can occur.

When conservative care fails, surgery should be considered. The authors review the various types of operations that can be done. Decompression or taking pressure off the spinal cord or spinal nerves was the first most common surgery. Part of the bone is removed called a laminectomy. The authors recommend using this treatment when there is spondylolisthesis with a stiff spinal segment.

Laminectomy with posterior fusion is the second type of surgery. No plates or screws called instrumentation are used. Bone graft holds the bones together. Based on the results of many studies, the authors say decompression with fusion and without instrumentation is a good treatment option.

The third type of surgery is a decompression with fusion using instrumentation. Plates and screws are used to hold the bone in place until bony fusion takes place. The idea is to get a more rigid spine for stability. The authors report most studies show that fusion rates are better with instrumentation.

Decompression with fusion from the front (anterior) and back (posterior) at the same time is gaining popularity as a surgical option. Increasing the fusion surface area gives better results. The newest change in this surgery is a move toward transforaminal lumbar interbody fusion (TLIF). TLIF fuses the anterior and posterior columns of the spine through a single posterior approach. Studies to compare this operation with the others are needed before this new method can be recommended.

As surgical techniques change, patient outcomes must be reviewed. In this study doctors report on a new blade retractor system (MaXcess) used during spinal fusion. The newer transforaminal lumbar interbody fusion (TLIF) approach was used.

With TLIF the disc is removed and fusion done from one side of the vertebra. There’s less damage done to the soft tissues. With only one side disrupted, stability of the spine is saved on the other side.

The new blade retractor system allows the surgeon to use a small incision but still see what he or she is doing. The retractor lets the surgeon make what is called an operative corridor. This passage way eliminates the need for endoscopes or microscopes to see inside.

All this is done with a small incision similar to the minimally invasive operation. The surgeon and patient have the best of both worlds. The patient has low blood loss and shorter operative time. The surgeon doesn’t have to move the instruments and operate by watching a TV screen.

Results were measured using pain, disability, and number of days in the hospital. X-rays were used to see the results of the fusion. Good to excellent results suggest the use of the MaXcess TLIF is both safe and effective.

With the understanding that low back pain (LBP) is a national problem this study looks at the incidence of LBP in women after hysterectomy or ovarian surgery. Data from the Women’s Health and Aging Study (WHAS) was used.

The WHAS studies women over age 65 who are disabled and living in Baltimore, Maryland. The subjects are interviewed and examined. Health and social information is collected from 4,137 women. Results from over 1,000 women are reported in this study.

Almost half of the women had LBP lasting at least one month. Pain was rated as mild, moderate, or severe. Most of the women were in the moderate to severe group. Gynecologic surgery was common. Almost half (448) reported either surgical menopause (hysterectomy) or ovarian surgery.

The authors conclude that women who have gynecologic surgery are more likely to have moderate LBP compared to women who don’t have pelvic or abdominal surgery. It does not appear that spine pathology is the reason for this pain. Effects of surgery on abdominal and pelvic muscles is more likely the cause.

Normal muscle function may not return without exercises. Rehab after gynecologic surgery may protect women from LBP. Core training or stabilization focused on the abdominal and trunk muscles is advised.

Sometimes doctors have as many questions about back pain as patients do. Could this patient really have a tumor? Should I order an X-ray? Would an MRI be better? What advice should I give the patient about bedrest or activity? Should I send him to physical therapy or to a chiropractor?

In this article, Dr. J. Katz from Harvard Medical School offers answers to these and other questions often asked by physicians treating low back pain (LBP) patients.

Tumors and infection as a cause of LBP should always be kept in mind. The physician must watch for red flags pointing to a more serious problem. These include previous history of cancer, fever, weight loss, and constant pain. Or the patient can’t find a comfortable position, and the symptoms just don’t go away no matter what is tried.

For the patient with nonspecific LBP, activity is better than bedrest. The patient should be encouraged to get back to daily and work activities as soon as possible. X-rays or other imaging studies aren’t needed at first. If there are red flags or the patient doesn’t get better in a couple of months, then further testing is advised.

There is a time and place for physical therapy or chiropractic care. Studies support the use of chiropractic for acute, nonspecific LBP. The use of chiropractic for spinal stenosis, disc problems, or chronic LBP is unclear at this time. Physical therapy is helpful in restoring motion and improving strength. A supervised exercise program can help prevent future problems.

The author also discusses the use of steroids and surgery for several types of back problems and reviews the differences between spinal stenosis and herniated discs. Physicians who can recognize signs and symptoms of each condition will have a better idea of how and when to treat each patient.

Low back pain (LBP) has become so common in today’s culture that many more studies are being done on the topic. Fear of movement and fear that the person will hurt him or herself again is also common. Studies show that pain-related fear is often present early in a patient with LBP. Does it predict future disability? That’s the topic of this study.

