News Category: Lumbar Spine

In this study, researchers from two large health care organizations predict prognosis for patients with acute low back pain based on return to work. This is a new way to look at recovery as most other studies use pain and function as the main measures of outcome for recovery.

Over 600 people participated in the study. Each one had an episode of acute low back pain (with or without sciatica/leg pain) in the last 30 days. They were later contacted by phone (six months later and again two years later) to ask about their experience. As part of the survey, they reported their work status (full-time, part-time, unemployed and seeking work, not seeking work, retired).

Other data collected for review and study included how long the back pain lasted, level of pain intensity, and number of days in bed and/or off work. Each individual was also asked to rate their recovery as they viewed it on a scale from much worse to fully recovered.

To give you an idea of how many people suffer an episode of back pain — in one year’s time, 42,650 people were seen at this health care facility for low back pain. The 600 patients in this study volunteered to participate and also met a series of additional requirements in order to be included. Everyone in the study was given usual care consisting of spinal manipulation, acupuncture, yoga, exercises, massage, or physical therapy.

Analysis of the data showed that prognosis when based on whether or not the person returned to work was much less favorable than when using other measures (e.g., pain, disability). Instead of the previously reported 10 per cent of patients who went from having acute low back pain to chronic pain, 13 per cent had chronic pain at six months and even more (19 per cent) had chronic low back pain at the end of two years.

Many of the remaining patients who did return to work did so with continued pain and physical limitations. Forty-one per cent (41%) reported having to change positions often just to get comfortable while 31 per cent tried to avoid bending or kneeling down. Other activities that posed problems for the group included turning over, walking quickly, getting up from a chair, or using stairs without a handrail.

In observing the results of the data, the authors make several other comments. First, there were quite a few people who were up and down with their back pain. Almost half of the group (47 per cent) had some additional recurrences of low back pain during the six months following their first episode. Second, patients with low back pain and sciatica (leg pain) were more likely to have a poor outcome. And third, results vary depending on the exact wording used to define acute and chronic low back pain.

Our knowledge of back pain, its natural consequence, and prognosis depend on research results. The authors suggest future understanding of this common problem is going to depend on finding some common ground to use when conducting studies. Right now, there is no consensus (agreement) and no consistent use of measures for outcomes, definitions of acute versus low back pain, or inclusion/exclusion criteria for patients participating in studies.

The problems of going back to work while still in pain and continuing to work despite symptoms and disability need to be addressed. The fact that people often still have back pain six months after the first episode and that increases the risk of developing chronic back pain also needs attention. Efforts are needed to find ways to prevent back pain, recurrent back pain, and chronic back pain.

Patients who have decompressive surgery and spinal fusion for stenosis, pseudoarthrosis, or adjacent segment disease can end up with persistent back and leg pain. This outcome is distressing to both the patient and the surgeon when just the opposite was expected (pain relief and improved function). Research to find out why these patients don’t get better has pinpointed depression as a possible factor.

By finding preoperative predictive factors, researchers hope to help surgeons identify and preselect patients for surgery who will have a good result. Predictive factors can be almost anything: age, health, sex (male or female), menopausal status for women, tobacco and/or alcohol use, body mass index (BMI), and so on.

In this study from The Spinal Column Surgical Quality and Outcomes Research Laboratory at Vanderbuilt University Medical Center, psychologic factors were examined. They evaluated 150 patients who had a second (revision) surgery for recurrent or persistent pain. Only patients with the three problems or diagnoses mentioned (i.e., stenosis, pseudoarthrosis, or adjacent segment disease) were included.

Spinal stenosis is a narrowing of the space in the spinal column for the passage of the spinal cord and spinal nerves. Pseudoarthrosis is a “false joint” that forms in a vertebral segment after fusion at that level has been done. Spinal fusion is supposed to create a stable segment that does not move. Pseudoarthrosis is the term given when there is no bridge of bone across the two vertebrae and movement is detected. And adjacent segment disease (ASD) occurs when spinal fusion results in a faster degenerative (break down) process of the spinal segment above or below the fusion site.

Previous studies have revealed that psychologic problems such as anxiety or depression can have an affect on patient results after surgery for these problems. But which came first: the depression followed by back pain or the back problem and then the depression? What is the role of depression on results of surgical treatment such as decompression and fusion? And finally, is depression a predictor of results after a second (revision) surgery? It is this last question that the Vanderbilt researchers evaluated in this study.

To conduct this study, each patient filled out several surveys and questionnaires before and after revision surgery. The areas assessed included pain (separate forms for back and leg pain), Oswestry Disability Index (ODI) for function and limitations, and the Zung Self-Rating Depression Scale. They measured the effect of depression present before surgery on the results two years after surgery.

The revision procedures included 1) arthrodesis (fusion) with hardware (called instrumentation for pseudoarthrosis, 2) decompression and extension of fusion for adjacent segment disease, and 3)fusion with instrumentation for stenosis.

They found that the presence of depression (as measured by the Zung Depression Scale) present before the revision procedure was an independent predictor of worse results. Patients with high scores on the Zung Scale were less likely to experience improvement in pain and disability after revision surgery. This effect was still present two years after surgery. The same link between depression and other types of spinal ssurgery has been reported in other studies.

Knowing the role of depression guides further research efforts. Recognizing that nonspinal health problems (including mental health issues) can affect the results of surgery is a big eye-opener. The next step may be to see if depression has the same influence on other types of treatment. Defining the role of other potential factors (e.g., diabetes, smoking, obesity, duration of symptoms before surgery) will also be important.

There are two things we know for sure about low back pain: 1) there is no known cause for the majority of people who experience this problem and 2) there’s no magic treatment that works for everyone. Despite this knowledge, physical therapists have not been scared away from trying to find effective ways to help people manage this condition.

We know that exercise as a form of therapy helps many patients in terms of pain reduction and improved function. With that in mind, the next step is to find out which specific exercise program works best. Research toward this goal has led to the development of a concept called patient classification. Patient classification divides people into groups of people who have similar characteristics. This creates more of a homogeneous (similar) group, which is easier to study and provides more reliable data.

Patient classification has then resulted in clinical prediction rules (CPRs). CPRs are guidelines to help therapists identify and recognize factors that predict a response or nonresponse to treatment. Clinical prediction rules (CPRs) are helping physical therapists find ways to identify which patients would likely respond best to individual treatment approaches.

Some of the treatment methods under consideration include spinal manipulation, lumbar stabilization, McKenzie (direction-specific) exercises, muscle retraining, and Pilates exercise. In this study, therapists investigate the possibility of developing a clinical prediction rule for Pilates-based exercise. By studying patients who respond well to this approach, it might be possible to tell (in future patients) which ones would do best with Pilates training.

The Pilates method includes breathing, balance, concentration, control, coordination, precision, and rhythm in movement. Each exercise starts out gradually and builds up in terms of range, strength, and endurance required. This type of exercise progression is referred to as graded-movement. Motor control of both the large (mobilizer) and small (stabilizer) muscles is a part of the exercise program. Mobilizing muscles allow trunk movement while stabilizers provide stiffness and support to each spinal segment.

