News Category: Lumbar Spine

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).

Everyone agrees that staying active is usually the best way to treat acute low back pain (LBP). There’s still a question about the use of physical therapy, especially the timing of treatment. United States guidelines advise early physical therapy. Australia and Great Britain say it’s best to wait and see what happens.

This study compares the two models (treat versus wait) for patients with acute LBP. Patients were tested before treatment and again six weeks, three months, and six months after treatment. The “wait group” was seen by a physical therapist six weeks after the initial exam. Patients in the “treat group” had physical therapy right away.

At six weeks the treat group had lower disability scores. They had fewer symptoms of depression and anxiety and a better quality of life. They also reported better social function and mental health at six weeks compared to the wait group.

Pain and disability weren’t different between the groups after six months. But mood, general health, and quality of life were still much better in the treat group. The authors conclude that timing of physical therapy does make a difference.

Early treatment for acute episodes of LBP leads to faster recovery and lower rates of disability. Advice to stay active is good, but combining it with early treatment gives better outcomes earlier.

A new study from Finland shows high levels of one type of cholesterol (LDL) block major arteries in the low back. The result is loss of blood supply to the discs, followed by disc degeneration. Reduced blood supply to the low back area can also cause pain. This occurs when waste products like lactic acid aren’t swept away by blood flow. Nerve endings get irritated, causing pain. The spinal structures supplied by those nerves start to deteriorate and waste away.

These are the findings of magnetic resonance aortography (MRA) in 51 patients with chronic low back pain. All patients were between the ages of 35 and 70. Regular MRIs didn’t show any specific problems. MRA showed missing lumbar and sacral arteries. This group had 2.5 times more blocked arteries than people of the same age without back pain.

The authors also report that back pain patients with above normal LDL levels had more nerve-related symptoms. They also had more severe pain than patients with normal LDL levels. In this study, blocked arteries from atherosclerosis were linked to disc degeneration and low back pain.

Is the amount of curve in the low back linked to problems with low back pain (LBP)? We know there’s a difference in lumbar curvature between men and women. Is there a difference in LBP based on gender?

Physical therapists measured the lumbar curve in 227 subjects with and without LBP. A special computerized three-dimensional device was used to take the measurements. Five specially trained physical therapists examined the patients with LBP.

Each patient was put in one of three groups. Groups were based on which movements cause pain, including bending forward, bending backward, or twisting (rotating) their trunks. The authors report the following findings:

More and more adults over 65 are having lumbar spine surgery. And more of these patients are overweight than ever before. Research shows that obesity is directly linked to quality of life in older patients. Does being obese affect the results of this surgery? Doctors in Israel reviewed 298 cases to find out.

Men and women older than 65 years were included. All had a decompressive laminectomy, discectomy, or both. Laminectomy is the removal of a piece of bone from the vertebra. This takes pressure off (decompresses) the disc or nerve root. Discectomy is the removal of the disc. Surgery was done when patients were in severe pain or unable to do daily activities.

Here’s what the researchers found:

Physical therapists use many methods of treating patients with acute (sudden or recent) low back pain. Two of these methods are manipulative therapy (MT) and interferential therapy (IFT). MT involves manipulating the spine. IFT is a form of electrical stimulation. These treatments are popular for the management of low back pain, but they haven’t been proven effective.

In this study, therapists from Ireland report on the use of MT and IFT. They used just one of the treatments on some patients. The therapists combined the two treatments for other patients. All patients were seen from four to 10 times during an eight-week period.

The patients kept up with their normal activities during treatment. Everyone received a book on back care to help them learn about back pain and its treatment. Results of treatment were measured using pain levels, quality of life, number of days missed at work, and use of pain relievers. Measures were taken before treatment, when treatment ended, and six and 12 months later.

Here are the main findings. Everyone got better and stayed that way for up to 12 months. It didn’t matter whether they had MT, IFT, or both together. Patients’ general health was unchanged as a result of treatment, but 70 percent had another episode of back pain later.

