News Category: Lumbar Spine

Surgeons continue to look for better ways than spinal fusion to treat chronic low back pain (LBP). In this study, a new method called the fulcrum assisted soft stabilization (FASS) was tested on human cadavers and on wood and rubber spine models.

Spinal fusion gives a stable spine but limits motion at that level. The goal of this dynamic stabilization is to hold the spine stable while keeping normal motion. Taking abnormal loads off the disc is also important.

Stainless steel screws were placed into the pedicles on both sides of the vertebra. The pedicles are the bony projections on either side of the vertebra that form the arch around the spinal canal. Screws were placed in the vertebra above the damaged disc and in the vertebra below the damaged disc. A plastic rod was placed vertically between the two screws. Then a rubber “O” ring was wrapped vertically around the ends of the screws.

The authors explained how the use of the plastic fulcrum is to unload the disc. This also helps keep the spine in a position of extension or lordosis. The “O” ring acting as a ligament applies a compressive force to open up the disc space slightly. Using the fulcrum and ligament together holds the spine in its proper position and spreads the load across the disc and joints. Normal motion occurs without abnormal slipping and sliding.

The spines with the FASS in place were connected to a special machine to test motion and loading. Using trial and error the researchers were able to find the length of the screw that unloaded the disc by 50 percent and then by 100 percent. They found that range of motion decreased and stiffness increased as the disc was unloaded more and more.

The new FASS system can unload the disc by using a fulcrum in front of a ligament wrapped around the pedicles. The system controls motion and maintains the lumbar spine in lordosis. With the ligament alone, the lordosis was present but the disc pressure increased. This is another step toward a future means of treating LBP without fusion. The FASS may be perfected to the point it can stabilize the spine yet still allow normal motion and position.

Two facts are well-known about chronic low back pain (LBP). 1) Exercise helps. 2) People quit exercising after a while. In this study researchers from the University of Vienna in Austria look at the long-term effect of combining exercise with a motivational program for patients with LBP.

Two groups of patients were included in this study. One group (control) did the standard exercise program. The second group was given the same exercises plus counseling. They also were given information, positive feedback, and a treatment contract. And they kept an exercise diary.

Everyone was seen one-on-one by a physical therapist for 10 sessions. Everyone was rechecked at three and a half weeks, four months, 12 months, and five years. Measures of success included pain, disability, and working ability.

The authors reported a big difference between the two groups. Both groups had better function and less disability. But the motivational group had more than twice the improvement. Patients in the motivational group were the only ones to show improved work ability after five years.

It appears that unsupervised exercise at home just doesn’t work for people with low back pain. Motivation and support does increase compliance with an exercise program.

The authors suggest two reasons for this finding. First, patients had a set of tools that could be used easily in the future. Second the extra motivational program may have helped patients do the exercises correctly instead of just doing them regularly.

Fear of pain and avoiding activities is common with patients who have low back pain (LBP). A survey called the Fear Avoidance Beliefs Questionnaire (FABQ) can be used to see if patients’ activities are controlled by their fears. In this study researchers looked to see if FABQ scores can predict the results of treatment with exercise.

All patients were from a Middle Eastern culture. Everyone was enrolled in a 10-week program of muscle strengthening. The low back muscles were the targeted area. No one was on worker’s comp. In other words none of the patients were injured workers. All patients completed a strength test of the lumbar extension muscles before and after treatment.

The results of this study showed two things. First, expected pain and actual pain got better for patients who finished treatment. Second, the amount of actual pain was not as much as expected. Results were the same for men as for women.

The authors point out that using the FABQ for people who don’t have worker’s compensation may not be helpful in predicting outcome. If we rely on the FABQ results before treatment it would look like patients would fail to improve after treatment. Therapists can still use the FABQ to identify patients who have high pain expectations.

Low back pain (LBP) can be very disabling. Prescription drugs are often used for pain relief in cases of acute LBP. These include opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and COX-2 inhibitors. In this study the patterns of analgesic use for LBP is described.

Doctors at the University of Pittsburgh Health System conducted this study. This is a large system with more than 5,000 physicians and 255,958 members. In one year (2001) about half the patients receiving back care were given a prescription drug. Opioids were used almost 40 percent of the time.