Everyone in the study (a total of 96 people) had low back pain but no previous back surgeries. Everyone filled out several surveys to assess pain, function, fear-avoidance behaviors, and general health. Range-of-motion measurements for the spine and trunk were recorded. Special tests for muscle endurance, ligamentous laxity, and spinal instability were also performed.

Everyone was treated twice a week for eight weeks with the Pilates method. Results were determined by retesting all the baseline measures. Slightly more than half the participants had at least a 50 per cent improvement in their test scores.

Then the authors examined a number of different factors or “variables” to see if any of them were consistently present in this successful group. They looked at things like age, body mass index, duration of symptoms, number of previous episodes of back pain, presence of leg pain or other symptoms, and hip rotation.

They found five predictors that suggested which patients with low back pain would respond to Pilates-based treatment. These included: trunk flexion (70 degrees or less); symptoms lasting less than six months; no pain, numbness, tingling, or other symptoms in either leg; being overweight (BMI greater than 24 kg/m2); and hip rotation greater than 25 degrees on either side (right or left leg). When three, four, or all five of these factors were present, there was a significant likelihood that Pilates-based exercise would help the patient.

These results are considered preliminary. Further study will be needed to confirm that the information fom this study can be used to set up a clinical prediction rule for Pilates-based exercise when treating low back pain. A randomized-controlled, clinical trial will be needed to validate this conclusion. If it all pans out as expected, therapists will be able to determine early on which patients will likely respond well to the Pilates method.

This report of a FDA-monitored clinical trial provides some encouraging news for the 20 per cent of patients who suffer increased back and leg pain after discectomy (disc removal). A new product called oxiplex gel is being investigated with good results so far.

Oxiplex gel is applied to all the soft tissues around the surgical site after the disc has been removed. A coating is placed on the nerve root, annulus fibrosus (covering around the disc), and dura (lining around the spinal cord). It works like teflon to create a mechanical barrier that keeps out pain messages. And it even reduces the amount of scar tissue called fibrosis that can develop after surgery.

In this study, two groups of patients were compared: one group received the oxiplex while the second (control) group did not. Patients in both groups had the same surgical procedure: a single level laminectomy or laminotomy and discectomy. A laminectomy involves cutting away some of the back of the vertebral bone (the lamina) in order to remove the central portion of the herniated disc. In a laminotomy, the surgeon drills a hole through the lamina to aspirate (suck out) the disc.

The results were measured based on back and leg pain before and after surgery and presence of other distressing (adverse) symptoms. Patient satisfaction and number of disability days were also compared. And each patient was examined for neurological and motor function (e.g., numbness, weakness, dizziness, headache, loss of sensation, muscle or joint pain, stiffness, muscle spasm). The last comparison made between the two groups was the number of reoperations necessary due to pain.

After analyzing all the data collected, they found that for patients with severe pain before surgery, the use of oxiplex gel made a significant difference. Those folks had less postoperative back and leg pain, fewer reoperations, and greater satisfaction with the results. There were also fewer patients in the oxiplex gel group who had adverse effects after surgery and there were fewer abnormal musculoskeletal problems as well.

From this preliminary study, it looks like this new oxiplex gel is safe and effective for relieving the postoperative pain many patients experience after discectomy. This was especially true for the more challenging patients who had severe back pain before surgery (a group likely to experience persistent pain after surgery). One of the other advantages of the oxiplex gel was the prevention of cerebrospinal fluid leaks. With the gel painted on the dura, the fluid was contained, which also prevented any postoperative headaches.

Total Disc Replacement (TDR) in the lumbar spine (low back) for degenerative disc disease helps reduce pain while preserving motion. There are several different types (brands) of disc replacement devices available now. In this study, patients who received the ProDisc-L are followed for a minimum of 5 years to assess outcomes.

Clinical success was measured in several different ways. They used the Visual Analog Scale (VAS) to measure pain, the Oswestry Disability Index (ODI) for function, and a sporting activity scale score. A minimum of 15-points in improvement on the Oswestry was required for the patient to be considered “improved” or “a success.” Patients were also asked two questions at the end: 1) how satisfied were you with the results of surgery? (e.g., satisfied, very satisfied, dissatisfied, or very dissatisfied and 2) If you had to do it over, would you have the surgery again?

Everyone in the study was treated by the same surgeon at one center. Follow-up was conducted at three months after surgery, then again after one year, two years, and finally more than five years later. The results were very similar to results from other studies using this particular implanted device.

First, early improvements were observed in the first two years after the procedure. But a decline in the positive benefits of this device was observed in the later years. To put some numbers to these results, 88 per cent registered at least a 15-point improvement on the ODI from before to after surgery. This number declined to only 71.4 per cent at the end of five years.

Only 60 per cent of the patients said, ‘Yes, if given the choice, I would have this surgery again.’ The authors expected that statement of satisfaction to be higher to match the increase in function in at least the 71.4 per cent group. There were no complications or adverse events in either group making it seem like the perceived success should be higher longer.

As they looked back over the study, the authors observed several things that might account for the disconnect between functional improvement and patient satisfaction. First of all, the cut off for a threshold of improvement using the ODI (15 points better = success) might be too conservative. A 10-point difference might have given a higher satisfaction rate while still registering significant improvements in function.

It’s possible that the decline in improvements seen over time is typical of lumbar disc replacement surgery no matter who does the surgery and/or no matter which device is used. In this study, they only used one implant and therefore did not compare the mid-term results with other devices. At five years out, further study is still needed to assess the long-term (10 years or more) results with all types of artificial disc replacements.

Physical therapists are commonly involved in the treatment of patients with chronic low back pain. Like all health care professionals, therapists must base treatment on evidence that the treatment is beneficial to the patient.

The evidence we have so far suggests that not all low back pain should be treated the same. Sometimes manipulation is the best approach whereas in other cases, exercises are advised. And even within those categories of treatment, there are subgroups to choose from. For example, exercise could include stretching for flexibility or strengthening to improve stability.

How does the therapist know what treatment to provide for each individual patient? And do therapists in different towns across the United States select the same treatment program for the same problem? The answer to those questions can be found in the recently published document: Low Back Pain. Clinical Practice Guidelines (CPGs) Linked to the International Classification of Functioning, Disability, and Health (ICF) from the Orthopaedic Section of the American Physical Therapy Association (APTA).

This publication is a must-read for all physical therapists who are working with patients who have low back pain. As the name implies, the 57-page document is a guide to assist therapists in knowing how to approach each patient with low back pain.

Risk factors, clinical course, diagnosis, examination, and outcomes are all discussed in detail. Information provided and recommendations made are all based on current evidence available. The approach taken is toward returning patients to their previous level of function. This is a shift from the past when everything was viewed as disability and dysfunction rather than ability and function.

