News Category: Lumbar Spine

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:

What’s the best way to treat back and leg pain from a herniated disc? This question remains the topic of debate among doctors. What’s the best way to find out the answer?

Researchers in Canada think it’s a good idea to find out which patients get better. Doctors can use this information to help predict who should have surgery to remove the disc. To find out who gets better, the authors used surveys. The surveys were given to 82 patients with lumbar disc herniation causing back and leg pain.

The surveys measured results before the operation and six to 12 months afterwards. Questions were asked about symptoms, function, and quality of life. Overall results showed that surgery to remove a herniated disc gave the patients considerable improvement.

Most of the benefits occurred in the first six months. There wasn’t much change between six months and one year. Pain and physical function were still lower than scores for healthy adults. Mental function was back to normal by six months.

Physical function after the operation was much worse some for patients. Patients who had the operation during the first three months of painful symptoms had the best results. Anyone who waited more than 12 months to have the surgery had worse physical results.

The authors conclude that quality of life improves with surgery to remove a painful disc herniation. In Canada the rate of surgery for this problem is lower than in the United States and elsewhere. The authors suggest that it’s too low, and that more Canadian patients should be considered candidates for this operation sooner.

Smoking is a risk factor for many diseases. It’s also a risk factor for low back pain (LBP). This means if you smoke you’re more likely to have LBP than someone who doesn’t smoke. How do smokers with LBP measure up strength-wise compared to nonsmokers?

This study looked at muscle strength of the lumbar extensor muscles in four groups of men:

How does surgery to remove a disc affect low back pain? Doctors in Japan followed 40 patients for up to 54 months after two different kinds of surgery to find out. The patients were divided into two groups. The groups were similar in age and had an equal number of men and women. No one was on worker’s compensation. All patients had a disc herniation at one level in the lumbar spine. They had low back pain and leg pain (sciatica) that didn’t get better with treatment.

Group one had the standard disc removal with an open incision called open discectomy. Group two had microsurgery. A small opening was made just large enough to insert a special tool with a tiny TV camera on the end. This method is called microendoscopic discectomy.

In all cases the loose disc material was removed. Nothing else was cut or taken out. Pressure on the spinal nerve root was relieved with both operations. Leg pain went away in all patients. For some patients pain relief happened right away. For others it decreased slowly over a month’s time.

Back pain was also improved for all but three of the 40 patients. Everyone who was working before the operation went back to work within two months of the surgery. All patients in both groups had about the same results in the same amount of time.

The authors report on previous studies that suggest disc removal helps with leg but not back pain. Their own study doesn’t support those findings. Removal of a herniated disc provided quick relief of both sciatica and low back pain. They suggest that the difference was that no patients in this study were on worker’s compensation.

Dr. Glenn Buttermann at the Midwest Spine Institute looked at the results of two treatments for large disc herniations. All disc problems were in the lumbar spine. When a disc protrudes or herniates, the center of the disc (the nucleus) pushes through its own outer covering (the annulus). It can push into the canal where the spinal cord is located or press on the nearby spinal nerves. A large herniation was defined as one taking up more than 25 percent of the spinal canal.

One hundred patients were either treated with a steroid injection or discectomy (disc removal). Everyone had tried at least six weeks of other treatment first, with little success.

Here are the results:

Degenerative lumbar spinal stenosis (LSS) is a condition that involves narrowing of the spinal canal. When the spinal canal narrows for any reason, the spinal nerves inside can become pinched. This can cause serious low back and leg pain. LSS has many different causes. Sometimes surgery can help. However, surgery is not always possible. And in some patients, nonsurgical methods can work over time.

There is no one best way to treat LSS nonsurgically. Many different treatments can help relieve pain, including epidural steroid injections (ESIs). When doctors give an ESI, they inject numbing medication and a steroid into the painful part of the lumbar spine. ESIs are used fairly often for LSS, but there is not much research on how well they really work.

These researchers interviewed 140 patients with LSS who had an ESI done at the same spine center. The patients were all older than 55. Over three years, they had one to seven ESIs for pain. The researchers asked them questions about pain, function, and their satisfaction with treatment.

Results showed that 20 percent of the LSS patients had gone on to have surgery. About 71 percent reported at least some improvement from ESIs; 32 percent reported more than two months of pain relief. About half of the patients still reported some pain relief and better function an average of 18 months later. Almost half said they were very satisfied with the results of their ESIs, while 74 percent were at least somewhat satisfied. In this study, gender, age, and other health problems didn’t seem to be linked to results.