This is the first study to report on the use of MT and IFT in the treatment of acute back pain. The results may challenge physical therapists who use either of these treatments alone or together for low back pain. Using MT and IFT together adds more cost without proof that either one works.

It’s best to treat the cause of any problem, not just the symptoms. With low back pain (LBP) the cause is often not clear. There’s a new system used by physical therapists (PTs) to help with this problem. It’s called the Treatment-Based Classification (TBC) system. It’s used to put LBP patients into one of seven groups. The groups are divided up by the treatment used to relieve the patient’s signs and symptoms.

Any system must be easy to use. It must apply to most of the patients. In this study the reliability of four therapists newly trained in the TBC system was measured. Can they use the system after a short training period? How much practice with the system is needed? Does each therapist classify each patient in the same way? This is called interrater reliability. High interrater reliability is the goal of any classification system.

Four experienced PTs but new to the TBC system rated 48 patients. Each PT read an article about the TBC system and took a one-day training course before seeing the patients. None of the therapists knew how the other therapists rated each patient.

The PTs in this study were unable to agree on patient classification using the TBC system. One therapist disagreed with the other three in all but two cases. The remaining three PTs agreed with each other about half the time. This is considered “moderate” interrater reliability.

The authors of this study think a one-day training course in the use of the TBC system probably isn’t enough for all PTs. More information and a better understanding of the TBC system may be needed before all PTs make the same decisions using it.

Other factors to explain the lack of agreement may include the inability to learn a new way of viewing patients. Or perhaps there’s an unwillingness to follow different rules in making decisions about patients. More study is needed before the TBC is adopted for use by all PTs.

This is a study of more than 1,000 people with spinal instability (looseness between two or more spinal bones). It was designed to help replace the wide range of results in other studies. Most of those studies were done with fewer patients using poor research or X-ray methods. Researchers from this project were very careful to prevent the problems other studies have had finding answers about spinal instability in the lower back.

An unstable spine may be the cause of low back and leg pain (sciatica). Doctors use patients’ symptoms and X-rays to diagnose the problem. Two problems can be seen on X-ray: slippage or tipping of the spinal vertebrae. The authors looked at which one is linked to the patients’ symptoms.

Translation is a measure of how much one vertebra slides forward and backward as the patient bends and extends the back. Angulation shows how much one vertebral body tips forward or back as the spine moves. Both movements are measured from the side view.

These two motions were measured at one level (L4/5) in all the patients. Symptoms were compared to the results of these measures. The authors report that translation affects symptoms more than angulation. In fact, too much angulation by itself didn’t seem to make any difference in patient symptoms. Too much translation and too much angulation at the same time may cause ongoing symptoms.

Wrestlers have just as much back pain as any other competitive athlete. The question is, what causes it? Sometimes X-rays show a structural problem. Is this the cause? Or is back pain linked to muscle weakness of the trunk? That’s what the authors of this study tried to find out.

They studied two groups of wrestlers. All subjects had chronic low back pain (LBP). One group had normal spine X-rays. A second group had X-ray findings such as disc problems and spondylolysis. Spondylolysis is a condition affecting the vertebra. In spondylolysis, a small crack or fracture occurs in the pillar of bone that connects the body of the vertebra to the facet joints of the spine.

Trunk muscle strength was measured using a special machine called the Biodex System3. Each wrestler moved the trunk in a bending and extending pattern at three different speeds. This measured the strength of the trunk flexors and trunk extensors. All the wrestlers were asked questions about their back function and ability to do daily activities.

The authors found that most of the trunk muscle strength was the same in both groups. There was no difference between the two groups in terms of trunk flexor strength. Only the group with normal X-rays showed a link between decreased extensor strength and level of disability.

The authors conclude that abnormalities in the spine seen on X-ray are not the cause of low back pain and disability among wrestlers. It’s more likely that poor muscle strength may be the real culprit. This may explain why wrestlers are injured when lifting their opponents in an attempt to pin them.