The authors provide a detailed accounting of how these recommendations were determined. After an in-depth discussion of each section, they offer a summary of the recommendations that make up the clinical guidelines. Here’s a brief review of some of those recommendations:

It is no secret that low back pain (LBP) is one of the most common ailments in adults and one they often seek medical help for. This fact seems to be a true constant around the world in developed countries. Now, a new study from the United Kingdom (England and Scotland) uncovers some additional information that may be more challenging than helpful.

In a study of over 15,000 adults 25 years old and older, they found a 28.5 per cent one-month prevalence rate. Translated, this means that in a 30-day period of time for the people in the study, almost one in three adults reported low back pain. This finding is consistent with the results of many other studies that show one-third of all adults surveyed at any given time will report similar symptoms.

There were some age differences in this study that may be important. First, it seems the older we get, the more likely we are to experience a bout with back pain. Second, in this group of so many thousands of participants, the adults most likely to report back pain were between the ages of 41 and 50 years old. And third, older adults (over age 80) still had low back pain but the percentages dropped to one in four instead of one in three.

The second focus of this study from England was to look at how low back pain is managed among the different age groups. As it turns out, there was a general trend observed in that younger adults were given exercises and older adults were more likely to be given painkillers.

A red flag was raised immediately with these results because evidence-based guidelines for the management of low back pain include staying active, exercise therapy, manual therapy, or acupuncture. Pain management with medications is recommended but not as the only approach. These surprising findings raise some additional questions.

For example, are these evidence-based guidelines suitable for older adults? In other words, has the research really been done with this particular age group in mind? Perhaps drug therapy (referred to as pharmacologic management) is the best way to deal with low back pain in older adults. If not, what is the most effective management strategy for older adults? And why are physicians relying on medications for older adults when the guidelines clearly state self-management should be conservative as described?

A closer look at the data showed that older adults were less likely to be sent to a physical therapist or other specialist for help with their back pain. Older patients were more likely to have been to the doctor for low back pain before and given exercise recommendations. With subsequent visits, they were less willing to accept exercise as the answer and more likely to tell their doctor “exercise won’t work for me.”

Older adults were also more likely to complain of pain elsewhere (e.g., hip, knee). This may be a factor in why they were given pain relievers and other medications instead of following the current accepted guidelines for the management of low back pain.

When cognitive behavioral therapy (CBT) was suggested, there was even more resistance and less positive attitudes. CBT is a form of counseling aimed at changing attitudes and fears about movement and staying physically active.

Some people with chronic low back pain are so afraid of causing pain that they start to avoid movements and activities that might cause pain. This attitude is called fear avoidance behavior (FAB). And FAB has been shown in many studies to be reduced with cognitive behavioral therapy with the net result of decreased pain and improved function.

These attitudes about exercise and behavioral therapy among older adults represent a new challenge in the treatment of low back pain that may not have been recognized previously. The authors suggest further studies are needed to find out what is the optimal management of low back pain in older adults.

It was suggested by these researchers that a thorough pain assessment should be performed in low back pain patients, including and especially in the older age groups. They firmly advocate that everyone (regardless of age) should receive optimal care.

In conclusion, factoring in attitude may be the missing key in explaining age-related differences in how younger versus older adults with back pain are treated. Education is important because older adults with other painful problems and other health problems may see exercise as impossible. But in fact, many studies have shown that exercise would benefit the additional problems and improve their overall health as well.

The mystery of low back pain and how to treat it continues. Pain, loss of function, and chronic disability can become the end result of an episode of acute nonspecific low back pain. Nonspecific means there’s no fracture, infection, or tumor. Some aspect of joint, soft tissue, and/or biomechanics (the way things move) is amiss.

Until scientists can pinpoint the exact cause of nonspecific low back pain, treatment is usually symptomatic: decrease pain as quickly as possible and restore normal movement. To that end, researchers have managed to find evidence-based clinical practice guidelines (CPGs) to direct conservative (nonoperative) care. Despite many publications outlining those guidelines, there are still many health care providers who do not follow them.

In this study, chiropractors from the School of Chiropractic and Sports Science in Perth, Australia attempt to give meaningful numbers to results of treatment for acute low back pain. They compare two groups of patients who have experienced nonspecific low back pain of less than six weeks’ duration. The two main measures of clinical outcome include disability scores and pain. As a second measure, they asked patients to quantify their level of satisfaction.

The first group of patients (the control group) received “usual” care from a chiropractor consisting of spinal manipulation, soft tissue treatments, exercise, and education or advice. The second group (experimental group) received care as outlined by evidence-based clinical practice guidelines.

First and foremost, patients received advice and education. A special book (The Back Book) was given to each patient. This book emphasizes self-care and provides information about the causes, course, expected course, and treatment of low back pain. Participants in this group were encouraged to stay active and return to work as soon as possible. Spinal manipulation, joint mobilization, and gentle soft tissue work was also provided.

The use of exercise therapy, massage, heat and cold, traction, corsets or supports, and electrotherapy was not employed. There is not strong, consistent, or reliable evidence that these types of treatments are effective.

Everyone in the study (both groups) was treated up to seven times over a period of four weeks. Results were measured at week two (mid-way through treatment) and at the end of week four (final treatment). Tools used to measure outcomes included the Oswestry Low Back Disability Index (ODI), Visual Analog Scale (VAS), and Patient Satisfaction Questionnaire (PSQ).

The results showed no difference in final outcomes at the end of four weeks. What was particularly striking was the fact that patients in the experimental group (following clinical practice guidelines) were significantly better after two weeks compared with the control group who received usual conservative care.

So for faster results which could mean getting back on-the-job or back to daily activities sooner than later, the evidence-based guidelines remain the first choice for treatment of acute episodes of low back pain. The authors note that this ‘less-is-more’ approach has been confirmed effective by other studies as well. Two sessions of spinal manipulation has been shown to reduce pain and disability by 50 per cent and should continue to be the first treatment choice for this type of problem.

Research has shown that patients with low back pain who develop fear-avoidance behaviors (FABs) are at risk for a poor outcome and greater disability. Studies have also shown that when FABs are addressed in treatment, patients have much better results. Despite this knowledge, routine care of low back pain does not include strategies to prevent or stop FABs.

Fear-avoidance behaviors (FABs) refer to ways patients change their behavior, actions, movements, and activities based on the fear that their pain will increase or that their actions will cause reinjury. Their thoughts and emotions rule their behaviors because of concerns, worries, and fears that further harm will come to their spine.

For the most part, these fears are unfounded and become an obstacle to recovery. Patients put much more importance on back pain and assume the pain means the spine is weak and vulnerable. This just isn’t true. But without proper education, the patient becomes anxious, depressed, and inactive. They may start using more and more medications and become more like a “sick” person than someone who is going to recover.

In this article, a summary is provided of what is known about fear-avoidance behaviors (FABs) and how to turn research data into practical clinical treatment. The information comes from a panel of six experts and 40 health care providers who attended a meeting on the topic of FABs.

At the workshop, the emotional and educational reasons for these behaviors were explained. Part of the problem is the fact that scientists really don’t know what causes most back pain. Without a known mechanism of pain, it’s difficult to prescribe one “best” treatment for everyone. Possible treatment approaches were offered at this conference based on placing patients in subgroups or categories of specific types of FABs.

The three subgroups identified by the panel include: 1) misinformed avoiders, 2) learned pain avoiders, and 3) affective avoiders. As you can see by the names, these groups are based on the emotions and beliefs held by patients and used to explain why they are avoiding certain movements and activities.

The misinformed avoider avoids activities that might provoke pain based on common sense that another injury would cause more pain. Therefore they avoid anything that might lead to another back injury. This group of patients can be swayed in their views with new information based on reasoning and logic.

The second group (the learned avoiders) developed fear-avoidance behaviors based on actual experience. When they moved in a certain way, their pain increased. So they stop any activities that are painful but they never go back to re-try those movements. If they did, they might discover there is no longer any pain associated with the activities they have been avoiding.

And finally, the affective avoiders are patients who are very distressed about their pain. They have an irrational fear of physical movement and refuse to see reason or try any new activities. This group tends to exaggerate any advice or precautions given to them by their physician or physical therapist. All their thoughts are focused on their back pain. They are said to be “hypervigilant.”

How can treatment be focused for each of these groups? The misinformed avoiders must be given new information and guided through stretching and easy movements so they can see it is possible to move and engage in physical activities without hurting themselves. They must be convinced that physical activity won’t cause further spine degeneration. Educational brochures, booklets, and videos may be helpful with this subgroup but they must come from spine experts or they aren’t effective. At least that’s what studies so far have shown.

What about learned pain avoiders? What’s best for them? This group is a little more difficult to reach with effective treatment. First of all, when they move, it does hurt. So they aren’t misinformed at all. The panel suggested that research is needed to find better ways to help these patients. Some studies have shown that back pain can be reduced for these patients by repeating the same motion or movement over and over. Why this works to stop the pain signals remains unknown.

The last group (affective avoiders) have fears so strong the fears become phobias. They are deeply entrenched in their beliefs. One program that has worked for this group is to re-introduce activities slowly starting with the least worrisome (and easiest) movements.

Slowly, with repeated actions and exposure, more and more activities are introduced. The patient is guided through the activities slowly and carefully by the physical therapist. Over time, they become more confident and more willing to engage in physical activities once again.

One other approach that seems to have merit for the affective avoiders is called functional restoration. The patient is given a certain number of exercises and activities to do each day. This is a quota-based approach. As the patient completes each task successfully, he or she becomes more confident that “hey, my spine can handle that just fine!”

At the same time, this group of patients is given counseling aimed at reducing and eliminating negative beliefs that result in disability. Studies show that this approach helps people get back to work. For those individuals who are still working, functional restoration helps them reduce the number of sick days.

The panel made one final note of importance. They pointed out that some health care providers hold fear-avoidance beliefs that are no different than their patients. As a result, they prescribe bed rest instead of activity for their patients with chronic back pain. Patients under the care of health care providers with high fear-avoidance beliefs have more physical limitations and greater disability. Studies show that health care providers with fear-avoidance beliefs can and do change with education.

Here’s a dilemma neurosurgeons and orthopedic surgeons face when it comes to advising patients with chronic low back and leg pain from disc disease. Epidural injections are a common way to treat this painful problem. For more information on the treatment of chronic low back pain with epidural (steroid) injections, see A Patient’s Guide to Epidural Steroid Injection.

Evidence is lacking in how well these injections work. The best way deliver the injections is also debated. With anywhere from 18 to 90 per cent effectiveness reported, it’s difficult to assure patients that this treatment will work.

When doing an epidural injection, the doctor inserts a needle through the skin so that the tip of the needle is in the epidural space. This space is the area between the bony ring of the spine and the covering of the spine called the dura. The dura is the sac that encloses the spinal fluid and nerves of the spine.

The epidural space is normally filled with fat and blood vessels. Fluid such as the lidocaine and cortisone that can be injected is free to flow up and down the spine and inside the epidural space to coat the nerves that run inside the spinal canal.

Epidural injections are commonly used to control back and leg pain from many different causes. These injections control pain by reducing inflammation and swelling. They do not cure any of the diseases they are commonly used for, but can control the symptoms for prolonged periods of time. In some cases, the reduced pain makes it possible for the patient to participate in a physical therapy program, become more active, and be better able to control the symptoms with a conservative program.

Some of the uncertainty in how well injections work for lumbar disc herniations is due to the fact that there are two different types of injections and three locations to give them. The injection solution can be a local anesthetic like lidocaine or bupivacaine. Or it could be one of those two numbing agents combined with a steroid (antiinflammatory medication).

There are several openings in the bones that surround the epidural space where a needle can be placed. The injection can be performed by placing the needle in one of three of these openings (caudal, interlaminar, transforaminal).

Each of these three types of ESI injections has advantages. But here is another dilemma in doing research studies to provide physicians with the evidence needed to support one approach over another. We don’t have randomized, controlled, double-blind trials to compare patient results when using different types and locations of injections. That’s where this study comes in.

The authors randomly divided a group of 120 adults with painful back and leg symptoms from lumbar disc herniation into two groups. Everyone in the study received at least one injection under fluoroscopic (real-time X-ray) guidance. All injections were given into the caudal opening.

The caudal injection is performed at the very lower end of the spine through a small opening in the bones of the sacrum. The sacrum is made up of several vertebrae that fuse together during development to form a single large bone. This bone is where the pelvis connects to the spine. The opening at the tip of the sacrum leads directly to the epidural space. Fluid injected through this opening can flow upward through the epidural space to coat the nerves throughout the lower lumbar spine.

The first group received a caudal injection of just an analgesic compound (numbing agent for pain relief). The second group received an injection of a solution that contained a mixture of an analgesic agent (lidocaine) and an antiinflammatory (steroid). A second or third injection was given only if there wasn’t enough pain relief or the pain came back. Patients could come back for additional injections for up to one year from the start of the study.

The patients did not know which group they were in. The physician who performed all of the injections didn’t know what type of injection was being given. That’s what makes this a double-blind (more objective) study. Results were measured on the basis of before and after pain levels, function, ability to go back to work, and use of oral pain relievers.

A successful result was considered pain relief with only one or two injections that lasted at least three weeks. It turns out that the steroid injection group had better overall results. They had more pain relief with the first injection than the other group. The pain relief lasted longer for the steroid group. And the steroid group had fewer injections during the year of this study.

The authors concluded that steroid epidural injections (more commonly known as epidural steroid injections or ESI) are superior to analgesic injections. This study only looked at patients with pain from disc herniations not any of the many other spinal problems injections are used for. And only caudal injections were used so there’s still a need for further studies to evaluate (and compare) results among all three injection sites.

For patients who do not want steroid injections, injection of a local anesthetic can yield good results, too. They should be told that the results may not last as long as with steroid injection and that more injections may be required. Even so, epidural injection of an anesthetic is an acceptable treatment approach.