Over 500 adults ages 18 to 65 with acute LBP were studied for a period of six months. Each patient was asked a series of questions before and after treatment. The survey included questions about the patient’s pain, function, and beliefs about movement and activity.

The authors report that fear of movement/(re)injury is linked with future disability. The study also showed that other factors such as age, pain intensity, and pain duration can also predict outcomes. Other findings included:

Patients with mechanical low back pain (LBP) of unknown cause are often lumped together. Everyone gets the same treatment. But a group of physical therapists suggest that patients with nonspecific LBP should be treated individually. Subgrouping patients during treatment gives better results.

They proved this by randomly dividing 123 LBP patients into three treatment groups. The groups included manipulation, specific exercise, or stabilization. Everyone was seen by a physical therapist twice a week for four weeks.

Patients who did well and improved moved on to Stage II treatment. The Stage II program included aerobic exercise on a treadmill or bike. Strengthening and flexibility exercises were also added.

Results were measured and compared to a previous group of patients whose signs and symptoms were used to decide which treatment was best. All patients were followed for one year after finishing the treatment program.

The authors conclude that classifying LBP patients into subgroups for treatment can be done based on signs and symptoms. Results are better than when patients are all treated the same without subgrouping. Chronic LBP and long-term disability may be avoided when patients are treated specifically because they recover quickly.

Experts who track diseases, illnesses, and other medical conditions say that nonspecific (unknown cause) low back pain (LBP) has become an epidemic. Eight out of 10 adults will suffer from some form of LBP. Twenty percent will go on to have chronic pain. Doctors need some answers on how to treat LBP patients.

In this review article, researchers summarize findings of studies on acute, subacute, and chronic LBP patients. They also include national and international guidelines on the treatment and management of LBP. A special focus was placed on knowing who needs surgery and how to prevent disability.

Best evidence says that acute pain (first month) should be managed with pain relievers and activity. A few sessions of spinal manipulation may help. Subacute pain (one to four months) responds to physical activity and exercise. Adding behavioral treatment reduces time lost at work.

Chronic LBP patients (more than three months) remain a mystery. Many different treatments have been tried. There has been varying amounts of success. Surgery works for some but programs geared toward psychology and behavior work just as well. It’s not clear yet who should get which type of treatment.

The authors say the bottom line is that patients and doctors must talk about treatment choices. The patient should be told what to expect with each one. Any risk factors for chronic pain should be identified in the first three months. In the end the patient must be responsible for managing his or her LBP.

Low back pain from disc herniation is still a common problem patients and doctors face everyday. With all the improvements in drugs, treatment, and technology patients may wonder, “Is there anything new in the treatment of lumbar disc herniation? Is it still the old standby: antiinflammatory drugs, physical therapy, and maybe surgery?”

Researchers from the New York University Hospital for Joint Diseases took the time to review articles published on this topic. Results were compared for traditional, alternative, and surgical treatment.

The authors found no advantage of one treatment over another. Some patients still seem to get better on their own with time and nature’s healing. Others only get better after surgery. Some don’t get better at all.

A flow chart or algorithm is given for making treatment decisions. The first six to eight weeks is devoted to nonoperative care. Research does not support the use of acupuncture, massage, lumbar supports, or spinal manipulation during this acute phase. Physical therapy and exercise are often a good way to reduce pain. The number of days missed at work is also limited. Surgery right away is advised for patients with severe neurologic problems with or without pain.

Patients should see the doctor again after eight weeks. Decisions about care and management depend on progress made so far. The physician and patient must decide what to do. Should the nonoperative care be continued? Should some other form of treatment be tried?

Surgery isn’t advised for the patient who is slowly getting better. More testing may be needed for the patient who just isn’t getting better. The same is true for the patient who has made very little progress. MRI is the best choice for diagnosing disc problems.

The authors say the best approach is one that looks at each patient one at a time. The anatomy and spinal pathology must be evaluated. The patient’s social and economic factors should be considered. Treatment is also evaluated one stage at a time. There doesn’t seem to be a “one-size fits all” treatment for lumbar disc patients.

Studies show that intense treatment for chronic low back pain (CLBP) helps improve function. It even lessens the pain somewhat. The next question is: how does a lighter workout compare with one-on-one with a physical therapist?

In this study 120 professional women with CLBP were divided into two treatment groups. Women in both groups had back pain with or without leg pain every day or almost every day for a year. The first group had 70 hours of group rehab including physical training, relaxation training, and back school. A home program of exercise was included. They also had some stress management.

The second group received 10 hours of physical therapy. Physical exercise and hands on treatment were given to each woman in the group one at a time. Everyone in both groups was followed for up to two years.

Measures used to gauge success of each program included pain level and number of sick days taken for back pain. They also kept track of the number of visits to a doctor or other health care specialist. Symptoms of depression and general well-being were recorded.

The authors report no difference between the two groups after rehab. The women in both groups had the same amount of pain relief and improved function. The sense of general well-being was slightly better in the intense rehab group. This group also had fewer visits to the doctor, nurse, or physical therapist.

High-intensity rehab programs can be costly. The results of this study show that a semi-light workout conducted in groups costs less and is still as effective. This was true even when compared to one-on-one treatment with a physical therapist. The authors say the next step is to identify which patients really need the more intensive treatment.

Artificial disc replacement (ADR) for the lumbar spine is still a new treatment of disc problems. Reports of problems and complications after implantation are few and far between. In this case study, doctors tell about one patient who had an ADR that had to be removed.

The disc implant moved forward and cut off a major blood vessel to the leg. Three weeks after the operation the patient reported increased back pain. By four weeks he had leg weakness and decreased sensation on the right side.

The ADR had to be removed and a spinal fusion done instead. The authors of this study give a careful and detailed report of the technical aspects in removing this ADR. The surgeon found that the top half of the implant had moved forward. Damage to the vertebra occurred as the anchoring teeth of the implant scraped across the bone.

This is the first report of endplate migration after ADR. Only one other case of ADR failure and removal has been published. In this case the surgeon who removed the device said that the implant was probably placed too far forward. The center of rotation of the ADR was forward of the patient’s natural center of rotation. The uneven force pushed the implant out of the disc space.

In the future ADR may replace spinal fusion for many patients. For now problems reported will help improve the implant design. Wear debris and movement of the implant are two major concerns with ADRs.

The Food and Drug Administration (better known as the FDA) has given pre-approval for the release of a new artificial disc device. Designed by the Synthes, Inc. company the new disc is called the ProDisc-L. It has been tested for use in the lumbar spine from L3 to S1 for patients with degenerative disc disease (DDD).

The ProDisc-L was tested on a group of 292 patients with single level DDD. Measures of pain, motion, and disability were tested. Patients were followed for two years with good results. The ProDisc-L is already on the market in Europe and Asia. It’s expected to be approved for use in the United States sometime this year.

Final approval is pending the FDA inspection of Synthes, Inc’s manufacturing plant located in Brandywyne, Pennsylvania. Researchers are already studying this new disc device for use in two or more (multi-level) lumbar levels. The ProDisc-L offers patients an alternative to lumbar fusion…one that preserves motion.

In this article the use of diskography to identify the disc as the source of low back pain is reviewed. Diskography is done by inserting two needles into the disc. One goes into the center of the disc called the nucleus pulposus. The other punctures the outer covering of the disc called the anulus.

A liquid dye is slowly injected through the needles into these two areas. Pressure from the liquid on the disc causes pain if the disc is the problem. For this reason the test is considered to be “provocative.” In other words, diskography provokes a painful response. The patient can only be mildly sedated so that pain is felt and reported.

The authors discuss the use of X-rays, CT scans, and MRIs in diagnosing disc problems. How these imaging studies compare with diskography is presented. Diskography is used when patients don’t get better with conservative care and surgery is being considered.

It’s a good tool to use because other imaging studies don’t always show a problem when there is one. Likewise many patients with abnormal MRIs have no symptoms. The patient with a true disc problem will have a positive response to diskography. In this way the exact disc that is a problem is identified. A normal disc will not produce pain with diskography.

Anyone with sacroiliac joint (SIJ) pain would appreciate a way to get pain relief. An injection into the joint could be the answer. But if the SIJ isn’t the cause of the problem the injection may not be needed. Researchers from the Netherlands found that when three out of five special tests are positive, then the SIJ is the source of the pain and an injection may help.

Tests used to confirm the SIJ as the source of pain are called pain provocation tests. In this study five pain provocation tests were used on 60 patients with low back pain (LBP). Each person was tested before getting two injections into the SIJ with a numbing agent. Pain levels were measured before and after the injections.

The authors conclude from the results of this study that LBP patients can be spared an unnecessary injection. If three or more provocation tests are positive, then the pain is likely from the SIJ. The patients in this study with positive provocation tests reported at least a 50 percent decrease in pain after the injections. If less than three tests are positive the examiner should look for some other source for the pain. Anyone with positive test findings may want to consider an injection.

In this study researchers from the Netherlands compare aerobic fitness in people with and without chronic low back pain (CLBP). It makes sense that a less fit person is more likely to have back pain, but is it really true?

To answer this question 115 patients completed a special bicycle test of aerobic fitness. The results were compared to a large group of healthy adults without back pain (control group). The groups were similar (matched) based on age, gender, and level of activity.