Wrestling is a high-risk contact sport. Improving strength of the trunk extensors may help prevent back pain and disability in this group of athletes.

Since the Genome project, spinal fusion has changed dramatically. New understanding of how bone grows is changing the way doctors treat chronic low back pain. This report reviews those changes in detail. The history of spinal fusion is reviewed from 50 years ago to today.

During this transition time, we are moving from using bone chips and metal screws and plates on the outside of the spine to fusion from the inside out. This new way to fuse the spine is called interbody fusion.

In interbody fusion, special bone growth cells are placed on a sponge the size of a thumbnail. The sponge is put inside a titanium cage. The cage is then inserted between two vertebral bones in place of the disc. The cage restores the normal disc height while new bone cells grow inside the cage. Over time new bone forms around the outside of the cage, forming a solid fusion.

The authors say doctors won’t give up other ways to fuse the spine. Each method has its own benefits and drawbacks. The key is to find out what each patient needs and match the fusion to those needs. For example, when three or more levels are affected, interbody fusion is not the best choice. The patient is more likely to need metal plates, rods, and screws.

Today’s surgeon must be able to use many different methods of fusion. At the same time, new ways to repair and restore the spine are being developed rapidly. This report suggests that interbody fusion, artificial discs, and vertebral bone replacement are all part of the future for the spinal surgeon.

Things are changing in the world of spine surgery. Artificial discs and new bone graft substitute are making repair of the degenerative spine possible. Doctors are entering the spine from the front of the body in an operation called anterior lumbar surgery (ALS). This approach avoids damaging the spinal cord. However, it does put the blood vessels at risk.

For this reason, special doctors called vascular surgeons are part of the surgical team for ALS. Vascular surgeons make sure the blood vessels are moved out of the way and left uninjured after the operation. But just how often do injuries to the blood vessels occur? That’s the focus of this study.

One doctor followed 1,310 patients after doing an ALS on each one. Only 25 patients had any problems with blood clots or accidental cutting of a blood vessel. That’s less than a two percent rate of complications. Risk factors for complications include gender (women have a greater risk) and spinal level (more problems occur at the L4/L5 level).

The authors sum up their findings by giving doctors the following advice:

Do patients with previous back surgery have worse health than patients who haven’t had surgery? This is the question researchers asked through a survey of more than 18,000 patients with low back pain (LBP). It’s the first study to look at the effects of back surgery on general health.

LBP patients at 27 spine centers around the United States answered questions about their physical and mental health. About 20 percent (3,632) of all patients had previous back surgery. Some had pressure taken off the disc and spinal nerve root. This procedure is called decompression. Others had spinal fusion, or decompression and a spinal fusion at the same time.

The results showed that patients who had previous surgery were more likely to be older males who were overweight. They were also more likely to be white, to smoke, and to have a high school education or lower. Most of the patients with a history of surgery had the operation more than two years ago.

This study also reports results from the survey based on the type of surgery performed. Patients who had a spinal decompression seemed to have the best health status. The authors suggest that rehab programs include ways to improve both physical and mental well-being after back surgery.

Studies suggest that low back pain (LBP) may say something about your general health. Patients with LBP often have other problems such as diabetes, headaches, hay fever, asthma, or dermatitis. Such extra problems are called comorbidities.

In this study from the Back Research Center in Denmark, 9,567 teenagers and young adults filled out a survey about back pain and other health concerns. The results showed an increase risk of headache and asthma in children with LBP.

In fact, when these two disorders occur at the same time, the chances of having back pain increase much more than if just one problem is present. Diabetes and rheumatoid arthritis weren’t linked to LBP in this age group. Back pain occurs more often in girls than boys. The increase in LBP is also common among women compared to men in adult studies.

The authors think the results of their study show that LBP starts earlier in life than we thought. It’s possible that some children are just more frail than others and more likely to develop these problems. If risk factors can be identified, then prevention could be started earlier. Maybe repeated bouts of LBP can be stopped with early treatment.