How do physicians decide what treatment recommendations to make for patients with acute (early onset) of low back pain? Is it based on whether that patient is a man or woman (suggesting a sex-biased health plan of care)? Does the patient’s socioeconomic status (SES) such as lifestyle, occupation, and education make a difference? And how much does the clinical presentation affect the decision-making process (especially if that presentation is from an emotional female)?

These are the questions put forth by the authors of this study. They surveyed 284 physicians from five different clinical sites (both primary care physicians and emergency department physicians). They asked questions about physicians’ decisions related to patients with low back pain.

Physicians were given a case scenario of a patient with recent onset of low back pain. After giving a written summary of the patient’s characteristics, physicians were asked about the diagnostic approach and treatment they might choose for this patient. Analysis of the data took into account the type of treatment recommended based on the three factors already mentioned (sex, socioeconomic status, and clinical presentation).

Each of these three variables was analyzed based on diagnostic tests physicians would order and the type of treatment recommended. Some of the diagnostic options included blood tests, urinalysis, X-ray, CT scan, MRI, or discography. Of course, no diagnostics was an option, too.

On the treatment side, physicians could recommend no treatment or referral to another physician (specialist), physical therapist, chiropractor, osteopath, or psychologist. Choices of specialists included orthopedic surgeon, physiatrist (physician who specializes in rehabilitation services), neurologist, gynecologist (for women), and anesthesiologist.

For half the physicians, no diagnostics and referral were recommended. Patients were given instructions to stay as active as possible, use heat or cold, and take pain relievers as needed (e.g., ibuprofen or other antiinflammatory). The natural course of the back pain would be explained and an educational pamphlet provided. Almost all physicians recommended a follow-up visit. When referral was recommended, it was most often to a physical therapist.

Of particular interest in the results was the apparent link between socioeconomic status (SES) and activity recommendations. It seems physicians were more likely to encourage patients to remain active if they were white-collar workers (higher SES status) and male. Blue-collar workers (e.g., manual laborers) and women were more likely to be told to take it easy, rest, and restrict heavy lifting or other manual work at home and at work.

The other nonclinical factor that seemed to influence physicians’ treatment decisions was the clinical presentation. Patients who expressed distress about their back pain were more likely to be given a prescription for medications. Though not stated, the authors presumed this behavior on the part of physicians was to reduce the patient’s suffering.

However, there is no scientific evidence that such treatment is beneficial or yields any better results than doing nothing. And there is plenty of evidence that staying active will improve outcomes. Clinical practice guidelines for the treatment of acute low back pain have been previously published.

One of the recommendations supported by studies is the use of chiropractic care for acute low back pain. Despite evidence to support this treatment option, not one of the physicians surveyed chose manipulation. Physical therapists perform manipulations but manipulation as a treatment option was not specified as chiropractic or physical therapy.

The authors summarized their findings by saying that this study provided more evidence that for the most part, primary care and emergency department physicians are not treating patients with acute low back pain according to current clinical practice guidelines. Instead, they are being influenced by patient characteristics such as gender (female versus male), socioeconomic status, and complaints of pain, distress, and suffering.

In a never ending effort to find ways to help patients with low back pain, many different treatment approaches have been tried. In this report, researchers from Spain take a look at the effectiveness of shock wave therapy (also known as vibrotherapy) and ultrasound in the treatment of both acute and chronic back pain.

Both of these tools provide mechanical vibration to the spine in an effort to increase blood circulation, improve soft tissue stretch, reduce pain and stiffness, and speed up healing. Other potential effects of shock wave and ultrasound therapy may include enhanced cellular metabolism, muscle relaxation, and increased trunk/spinal motion.

They conducted the study as a systematic review. This means they searched all the currently published literature looking for studies on either of these two treatment methods. They found a total of 13 studies but only four randomly controlled trials.

The reported results then are based on the experiences of 252 patients. Various treatment methods were used and compared with ultrasound such as lumbar traction, low power laser, electrical stimulation, and spinal manipulation.

It was a bit difficult making clear comparisons since every study had its own duration (e.g., treatment three times a week for three weeks; treatment daily, five times a week for three weeks; treatment once or twice a week for a total of four sessions, etc). And results or final outcomes were measured using different tools (pain assessment, function, disability, walking distance, spinal motion, emotional functioning and coping).

The one constant in all the studies was that ultrasound was compared to a sham procedure. Sham treatments are a placebo created by using the machine (e.g., laser, electrical stem) but without actually turning it on. Here’s a summary of the results:

Many people with lumbar disc herniations opt for a wait-and-see approach to treatment. And that approach is usually recommended by most surgeons. But can you wait too long? Does the duration of symptoms have an unfavorable effect on final outcomes? This is the focus of a study conducted as part of the Spine Patient Outcomes Research Trial (SPORT).

The SPORT database provides information and data from 13 multidisciplinary spine practices across the United States. By combining patient information, studies like this make it possible to get more statistically accurate analysis of risk factors and variables (like duration of symptoms) that might affect treatment results.

In fact, it’s studies like SPORT that have made it possible to see that surgery for lumbar disc herniation yields better results than conservative (nonoperative) care. But the question of when it’s best to have that surgery remains unknown.

Patients in this study were divided into two groups: those who had symptoms for six months or less and those who had symptoms for more than six months. The researchers compared these two groups within two larger groups: those who had surgery and those who didn’t. And in case you are wondering, surgery consisted of a traditional open incision discectomy (removal of the disc). Conservative care included physical therapy, antiinflammatory drugs, education, and/or counseling.

Results were based on change in pain, other symptoms (e.g., leg pain, numbness, weakness), and physical function. Comparisons were made from baseline to follow-up four years later. They found worse results in patients who waited more than six months to get treatment. This was true for both groups (operative versus nonoperative). But the duration of symptoms did not seem to be a factor or reason why patients responded better to surgery.

The natural next-step in a study like this is to look at the two groups of patients (symptoms less than six months, symptoms more than six months) and see if there’s more to it than just a number of pretreatment months. In this study, there were 927 patients in the six months or less group and 265 in the more than six months group.

The differences observed between the two groups were listed as more depression and a sense that the symptoms were getting worse in the six months or more group. Patients who had surgery sooner had more severe symptoms early on.

The patients who had surgery were also more likely to show more than just a protruding disc on MRIs — the discs were often more out of the disc space than in. There were also a higher number of patients with severe symptoms less than six months’ duration with sequestered types of herniation. Sequestered means a portion of the disc has been pinched off and separated from the rest of the disk. The free-floating fragment can create serious problems if it presses against the spinal cord or spinal nerve roots.

The authors concluded that symptom duration is a factor that should be paid close attention to. Whether treatment is conservative or with surgery, patients who had intervention of some kind within the first six months had better results.

It is still recommended that patients try conservative care first for symptomatic lumbar spine disc herniation. If surgery is going to be done, results will be better if the disc is removed sooner than later and before six months has passed. In agreement with the results of other studies, this study also showed that even late treatment (one to two years after the start of symptoms) offers patients some benefit by way of pain relief and improved function.

Everyone has a duty to help reduce health care costs. In this article, physical therapists step up to bat with one idea: determine when advanced imaging is really needed. They start by looking at a patient population group that is very common in a physical therapy clinic: people with low back pain.