Opioids are strong pain relievers related to opium. Natural forms include codeine and morphine. COX-2 inhibitors (a special NSAID that’s easier on the stomach) were only used for six percent of the back pain patients. The rest of the patients got a standard NSAID. Patients who were given an opioid also had other services for their LBP.

The authors aren’t sure if the use of opioids by this many patients was appropriate. They do suggest this rate of usage is higher than reported in the past. The results point out the need for this hospital system to develop patient education programs.

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.

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.

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.

Muscles work differently in people with low back pain (LBP). This study uses ultrasound to show what happens to the abdominal muscles in LBP patients. The researchers also confirmed that ultrasound is a good tool for checking the abdominal muscles.

Two groups of 10 people were studied. The first group had recurring episodes of LBP. The second group had no back pain at all. Ultrasound was used to measure changes in thickness of three abdominal muscles. Electromyography (EMG) was also used to record muscle activity.

Measurements were taken during leg movements. The researchers report differences in thickness of only one abdominal muscle between the two groups. The transverse abdominal muscle (the deep abdominal muscle) was much thicker in the group without pain, and it was active with both leg flexion and extension. This wasn’t true for most of the LBP patients.

Results of this study show that patients with LBP use trunk muscles differently than people without back pain. Activity of the transverse abdominals was lower for patients with LBP in one direction of movement. This may mean that the transverse abdominal muscle doesn’t contract when it should in people with LBP.

Until now scientists haven’t had a good way to measure activity of muscles deep inside the body. The authors of this study conclude that ultrasound can measure changes in muscle thickness. Ultrasound directly measures muscle contraction. Finding muscles that aren’t working properly in patients with LBP will help develop better treatment.

What happens to the spines of career athletes years after they quit playing? That’s the subject of this study from Germany. X-rays taken of former elite male athletes from seven track and field events were studied. Football players have been studied before, but there are no previous studies among track athletes.

The researchers also looked at age, body size, and current physical activity as factors leading to changes in the spine. X-ray findings were compared to the former athletes’ level of daily activity. Measures used included the height and shape of lumbar discs and the presence of any bone spurs.

The authors report more bone spurs in javelin throwers than any other group. Shot putters, discus throwers, and high jumpers had the next highest level of changes on X-ray. Disc heights at different levels of the spine are reported for each group.

Most of the changes in disc space occurred in the lowest levels of the spine. This was true for all throwing and high jumping athletes. Former shot putters and discus throwers remained much heavier in body weight than other athletes. Former marathon runners had the lowest weights. Marathon runners also had the fewest changes in the spine.

The results of this study suggest that bone spurs develop in areas where heavy loading has occurred in the spine. For example hyperextension and rotation in the high jumper leads to spurs in the lower spine. There were no limits on activity caused by degenerative changes in the spine in any of the former athletes.

Studies so far haven’t been able to show any specific type of exercise helps patients with back pain. Doctors advise patients to stay active and get back to normal routines as soon as possible.

Some researchers think studies of exercise have lumped all back pain patients together. Everyone is given the same exercises and that’s why exercise programs don’t seem to be helping. It’s possible each patient needs a specific exercise program based on which movements cause pain.

In this study patients were divided into two main groups. The directional preference (DP) group reported pain every time they moved in one direction. This group was further divided based on which direction made the pain better. The second group(no DP) didn’t seem to have pain caused by or relieved by a direction of movement.

Three types of exercise were given. Some patients got exercises matching their DP. Others did exercises in the opposite direction of their DP. A third group was given general exercises to include movement in all directions. Everyone in all three groups worked with a physical therapist for three to six visits over a two-week period of time.

The authors report a large number of patients dropped out of the study. One-third of the opposite direction and non-direction groups withdrew because they were no better or they were worse than when they started the program. Overall the rest of the patients in all groups improved. Patients in the matched DP had the best results. Patients who did movements in the opposite (painful) direction had the worst results.

According to the results of this study, patient activity and education are the way to treat low back pain. Instruction in these areas should match the patient’s DP for the best results.