The group of back pain patients had a much lower level of fitness compared to the control group. Men seemed to be affected more than women in the group. Most of the patients were moderately to severely disabled. More than half of them were not working at all because of their back pain.

The authors say it looks like back pain patients are less fit but not for the reasons predicted. The researchers thought that pain levels, fear of injury, and level of disability would reduce CLBP patients’ fitness. But these factors weren’t linked to the results of the bike test at all.

Now they plan to look at the activity and fitness level before back pain occurs. The next question is: are people with lower levels of aerobic fitness more likely to develop back pain? Stay tuned!

Physical therapists are looking for ways to treat low back pain (LBP) patients as effectively as possible. One way to do this is to treat patients based on clusters of exam findings. This is called a classification method or approach to patient care.

So far it seems to be working. Patients who are classified before treatment have better results than patients who are not classified. In this study physical therapists (PTs) looked at how reliable the exam items were. PTs with all levels of experience tested patients ages 18-65 years old with LBP of less than 90 days.

Patients were examined by one PT and placed into one of three treatment groups. The groups were manipulation, specific exercises, or a stabilization program. Then each patient was examined by a second PT (before starting treatment). Exam results for the two groups of PTs were compared.

The results of this study support the use of a classification system. The method can be used by all therapists and still get the same results. Level of experience doesn’t make a difference.

The Swedish Lumbar Spine Study Group has shown that spinal fusion works better than nonsurgical care for chronic low back pain. The goal now is to find a way to fuse the spine with the least amount of surgical invasion. Toward this end researchers in Germany tested a new stand-alone device against three other fusion methods.

Fusion can be done from the front (anterior) or back (posterior) of the spine. An implant or cage placed between the two bones of the vertebrae is often used. This is called an anterior lumbar interbody fusion or ALIF. Screws may be added through the bones from the back to add stability.

The Swedish Study Group has shown now that the added screws don’t help. The extra surgery costs more and often means more problems. The new stand alone ALIF tested in this study is inserted anteriorly. It doesn’t need any extra screws posteriorly to hold it in place.

When tested in eight cadavers the results of the new “stand alone” device were just as good as with the standard fusion methods. The new ALIF implant has a cage that fits between the vertebrae from the front. There are two fixation screws. One goes into the bone above and the other goes into the bone below. Both screws are inserted at an angle instead of straight in.

The stand-alone ALIF gives just as much, if not more, stability as the other standard ALIF devices but without the added posterior screws. This study does not show how long the fusion will last or how it will hold up under daily use. The next step is to conduct clinical trials with the new device on a small number of people over a longer period of time.

What do patients expect after back surgery? Do they get what they want? These are two questions asked by doctors at the Kimitsu Chuo Hospital in Japan.

Two groups of patients who had lumbar spine surgery were studied. Group one had the disc removed (discectomy) for lumbar disc herniation. Group two had a a piece of bone removed (laminotomy) for lumbar spinal stenosis.

Results of the operation were measured based on the intensity of low back pain, leg pain, and numbness. Walking ability and activity of daily living were also recorded. Patients were asked to list (in order of importance) their reasons for having the surgery. After the operation they were asked if they were better, same, or worse than expected.

The authors found that in general patients who expected greater success were happier with their results. Some patients said they didn’t improve as much as hoped but they would have the same surgery again if they had to do it over.

They also found that patients with disc herniation had better results than the spinal stenosis group. Both groups had positive expectations. The authors aren’t sure why the difference. They offer some ideas. Perhaps the surgeons led them to expect too much. Or maybe the patients expected more than the doctors said was possible. Finally, it’s possible that the patients formed their own opinions regardless of what the doctors told them.

What’s better? Lifting with a flat or flexed back? There’s still a lot of debate over the best posture to use when lifting heavy loads. In this study the effect of lumbar posture is measured on the muscles, ligaments, and internal loads of the low back.

Fifteen (15) healthy mean were tested using three different lumbar postures. Sometimes the subjects lifted with a flat back (kyphosis). At other times they were told to use a swayback (lordosis) position of the lower spine. In an equal number of trials they could lift however they wanted (freestyle).

Electrical signals from the muscles were recorded during each lift. They found the muscle force increased with lordosis when no load was carried in the hands. The opposite occurred when carrying a load. Changing the lumbar posture from lordosis to kyphosis had a greater effect on shear force compared to compression.

Overall the results of this study support using a freestyle method of lifting. Lifting with slight flexion of the low back is the second best choice. Using the swayback or lordosis position seems to increase muscle activity. Over time these muscles will get tired from repetitive or sustained loads. Greater muscle activity increases the risk of back injury.