These are better outcomes than earlier studies. The authors aren’t exactly sure why. They note that this was the only study to use a special imaging device called a fluoroscope. The fluoroscope lets the doctor make sure the needle is in the correct place before giving the injection.

The authors conclude that ESIs can be a useful part of a treatment program for patients with LSS. They say ESIs can be most helpful in getting patients through flares-ups of pain.

What’s the best test for measuring results of treatment for low back pain (LBP)? That’s what researchers at the University of Sydney in Australia tried to find out. They tested 155 patients with LBP using four different tests. Each test was given before treatment and again six weeks after treatment. Various types of conservative treatment were used. Surgery was not included. The tests were:

This is a follow-up study of 45 patients treated for chronic low back pain at the University of Iowa Spine Treatment Center. In the first study in 1992 patients were put in one of two groups. One group was in a multidisciplinary program. That means the group did physical therapy, aerobic exercise, and vocational counseling. There were also classes on many subjects about back pain.

The second group had standard treatment along with psychological and behavioral therapy for pain management. In this follow-up study, all 45 patients were contacted 13 years later. Four measures were used to assess the final outcome. Patients were asked about pain, mood, employment, and general health.

The authors report that patients held onto their improved health and decreased back pain. This was true even though everyone was 13 years older. More than half were still working. Most of the patients who weren’t working reported that it wasn’t because of back pain. General health was the same compared to adults their own age without back pain. The patients gave a report of higher pain levels in general compared to the norm.

The results of this study support the use of a multidisciplinary approach to chronic low back pain. The multidisciplinary approach showed positive long-term outcomes. Short-term treatment gains were still present 13 years later.

Do steroid injections work for low back pain (LBP) from a disc problem? Probably not, report these doctors. They came to this conclusion after a year-long study of 120 patients. Two groups of 60 patients each were included in this study. All patients had signs and symptoms of discogenic LBP with positive MRI findings.

Each patient had a discography. This is a special test to show if pain occurs when the disc is pressurized. If the test was positive the patient either got a steroid injection or a saline (placebo) injection. The two groups were compared at the end of one year. Results were measured by change in disability and change in pain levels.

The authors report no difference between the two groups at the end of one year. Thus, they can’t recommend the use of steroid injections in patients with discogenic LBP.

Most medical research focuses on patients. For a change, this study focuses on healthcare providers. It looks at the way physical therapists’ attitudes can affect treatment of patients with chronic low back pain (LBP).

In the past, most healthcare providers would have described LBP as a purely physical problem. Recent studies have shown that chronic LBP is more complex than that. Long-lasting LBP seems to be a combination of physical, mental, and social factors. That means that attitudes can be important in successfully treating chronic LBP.

The authors looked at the way six physical therapists in England treated patients. Researchers interviewed the therapists and observed treatment sessions. The therapists strongly believed in the value of their experience and techniques. The therapists also showed very strong beliefs about “good” and “difficult” patients.

Patients were considered good if they had simple injuries and took an active part in treatment. Patients who wanted quick results and didn’t follow treatment plans closely were seen as difficult. The authors note that patients with complex problems were also seen as difficult. This was not because of the patient’s personality, but because of the therapists’ problems treating them.

Despite recent research, the therapists generally believed that LBP had purely physical causes. Sometimes the therapists would say that a patient’s mental state might be part of the problem. However, they still did not recommend treatment that would address the mental factor.

The authors concluded that the therapists’ beliefs did affect treatment. Beliefs affected the way therapists gave information to patients. It also affected how likely they were to send a patient to a specialist. The authors say that it is very important for therapists to remember that it isn’t only the patient’s attitude and beliefs that matter.

IDET is a fairly new treatment for chronic disc-related low back pain. IDET stands for intradiscal electrothermal therapy. It’s a form of heat treatment to the disc to decrease pain and increase stability. How useful is this treatment?

Research shows mixed results with success in about 60 to 70 percent of patients. The purpose of this study was to follow patients for one year and report pain and function levels. Spine specialists from all over Los Angeles sent patients to one surgery center for IDET. Forty-four patients were part of this study.

A year after the operation, patients were contacted by phone. They were asked about pain, function, work status, and medicine use. They were also questioned about any further treatment for their back pain. Patients also filled out a survey with more questions about exercise, smoking habits, and alcohol use.

The results of this study show about one-third of the patients were happy with the results of IDET. Slightly more than half would do it again. But nearly everyone reported they still had pain a year after IDET. Six patients (about 14 percent) ended up having back fusion a year later.