Low back pain (LBP) is a common problem in adults. As it turns out, adults are more likely to have back problems if they had back pain earlier in life. One in three teenagers (about 30 percent) will have back pain. LBP occurs again later for 88 percent of those teens. Verifying these figures and finding ways to prevent back pain are the goals of this study.

The researchers asked 1,552 university students questions about LBP and what caused it. They found that about 41 percent of the students had LBP in the last month. Age does seem to be a factor, meaning that the rate of back pain increases with age. Women have more back pain than men, but in this study, LBP wasn’t linked to gender as a risk factor.

The two major factors in LBP for these college-aged students were: trauma, such as slipping on ice or falling down stairs; and giving up regular exercise. In this study the influence of sports and activities went both ways. Quitting sports participation was linked to LBP, and LBP was a reason to stop playing.

The authors conclude that the rate of LBP is increasing as time goes by. Now is the time to find ways to slow down this trend. Preventing falls and injuries is the first step. An important key is to exercise on a regular basis. Students who go to college and stop sports or physical activities are at greatest risk for episodes of LBP.

Doctors often give muscle relaxants to patients with low back pain (LBP). This study reports on the type of patients who take these drugs. A second part of the study measured how well muscles relaxants return patients to health.

Past studies have shown that muscle relaxants are better than no treatment. However, they don’t work as well as nonsteroidal anti-inflammatories (NSAIDs). Using muscle relaxants together with NSAIDs doesn’t seem to give better results than just using the relaxants.

Data collected for the North Carolina Back Pain Project was used in this study. Patients were seen by a medical doctor, nurse, chiropractor, or physician’s assistant. Results were measured by asking patients if they were back to doing the activities they did before back pain struck.

The authors report that some types of patients were more likely to take muscle relaxants:

Doctors give mixed reviews of spinal fusion as a treatment for low back pain. Some researchers say the studies done so far are of poor quality. This study was designed to improve the quality of data collected from patients. The idea was to find out how well the operation worked. Patients were also asked if they were satisfied with the results.

Besides patient satisfaction, other measures of outcomes were pain levels, return to work, and use of drugs. Thirty-five patients had spinal fusion, but only 28 stayed in the study. Patients rated their results as excellent, good, fair, or poor. The also reported whether they would do it again if they had the choice.

Most of the patients (86 percent) said they would have the same operation if they had to do it over. This was true even though only 28.6 percent thought the operation was a success. The authors think this response reflects the fact that patients improved but weren’t cured after spinal fusion. Pain levels were better, and the patients could use less medication. Many were able to go back to work.

The findings of this study support the use of spinal fusion. The authors suggest patients should be told to expect to get better but not to expect a complete recovery.

A new study shows that patients can get pain relief in the first 24 hours after spine surgery. The treatment is an injection of a local anesthetic into the epidural space of the spine. This is an example of preemptive analgesia. Preemptive analgesia involves treating pain before it happens. Preemptive analgesia works by preventing pain signals from reaching the nervous system and causing oversensitivity to the pain signal.

Two groups of patients were tested. The control group got an injection of a saline solution. There was no pain reliever. The study group received the injected analgesic. In both groups the injection was given at least 20 minutes before the operation started. All patients had a disc removed.

Pain was first measured when the patients woke up from the operation. It was measured again at four, eight, 12, and 24 hours after the surgery. The researchers found better pain relief in the study group. The study group also went longer before asking for any pain medication.

The authors conclude that pain control after spine surgery can be done preemptively. Patients can get safe and effective pain relief with one injection before the operation. Some pain is still present, so patients may still report problems early on. The authors suggest using an epidural injection of bupivacaine (anesthetic) and tramadol (narcotic).

Dr. Burger provides an update on artificial disc implants. The first disc replacement of this kind was tried in the early 1950s. Since that time new and better implants have been developed. Each new revision is called the next generation implant. Research has shown that the new disc must be able to handle load and movement at the same time.

The following facts are offered based on research from around the world: