News Category: Lumbar Spine

This is the first report of artificial disc replacement (ADR) for disc herniation. Fourteen (14) Swiss patients with long standing degenerative disc disease (DDD) and recent disc herniation were included. All patients had chronic low back and leg pain due to DDD.

Until now disc replacements have been used for patients with DDD but without disc herniation. The authors report the ADR doesn’t work well with a narrow disc space. Patients need at least one-third or more of the normal disc space height to have this operation.

This is because as the disc space gets smaller, the spinal ligament shrinks and tightens. The ADR restores motion in the front (anterior) half of the vertebra. The facet joints in the back (posterior) half of the vertebra are needed for complete motion.

Pain and work status were used to measure the results of this operation. Eleven patients had excellent results. The remaining three had good results. The authors conclude ADR can be used successfully with patients who have long-standing DDD and new onset of disc herniation.

Doctors often ask patients with low back pain to show their pain and symptoms on a drawing. Researchers doing this study looked at the ability of pain drawings to point out patients with psychological problems.

They found that pain drawings aren’t able to detect patients with anxiety or depression. The results of this study confirm findings in other studies. Pain drawings can’t predict psychologic distress.

The goal is to find an easy-to-use tool to assess back pain and psychologic status. The test must be repeatable. This means the same results occur when different examiners give the test to the same patient. For now, it looks like the pain drawing can be used most accurately when combined with other tests.

It’s not clear what long-term training program gives the best results after lumbar disc surgery. This study compares 12 months of combined strength training and stretching with a program of just stretching. Patients with severe back and leg pain from lumbar disc herniation were included. It was the first lumbar disc surgery for each one.

Measures of success included pain, strength, motion, and flexibility. Strength couldn’t be tested before surgery because of extreme pain. Trunk and leg strength and flexibility were tested right after the operation. Results after surgery were compared with results 12 months after the operation.

The strength-training group (STG) was given a home program for 12 months. They did strength exercises using body weight or handheld weights for resistance. They also did stretching exercises three times a week. The second (control) group (CG) was given the same stretching exercises to be done three times a week.

There was no difference in results between the two groups. Both got better following the exercise program given to them. The authors report patients in both groups did their exercises but not as often as they were supposed to. It’s possible the training frequency was too low in the STG to make a difference.

The researchers advise better supervision and support is needed to keep patients motivated in long-term rehab programs.

Low back pain (LBP) is a common problem and one for which we don’t have a “one-size-fits-all” treatment. In this study researchers at a center for work rehabilitation in Switzerland compared two treatment methods for LBP.

Three weeks of function-centered rehab were compared to three weeks of a pain-centered program. Number of days at work, pain levels, strength, and lifting capacity were used as measures of results. Follow-up was for three months.

Patients in both groups had missed at least six weeks of work due to chronic LBP. The function-centered treatment (FCT) group spent four hours each day, six days a week for three weeks doing work activities and strength training. Their program also had endurance and aerobic training. The main goal for this group was to increase their work capacity.

The pain-centered treatment (PCT) group took back care classes and got joint mobilization and stretching. They also did strength training. The program lasted two and a half hours each day, six days a week for three weeks. The goal for this group was to decrease pain. Increasing strength and function were secondary goals.

The authors report much better results for the FCT group. The PCT group did not have the pain relief expected. Pain did decrease in the FCT group even though they were told to move when it hurt. The FCT group were much more confident during normal, daily activities.

The authors conclude fear of pain may be more disabling than the pain itself. The FCT program works best to decrease work-related disability.

Magnetic Resonance Imaging (MRI) scanning is a very useful tool when it comes to finding the cause of low back pain (LBP). But many people with abnormalities seen on MRI don’t have any symptoms. In this study a large number of 40-year old patients had an MRI done. The doctor reading the MRI didn’t know if the patient had any symptoms or not.

MRI findings were reported for this group as follows:

This report gives an updated review of studies done using acupuncture. All patients included were at least 18 years old. Everyone had nonspecific low back pain.

Thirty-five (35) studies from 1996 to 2003 were reviewed. The last review had 11 studies from 1966 to 1996. Acupuncture was compared to other therapies, no therapy, and sham therapies. Acupuncture combined with other treatments was also compared.

Results were measured by pain intensity, function, and return to work status. Other, less important measures were viewed. These included range of motion, muscle strength, general health, and use of medications for pain relief.

The researchers looked at how well the study was done. They also judged how the acupuncture was done. The biggest problem was the quality of reporting. Some studies didn’t give enough information to allow for judgment of the study. The same was true for some of the study research methods. They were either very poor or not described well enough to judge.

According to this review, acupuncture is better than no treatment. This is only true for short-term pain relief. The positive effects don’t seem to last. Acupuncture works better than a sham treatment. Again this finding is only true in the short-term. There’s no difference over the long-term.

There was no difference (short-term) between using acupuncture to treat chronic low back pain and anti-inflammatories, massage, or self-care education. Massage did have a better result in the long run. Acupuncture combined with other forms of treatment had better results than acupuncture alone.

Finally, the authors couldn’t see that one type of acupuncture was better than another. The small number of patients in many studies and low quality suggest that larger, better studies of acupuncture are needed before firm conclusions can be made.

How good is the information on the Web about lumbar disc herniation (LDH)? Is it accurate? How often do advertisers sponsor the web sites?

There are no standards for medical information on web sites. This study looked at the type and quality of information on the Internet about one medical problem (LDH).

Twenty-five web sites were reviewed for content and origin. Some sites were hospital-based. Groups like the American Medical Association sponsored others. There were university or research clinics (academic) sites. Doctors and commercial suppliers also had sites with information on LDH. Commercial sites offered products or services for sale
to the internet user.

The results from this study are as follows:

Surgeons at the Hospital for Special Surgery in New York City report five cases of an unusual problem after lumbar discography. After the procedure there was a new herniated disc or an increase in the size of a herniated disc already present for all five patients.

Lumbar discography or discogram is a way to show if the patient’s pain is coming from the disc. The exact disc level is also identified. During discography a needle is placed into the disc. A small amount of contrast dye is injected into the disc.

A CT scan is taken right away. The scan can show any place where the dye leaks out of the disc. Dye outside the disc means there’s a tear in the outer covering (annulus) of the disc. The opening allows the inner disc material (nucleus) to protrude or herniate.

In these five cases symptoms were much worse after the discography. Repeat MRIs showed disc leakage or new fragments of disc not present before the discogram. This occurs when the pressure of the injected dye damages an already weakened annulus. A small tear can become a large tear. A piece of the nucleus can get pushed out. This is called a discography-induced herniation of disc material.

The authors conclude that tears or damage to the annulus can put patients at risk when having a discography. Symptoms can get much worse after the discogram. A repeat MRI is advised for any patient with increased back or leg pain or new neurologic symptoms after discogram.

This is the second part of an ongoing study on the long-term results of patients with lumbar disc herniation. None of the patients had surgery. The first study reported on results after two years. The disc herniation decreased during the first year and even showed improvement during the second year.

The authors continued to follow the same patients for seven years or more. Only half of the patients in part one were in part two. Some couldn’t be found. Others objected to the waste of time and money. Some refused to come because they didn’t have any symptoms.

For those who were part of the study, their symptoms were compared with MRI results. The MRI showed the size of the herniated disc in relation to the spinal canal. It also showed how much the disc had degenerated.

In 95 percent of the patients the herniation got smaller over time. The amount of shrinkage didn’t seem to be related to the initial size of the herniation. The speed at which the herniation went down wasn’t related either.

And there wasn’t a link between patient symptoms and MRI findings. In other words, there was no difference between patients with and patients without symptoms in terms of herniation decreasing in size.

Knowing the final outcome of disc herniation treated without surgery may help doctors plan treatment for new patients with disc problems. In this study the researchers were unable to find any factors that would tell who would have continued back or leg pain. They do confirm the fact that recovery from disc herniation is possible without surgery.

Research shows exercise works well for patients with back pain. The question is: what kind of exercise is best? So far there’s little proof that one type of exercise is better than another. This study compares two kinds of exercise for patients with nonspecific back pain.

In this study the first group followed a training program of general exercises. The second group did general exercises plus trunk muscle stabilization (core) exercises. Both groups did the exercise program twice a week for eight weeks. Everyone also read a book on back care.

Results were measured in terms of reduced pain and improved function. Both groups got better after exercise. The general exercise group improved more right away. After three months the results were equal.

The authors concluded the stabilization exercises don’t give an added benefit to some low back pain patients. If there are no signs and symptoms of spinal instability, there’s no need to do stability exercises. A program of safe, general exercises may be all that’s
needed for patients with recurrent, nonspecific low back pain.

There are many ways to fuse the lumbar spine with an operation. The transforaminal lumbar interbody fusion (TLIF) is the one reported in this study. Surgeons at the University of Minnesota discuss how the TLIF was done in 49 patients. They used a minimally invasive approach. Details of the operation and its results are included.

The TLIF makes it possible to fuse the spine from the back of the body without disturbing the muscles or nerves. Minimally invasive means the operation is done without making a large cut to open the spine. The fusion goes all the way around the spine in a 360-degree
circle.

Patients were followed for 18 to 28 months. Pain levels, drug use, and function were all measured before and after the operation. Everyone got relief from back and leg pain present from before the operation. Most patients were able to return to their full activity level three months after the surgery.

The authors say early results of this operation are promising. It takes time for the surgeon to learn how to do the fusion this way. This is called a learning curve. The benefits to the patient are worth it. Less blood loss, shorter hospital stay, and less pain are just a few advantages. The patients in this study will be followed further to see the long-term results.

Degenerative disc disease causes many cases of low back pain. Tears of the outer covering called the annulus fibrosus often result in pain lasting for years, even decades. Treatment with radiofrequency is used to stop the nerves from sending pain messages to the brain. This study investigates the use of a new tool used to deliver the radiofrequency.

Until now a flexible tube or catheter called the SpineCATH has been used to gain access to the disc. The tube is moved from the front of the disc to the back between the two main parts of the disc. Some surgeons thread the tube around the disc from one side to the other.

The new device (discTRODE) is stiffer and can be placed directly in the annulus. Patients having radiofrequency treatment with the discTRODE were followed for one year. The results were measured by pain levels and function and then compared with a control group. The control group didn’t have radiofrequency.

The authors report pain was reduced almost 40 percent in the treated patients compared to an increase of three percent in the control group. At 12 months the radiofrequency group had improved function. There was no change in function for the control group.

Researchers were surprised to find no change in medication usage or return to work status after pain improvement in the treatment group. They suggest entrenched drug behaviors from chronic pain leads to continued drug usage. Something other than pain and physical function may explain why patients didn’t return to work as expected.

Patients with low back pain are often examined by physical therapists. Finding the right tests to guide the therapist’s decisions about treatment is the focus of this study. The goal is to find out which tests will accurately measure the patient’s symptoms and function. Finding the link between physical examination tests and the severity of low back pain (LBP) and level of function can help therapists plan better patient care.

Older adults (men and women 55 years old and older) with degenerative spinal conditions were included in this study. All had LBP for six months or more. At least half the patients had spinal stenosis. Stenosis is a narrowing of the spinal canal. Everyone’s back pain was made worse by extending the low back area.

Tests included muscle strength, sensation, movement, and pressure through the spine. One special test called the quadrant test extends and rotates the lower spine while putting pressure through the spinal column. This position narrows the space for the spinal nerves and causes pain with pressure on the nerve.

The tests that best matched the patient’s symptoms were (in order from best to least predictor):

Protecting the back from injury is a major focus of the physical therapists (PT). In this study PTs from Canada take data from five abdominal and two back extensor muscles. The measurements are recorded during a core strengthening exercise.

The “core” abdominal and back muscles are thought to hold the spine in a neutral position. A strong core may protect the spine during repetitive activities. Eighteen healthy adults (men and women) with no back problems were included in this study.

Electrical activity of the seven muscles was recorded during a core training exercise. The exercise had five total levels. Each level was harder to do than the last level. The researchers thought there would be different amounts of muscle activity based on the demands of the exercise levels.

Instead what they found was that the abdominal muscles stayed the same until the highest level. This suggests the load on the muscles was low until the last exercise. Level five had the highest muscle activity for all the abdominal muscles. At level five the load on the abdominal muscles increases. This occurs as they help counteract rotation of the pelvis and extension of the low back.

Results from the back muscles showed each muscle was active at different times. None of the muscles used more than 40 percent of their maximum capacity. There wasn’t the expected increase in activity as the exercise got harder.

Results show how each muscle has a different job to do with each exercise. From this study it looks like core-training exercises don’t increase muscle strength. The authors think that with increased repetitions, the exercises may improve muscle endurance.

Whatever happens to the patients in clinical studies testing a device or operation before it’s approved? A special cage device for spinal fusion was approved in 1999 by the Food and Drug Administration (FDA). From 1991 to 1993 it was tried on a group of patients as part of a research study. The authors of this study report on the results of these patients 10-years after the cage was put in.

Cages are used to fuse two vertebral bones together in the spine. The disc material between the bones is taken out and the cage is put in its place. Bone chips fill the cage. Fusion occurs as the bone grows inside and around the cage.

The cage in this study was made of carbon-fiber that is somewhat elastic like bone. It’s held in place with screws and plates. The design of the cage allows the screws to be put in different places at different angles. This is called the Variable Screw Placement (VSP) system.

Success was measured using pain, function, and medication usage. X-rays were also taken to show if there was a solid bridge of bone at the fusion site. X-rays also showed if there was any movement at the fusion site (a sign of failed fusion).

Thirty-three of the original groups were traced by telephone and by the internet. The authors report fusion success in all but one patient after 10 years. The X-rays did show degenerative changes at the next level in more than half of the patients. None of these patients were having any symptoms or problems from the degeneration.

The authors conclude that there is a high rate of long-term success with the VSP carbon-based cages used for lumbar fusion.

Studies of patients with low back and sacroiliac (SI) joint pain have shown the effect of the abdominal muscles on chronic pain. In particular, the transversus abdominis (TrA) that wraps around the abdomen is important. Back and SI pain are linked to changes in the timing of the contractions of this muscle. Maybe groin pain can also be linked to the TrA muscle.

In this study, a group of 10 Australian football players with chronic groin pain were examined. EMG (electrical readings) of the three parts of the abdominal muscles were measured while raising the leg off a table. Each person was tested while lying down on his back.

The TrA was one of the abdominal muscles tested. The results were compared to a group of 12 subjects who were healthy and free of any groin pain. The authors report a delayed response in the TrA muscle contraction for the injured football players compared to the healthy subjects.

This study couldn’t answer the question of which came first: groin pain or delayed muscle contraction? It’s possible that pain causes a change in motor control of the TrA. The results of this study at least help physical therapists manage patients with chronic groin pain. Giving patients an exercise program to restore neuromotor control of the TrA is a good first step.

Humans have a tailbone at the end of their spines called the coccyx. The word “coccyx” comes from the Greek for ‘cuckoo’ because it’s shaped like the beak of the cuckoo bird. When pain occurs in the tailbone or coccyx it’s called coccygodynia. Treatment for coccygodynia using steroid injection versus surgery is compared in this study.

Two groups of patients with coccygodynia were included. Group one had the coccyx taken out. This operation is called a coccygectomy. Group two received up to three injections into the coccyx over a period of six months. The injections were made up of a numbing agent and a steroid.

X-rays were taken before and after the operation for group one. Patients in both groups answered questions about pain, function, and disability before and after their treatment. Results were compared and reported as follows.

Low back pain from disc problems is a common problem. Most disc herniations occur at the L4-L5 and L5-S1 levels. Less than 10 percent occur in the upper lumbar spine at L3-4. In this study two groups of patients were compared. The study group had a L3-L4 disc herniation. The control group had L4-5 or L5-S1 herniation.

The disc is like a cushion located between two vertebrae. If damaged, torn, or worn, disc material can get pushed out of the disc space in any direction. Disc herniations are labeled according to their anatomic location. For example, if it pushes straight back it’s called posterior. If it moves to one side or the other, it’s classified as lateral. A disc that protrudes to the back and side at the same time is posterolateral.

The authors used CT scans and MRIs to see where herniations occur at the L3-L4 level. They compared this to herniations at lower levels. Most lower disc problems are posterolateral. The authors assumed disc problems in the upper lumbar spine would be more lateral.

They were right. The herniation occurs where there is the least resistance. A ligament behind the vertebrae at L3-L4 called the posterior longitudinal ligament (PLL) keeps the disc from pushing back. The path of least resistance at this level is to the side (lateral).

They also found that L3-L4 herniations are most likely to occur in older adults. These patients report thigh pain. On exam there is weakness in the quadriceps muscle. This is the muscle used to extend the knee. The knee reflexes are also decreased.

The authors say this information is helpful. When an older patient presents with these symptoms, the doctor will know to look for a disc problem in the upper lumbar spine. Knowing where the disc is likely to protrude will help doctors use imaging studies to trace the path of the herniated disc.

Spinal fusion is a common treatment for an unstable spine. But increased motion at the level above is often a problem. This is called adjacent segment degeneration. Doctors at the Oregon Health & Science University are testing a way to prevent segmental motion. Instead of ending the fusion at L5, they fused L5 to the sacrum.

Seven human cadavers (spines preserved after death for study) were used in this study. Researchers fused the L4 and S1 segments with rods and screws. They did the fusion so that each spine could be tested for a L4 and L5 fusion, as well as a L4 to S1 fusion.

Then spinal motion was measured in flexion, extension, side bending, and rotation (twisting side to side). The results of spinal segmental motion were compared for each level of fusion.

The authors report that more motion occurs in the L4 and L5 fusion. The motions affected most were flexion and extension. No changes were seen with side bending or rotation. Fusing the spine all the way down to the sacrum (S1) may protect the level at the top of the fusion (L3).

Radiofrequency neurotomy (RFN) is a way to stop low back pain caused by facet joints in the spine. (Facet joints are the small link joints along the back of the spinal column.) Spinal nerves to the joint are heated enough to cause injury. RFN keeps the nerve from sending pain signals from the joint to the brain. This is called a medial nerve block.

RFN works well, but sometimes patients relapse and need a second treatment. In this study researchers looked at the success of a second RFN. They measured how long pain relief lasted after each RFN treatment. Twenty patients had repeated RFN. Some had as many as seven treatments. Some patients had just one nerve blocked. Others had nerves blocked at several levels on both sides of the back. Success was defined as at least 50 percent pain relief.

It’s important to know if a treatment is working before repeating it. The authors of this study say that repeated RFNs are often effective and can give long-term relief of low back pain. Repeated RFNs work more than 85 percent of the time and last up to nearly 11 months. However, RFN doesn’t usually cure the problem.