It’s estimated that half of all patients seeing physical therapists in outpatient clinics have come for one thing and one thing only: low back pain. With direct access (patients can see a physical therapist without seeing a physician first), therapists need to know when patients should have X-rays and/or other imaging studies. Likewise, the physical therapist must be able to decide when such diagnostic aids are not needed.

Many studies have shown that findings of degenerative disease, malalignment of the spine, and other anatomic problems or deformities don’t always cause symptoms. And the opposite is true, too — patients with severe pain may have very normal looking X-ray, CT scan, or MRI results. Successful, evidence-based treatment may not depend on imaging results.

In fact, sometimes patients who see the changes on imaging studies (or who are told about them) end up worse off. Their perception of health deteriorates. They start avoiding certain activities or movements that “might cause pain.” The end-result is worse pain and decreased function. Not only that but the rates of surgery have increased two to three times what they were 10 years ago.

So, when should X-rays or other diagnostic imaging be done with low back pain patients? According to the American College of Physicians and the American Pain Society there are three basic guidelines. First, don’t order X-rays or other imaging studies routinely.

Second, don’t order diagnostic imaging studies unless there are strong clinical signs that surgery or steroid injectins may be needed. And third, use imaging studies when there are severe neurologic signs and symptoms that could result in permanent neurologic damage (including permanent loss of strength, sensation, or even paralysis).

These guidelines were first published in 2007 and remain appropriate today. They were based on numerous quality randomized clinical trials. Despite these evidence-based recommendations, studies show that one-third to one-half of all referrals for advanced imaging are inappropriate.

Additionally, exposure to radiation is recognized as an important concern now that we have the means to measure the risk of cancer from radiation. For example, one X-ray of the lumbar spine exposes the human body to the same dose you would receive from background radiation over a six-month period of time. And one lumbar spine X-ray is equal to 75 chest X-rays.

In summary, there is agreement among experts who have studied the use of imaging studies that most patients with low back pain don’t need X-rays, CT scans, or MRIs. Those who would benefit from imaging can be discerned on the basis of history and physical examination. The biggest concern is for tumors, infection, and fractures.

Physical therapists know how to screen patients for these kinds of problems and what to look for that might suggest a higher likelihood of serious problems. Anyone with low back pain can be confident that seeing a physical therapist first will save them money in the long-run. The therapist also monitors patients over a period of time and can see changes (or lack of change) to help assist in the decision-making process.

With evidence-based testing, the therapist will know who needs to see a physician and who can benefit from physical therapy intervention. Studies within the field of physical therapy have also provided evidence to help the therapist know the best approach to different types of low back pain. It’s a fact that many, many people with back pain and “positive” X-rays showing disc or other spine degeneration recover fully from their painful symptoms even when the X-ray doesn’t change.

Future studies will continue to provide information that will help people with low back pain understand the role of self-care, get the right kind of treatment when needed, and save money in the process. Staying active, engaging in movement of all kinds, stretching, and maintaining flexibility are all valuable ways to maintain good spine health and an active, pain free lifestyle.

Magnetic resonance imaging so well-known simply as MRI has been around now for 35 years. We have a better sense of when to use them to diagnose and measure results of treatment. In this article, a group of physical therapists present how MRIs can be useful to the physical therapist in planning treatment and assessing outcomes. The specific focus is on magnetic resonance imaging of the spine. Reviewed in this context, the pearls and pitfalls of this tool are reviewed.

First, let’s look at when MRIs are useful and what they show when directed toward the human spine. When you look at an MRI of the spine, you can easily see the bones, discs, spinal cord, ligaments, and even the cerebrospinal fluid in shades of black, white, and gray. Varying structures show up in different shades based on signal intensity picked up by the MRI.

MRIs are very helpful after trauma to the spine to look for neurologic damage. Likewise, vascular damage with blood loss or internal bleeding can be seen with MRIs. Pressure on the spinal cord or spinal nerve roots show up clearly. Injuries to the ligaments and other soft tissues can also be seen. Changes in size, shape, and orientation of the muscles are also visible. Any part of the spine from the head down to the tip of the spine (the coccyx) can be viewed.

The authors present the benefits (pearls) and disadvantages (pitfalls) of MRIs of the cervical spine (neck), thoracic spine (midback), and the lumbar spine (low back). As a diagnostic tool, MRIs help the physical therapist understand the underlying pathology. That’s considered a clinical application.

But there’s also room for using serial MRIs (several images of the same area taken at different time periods) to show the effect (or lack of effect) of treatment. This is the research application of MRIs. Though there is some expense involved in doing serial MRIs, there is also a high cost of health care when an ineffective treatment is applied over the course of weeks to months. Using imaging studies like MRI may offset the cost by providing information needed to guide treatment.

One of the best advantages of MRI (a pearl) is that it does not expose the body to ionizing radiation like X-rays and CT scans do. And it provides the only real way to look at the spinal cord. MRIs are better than X-rays for finding subtle or difficult-to-spot bone fractures. MRIs also show bone bruising and tumors that aren’t readily seen on X-rays or CT scans.

One of the biggest downfalls (a pitfall) is the appearance of artifacts. Artifacts refer to anything that shows up on the MRI that isn’t really there. An error on the part of the technician conducting the test can create artifacts. But so can the pulsations of blood or cerebrospinal fluid as they flow through the body.

Dental implants show up as dark spots. Fat and water in the body shift position causing artifacts. Even chemicals shifting in the body can become artifacts. Any of these factors creating artifacts can also result in a false positive meaning the MRI suggests a problem that doesn’t exist.

One other pitfall to all imaging studies (including MRIs) is the fact that many people have changes that don’t create symptoms. In fact, studies show that some of the damage to ligaments and other soft tissues associated with whiplash injuries are also present in people who have never injured their necks. On the other hand, it has been shown that some patients with severe neck or back pain have perfectly normal-looking imaging studies with no obvious damage to account for the symptoms.

In conclusion, MRIs offer some valuable information to the physical therapist. But all findings must be viewed with caution. The patient’s history and clinical presentation (signs and symptoms) must be considered along with the imaging results when planning, assessing, and modifying treatment. Unless there is a strong suspicion of spinal fracture, infection, or tumors, or consideration of the need for surgery, MRIs may not be needed.

The use of MRIs in research to document changes in response to different treatments applied may be expanded in the future. As a research tool, MRIs show changes in muscle, soft tissues, and even at the cellular level. This can be valuable information for the physical therapist. Cost is the only deterrent since the patient is not exposed to any hazardous radiation. Continued advancements in improving MRI systems may also expand the use of this modality in both clinical and research applications.

Chronic low back pain remains a problem without a good solution. No single type of treatment works for everyone. Most patients end up combining multiple different treatments until they find the right mix that is effective for them. This may include medications, counseling or behavioral therapy, physical therapy, and surgery.

Medications often include pain relievers (analgesics) such as tylenol and antiinflammatories such as ibuprofen, naproxen, or other prescription nonsteroidal antiinflammatories (NSAIDs). Sometimes mild narcotics such as codeine or tramadol are prescribed.

A new drug called Tanezumab developed as a treatment for pain has been shown effective in patients with osteoarthritis, interstitial cystitis (bladder pain), and bone pain from cancer. Tanezumab is a monoclonal antibody (mAb) that works to alleviate pain because it neutralizes nerve growth factor (NGF). Nerve growth factor sets up pain signals and even heightens the body’s responsiveness to painful stimuli. This means the nervous system responds faster to smaller inputs creating larger pain responses.

Tanezumab stops nerve growth factor activity. Tanezumab was undergoing Phase II and III clinical trials for the treatment of various pain problems, including chronic low back pain, bone cancer pain, and interstitial cystitis. But studies were halted in June 2010 when some patients with osteoarthritis got much worse after taking tanezumab and ended up needing hip replacements.

The reports included 16 patients who had X-ray evidence of bone necrosis (bone death) that required total joint replacement. It is possible that joint failure occurred as a result of excess wear and tear on the joint when pain was absent. In a sense, tanezumab as a pain reliever may have been too effective for these patients with painful hip and knee osteoarthritis. Eliminating the pain did not stop the degenerative processes and the increased activity further damaged the involved joints.

So for the moment, tanezumab is on regulatory hold due to the adverse effects in osteoarthritis patients. In the meantime, the results of this study comparing tanezumab with naproxen and placebo for chronic low back pain (conducted before the hold) are reported.

Over 200 patients with chronic low back pain caused by osteoarthritis were included in the study. They were randomly divided into three groups. Group one received a single intravenous dose of (real) tanezumab and a placebo (sugar pill) naproxen (antiinflammatory). Group two were given an intravenous tanezumab placebo with real naproxen. Group three received placebo tanezumab and placebo naproxen. Group one was labeled the tanezumab group. Group two was the naproxen group. And group three was the placebo group.

The patients each kept a daily electronic diary recording pain levels and the use of any “rescue” medication. Rescue medication refers to any pain reliever used when painful symptoms were intolerable. Pain intensity and rescue meds were two of the measures used before and after to compare results. Questionnaires were also used to measure function and disability.

The effectiveness of tanezumab for chronic low back pain was measured using these outcomes. Safety was also a concern and was assessed by reviewing adverse effects reported by the patients. Review and analysis of the data showed that everyone in all three groups had measurable pain relief. The tanezumab group had the best results, naproxen second best results, and placebo ranked third after the other two.

These were the results during the early weeks (zero up to six weeks). After eight weeks, the naproxen and placebo groups were equal. The tanezumab group continued to report the best results throughout the 12 week treatment period. That answers the question of efficacy or effectiveness — tanezumab clearly outperformed the other two (naproxen and placebo).

What about safety? What were the side effects (if any) in the tanezumab group and how did they compare to the other two groups? There were reactions in all three groups but the tanezumab-treated group did have the highest incidence of problems. Joint pain, headaches, muscle pain, and painful responses to stimuli (e.g., touch) that shouldn’t be perceived as painful were reported in the tanezumab group. These side effects were temporary and all gone by the end of the study.

No one in any of the groups had serious complications (i.e., permanent paralysis or death). Overall, tanezumab provided better pain relief and resulted in better function than either naproxen or placebo. Adverse side effects of the tanezumab were mild-to-moderate and temporary.

Long-term studies are needed to see if recurrence of back pain (common among back pain sufferers) can be changed with tanezumab and if there are any long-term side effects such as bone necrosis. The possibility of having an effective nonnarcotic medication for patients with chronic low back pain that has been unresolved with other treatments is worth pursuing.

The authors suggest resuming studies of this medication for chronic low back pain if/when the ban on its use in studies is lifted. There is enough evidence from this study (and other studies) that the use of tanezumab is safe and effective with chronic low back pain patients.

Have you ever noticed how some people give in to their back pain while others push through and do whatever they want regardless of the pain? What makes the difference in these two groups of patients? What makes the persistent group keep on keepin’ on? Why does the avoidance group give up?

One way to better understand the difference in behavior among chronic low back pain sufferers is to look at self-discrepancies. These are the differences between how the patient sees him or herself versus how he or she would like to be. Other measurable self-discrepancies include who you would like to be versus who you think other people want you to be. There is also the difference between who you are and who you are afraid to be.

Differences between these conflicting viewpoints can create anxiety, fear, depression, distress, and more pain. Understanding that these conflicts exist, measuring them, and reducing them may help improve function and eliminate disability among chronic back pain sufferers.

Researchers in The Netherlands have been working on creating a model to identify and measure self-discrepancies based on behavior. Now they are using this tool to evaluate level of perceived disability and quality of life. They hope to be able to uncover the thought process behind avoidance versus persistence actions. Finding better ways to treat chronic low back pain may depend upon recognizing these behavioral variables.

Over 100 people participated in the study. They all had similar chronic low back pain. Everyone completed a variety of questionnaires about pain, depression, activity level, and quality of life.

Everyone was interviewed about their health-related quality of life. Each of these measures was taken twice: at the beginning of the study and again six months later. Everyone also carried a special device called an accelerometer for two weeks. This tool measured level of activity by calculating how much time each person was up and moving.

They found a curious mix of results. First, men were more likely to demonstrate persistent behavior (push through the pain). Patients who were most like who they wanted to be were also more likely to be persistent in their behavior.

But patients who were far away from being their ideal-self were also more likely to engage in persistence behaviors. In both groups (avoiders and persisters), the stronger these behaviors, the more disabled the patients perceived themselves. Overall, higher pain levels translated into poorer perceived quality of life and mental health.

You might think that people who are up and going despite the pain would be close in who they want to be and who they are (called the ideal self). But in fact, in this study the authors said it was more likely that there is a subgroup of persistence patients.

This subgroup (called endurance copers) overdo in order to “get everything done.” They end up pushing too hard and suffering more pain, which then puts them farther from where they want to be.

What are the implications of this study? In other words, how is this information going to help chronic low back pain sufferers? The authors say it’s not clear yet just what can be determined from the results of this study. They are just in the first phase of making hypotheses (theories) about the relationship between chronic pain and behavior and testing them out.

In the end, the hope is to find better ways to help and treat patients with chronic low back pain. If it turns out that self-discrepancy behaviors are part of the problem, then treatment strategies directed toward regulating these thoughts and actions may be helpful.

Men involved in heavy manual labor worry they may end up with a herniated disc. How likely is this occurrence? Who is at risk and why? These are the questions asked by a group of researchers carrying out the Copenhagen Male Study and reported on in this article.

The Copenhagen Male Study was started over 30 years ago. Over 5,000 men participated in the study. They started by completing a survey with questions about the presence of back pain. Many other individual characteristics were also collected (e.g., age, social class, working conditions, height, weight, lifestyle).

By comparing men who reported back pain at the start of the study with men who did not have back pain, they were able to identify risk factors for disc herniation. It’s natural to assume that heavy lifting, carrying heavy objects, and sustained postures required by work conditions could contribute to low back problems.

It’s also logical that these kinds of problems should decline with age as men perform less strenuous work activities. And there are some experts who suspect height and weight may be predictive risk factors.

The Copenhagen Male Study evaluated a dozen potential risk factors associated with disc herniation in men 40 years old or older. These risk factors included load to the back (low, medium, or high), strenuous work (seldom/never, occasionally, often), and leisure time physical activity (low, medium, high). The effect of other factors such as social class, mental stress (at work, during leisure time), and the use of sedatives, alcohol, or tobacco were also assessed.

One assumption was proven right. The other was not. Physical load and strain were considered risk factors for disc herniation. Reduced risk with age was not the case. Rather, there seems to be a continued (cumulative) effect of heavy lifting, pulling, and pushing.

In other words, over time, the effects of these activities build up and influences disc health even after the man is no longer involved in those activities. Exposure will certainly change for most men over time. After 30 years in this study, many men were past retirement age and no longer engaged in heavy manual labor. Yet, their rate of disc herniation was higher than the younger men who were also involved in heavy physical activity.

When physical activity during leisure time was examined, there was no apparent link to herniated discs. Apparently, the type of physical stress and strenuous physical activity required by leisure activities is not a risk factor for disc degeneration. It’s more likely that the duration of exposure (number of years) is really a very accurate predictor of disc-related back problems later in life.

There was one other key predictive factor of interest and that was physical height. Whereas we once though height and weight measured by the body mass index or BMI was predictive of low back problems, this study highlights the greater influence of height over weight. The taller the person, the greater the risk of disc degeneration.

Knowing that men without a history of back pain but engaged in lifting activities can be at risk for hospitalization for disc herniation is an important finding. With height as a separate, independent risk factor men in jobs requiring manual labor can be identified early. Finding ways to reduce the risk is the next step.

Low back pain from degenerative spondylolisthesis is often treated with spinal fusion when conservative (nonoperative) care fails to improve symptoms or function. But spinal fusion often results in the need for a second (revision) surgery. One common problem that develops is adjacent segment disease (ASD). The question this study attempted to answer is whether or not extending an L5-S1 fusion to include the sacrum can reduce the risk of adjacent segment disease.

Before we go any further exploring this topic, let’s clear up a few terms. First, what is degenerative spondylolisthesis? In this condition, one of the vertebrae (spine bones) slips forward over the one below it.

Normally, the bones of the spine (the vertebrae) are neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis alters the alignment of the spine and creates a narrowing of the spinal canal. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. Low back pain and leg pain are the main symptoms but there can be sensory changes with numbness, tingling, and loss of sensation as well.

The degenerative aspect of spondylolisthesis tells us the condition develops over time as we age. Adults over age 50 are affected most often. There are degenerative changes in all parts of the spine including the joints, discs, and soft tissues. Slippage at the L4-L5 segment is the most common in this age group with this condition.

Without the normal alignment, spacing, and proper shock absorption, increased load is transferred through the spine. The disc at the L5S1 spinal level takes the brunt of it, so this is the area where degenerative disc disease is the worst in many patients.

Removal of the disc between L4-L5 with fusion of the same segment is referred to as a lumbar floating fusion or LFF. LFF is separate from a lumbrosacral fusion (LSF) where the L5 segment is fused to the main body of the sacral bone. So with this information in mind, we come back to the original question. Does extending the L4-L5 fusion down to also include the L5-S1 level yield a better result? And are there fewer cases of adjacent segment disease (ASD)?

By following 107 patients for five years or more, surgeons from the UCLA Comprehensive Spine Center at the University of California (Los Angeles) gained some new perspective on this issue. They found that the extended fusion did NOT improve results. There is no need to fuse the L5-S1 segment as a preventive measure against developing adjacent segment disease. The authors suggest that lumbosacral fusion should be used for patients with instability at the L5-S1 level (not just for disc degeneration).

Outcomes used to measure final results included X-rays, clinical presentation (signs and symptoms), and function. Function was measured using two well-known and commonly used tests: the Oswestry Disability Index (ODI) and the modified Brodsky criteria.
Careful records were kept of before and after results, age and sex (male versus female) of the patients, and spinal levels operated on.
Results were analyzed taking all of these additional factors into consideration.

How good are the results of a lumbar fusion that does not go past the L5 level? For the most part, clinical results (improved pain and function) and patient satisfaction were good-to-excellent in 82 per cent of the patients. The incidence of adjacent segment disease (ASD) was actually less in this group (the lumbar floating fusion group) compared with the (extended) lumbosacral fusion (LSF) group.

The higher rate of adjacent segment disease in the lumbosacral fusion (LSF) group may be the direct result of a longer fused rigid segment. With a longer area fused, there is an increased load and stress on the
normal segments above. Some researchers have concluded from their studies that increasing age is a risk factor for ASD but age was not statistically significant in this study.

In summary, extending spinal fusion to include the sacrum for patients with degenerative spondylolisthesis is not helpful. In fact, the extended fusion increases the risk of adjacent segment disease above the start of the fusion. Without this extension, the surgery is shorter and with less blood loss. There is also the advantage of less bone graft and a lower risk of pseudoarthrosis (failed fusion with spine motion still present) with the lumbar floating fusion.

In this study, orthopedic surgeons tried to see if patients having low back spine fusion using their own bone graft have more pain than those who don’t have a bone graft. Those who did not have bone graft to help with the fusion were given a bone substitute instead.

The bone graft does not require harvesting bone from the patient. After surgery, each patient was tested for tenderness over the incision site as well as over the back of each iliac crest (posterior right and left).

The iliac crest is the area of the pelvic bones where bone graft is taken most often. You can feel this bone when you put your hands just below your waist. The authors were surprised to find out that just as many patients without a bone graft had tenderness over the bone in this area.

Fifty-seven per cent (57%) of the bone graft group had tenderness or the posterior iliac crest on one or both sides. This compared with 51 per cent in the bone graft substitute group.

And oddly enough, patients in both groups had pain over both iliac crests (not just the donor side and not just in patients who had their own bone harvested for the fusion site). The severity of pain (as rated by each patient) was no different between the two groups.

Of course they wondered what could be causing this type of pain response in patients who have not had any bone harvested from the iliac crest. The presence of pain in both groups may suggest something else besides bone harvesting from this site is causing the tenderness.

One possibility is referred pain from new lumbar spine pathology. Other sources of iliac crest pain following lumbar spine fusion include inflammation, nerve root irritation, or muscle scarring from the fusion procedure. And it’s possible that the iliac crest tenderness was really caused by residual pain from the low back area.

The authors did not test patients in either group for the presence of iliac crest tenderness before surgery. It may be they all had iliac crest pain/tenderness that didn’t go away after surgery.

One other unanswered question has to do with the patients in both groups who did not have any posterior iliac crest pain or tenderness after surgery. This group was made up of nearly half of all the patients. Future studies to determine any factors that might predict who will or won’t have post-operative iliac crest pain may be helpful in preventing this problem.