The authors conclude that IDET looks promising, but it’s not good enough yet. More long-term studies are needed to show if IDET really works. There’s still some concern about disc breakdown over time. Patients could end up with worse pain or other problems much later.

Many studies have been done to find a treatment that works for chronic low back pain. Researchers in this study turned their attention to treatment after first-time lumbar disc surgery. They compared two forms of treatment: usual care (UC), and treatment with a behavioral guided activity (BGA). Both treatments were delivered by physical therapists.

The patients were divided into two groups. The first group received UC, and the second was given BGA. All patients had the same number of treatment sessions. Physical therapists instructed patients in proper posture and lifting. Exercises were given to increase strength of the trunk muscles. Sometimes electrical therapy, massage, or manipulation was used. The goal was to decrease pain and muscle tone.

Each patient in the BGA group got a personalized exercise program. The goal was to increase activity while reducing fear of movement and avoidance behaviors. Everyone kept a cost diary for two periods of three months. Any money spent directly or indirectly was recorded. This included medications, equipment, health care, help from friends and family (paid or unpaid), and lost wages at work.

They found no difference in how well the two different treatments worked. The cost of the BGA was higher. The authors suggest there’s no need to use BGA after lumbar disc surgery. Patients who receive BGA don’t appear to get better than patients getting usual care, and BGA costs more.

Two concerning spine problems affect children and teens. Spondylolysis is a crack or tiny fracture in the bony ring that protects the spinal nerves. Spondylolisthesis occurs when the vertebra slips forward on the one below it. What causes this slippage?

Until the bones are fully developed in children, there’s a separation at the end of the bone where bone meets cartilage. This is called the growth plate. Until that cartilage hardens and becomes bone at the end of growth, the growth plate is visible on X-ray. Scientists wondered if slippage occurs if the bone and cartilage separate.

Japanese researchers used rat models to test this idea out. They were looking for the cause of slippage in spondylolisthesis. Part of each rat spine was cut away to make it unstable. X-rays were taken and the cells studied under a microscope to find out what happens after surgery.

Researchers found no slippage before day five. Most cases of forward slippage occurred around day seven. There was no sign of disc degeneration. The results showed that growth plate separation was the reason for slippage in the immature spine. The extra stress of the spondylolisthesis breaks the growth plate. The cartilage separates from the bone and the bone slips forward.

The authors say this makes sense because slippage doesn’t occur when the growth plate disappears at maturity. Future studies are needed to find out what biologic events occur leading up to point that the growth plate gets weak and comes apart.

Physical therapists working with patients who have low back pain (LBP) need a way to measure progress. Do patients have better function after treatment? Have they made any progress? Finding one tool to assess outcomes no matter how old the patients are is a challenge. The same thing goes when patients also have other health problems. There are many tools already in use, but not one that can be used with everyone. Having patients fill out more than one survey takes too much time. And the different surveys often ask some of the same questions.

Physical therapists in Australia tried combining items from three surveys already commonly in use. They used items from the Short Form-36 Physical Functioning scale (SF-36-PF), the Oswestry Disability Questionnaire, and the Quebec Back Pain Disability Scale.

For this study, 140 subjects from 18 to 89 years of age were recruited. Patients from local health clinics, hospitals, and private practice settings were included. All patients had LBP and were having physical therapy treatment. Everyone answered the same questions twice, six weeks apart.

The results of using this new scale were compared to the original scale. The authors report that the new scale may be better than the original tools for patients with LBP. The new scale is brief, easy to fill out, and finds out about activities most often linked to back problems. This back-specific scale combines the good points of three scales into one with fewer total questions.

Bleeding as a complication after lumbar spine surgery doesn’t happen very often. When it does, it’s an emergency.

The large blood vessels including the aorta and its branches lie in front of and very close to the column of vertebral bones. They don’t move much and can’t be pulled out of the way very easily. When the patient is operated on in the face-down position, the spine presses closer to these blood vessels.

The blood vessels can be damaged easily. Bleeding can result in very low blood pressure early after the operation. This same problem can also occur up to nine years after the operation.

The treatment is immediate surgery to repair the damaged blood vessel. The surgeon may be able to stitch the blood vessel closed. If not, then a Dacron graft is used. This graft is made of synthetic materials tightly woven together in a tube or blood vessel-like shape. The graft is used to repair or replace the injured vessel.

Occasionally the surgeon opens the patient up to do the repair and doesn’t find a bleeding problem to explain the signs and symptoms. This doesn’t happen very often, but it is an accepted practice. If the diagnosis is delayed too long, the patient can develop much worse problems. The author of this report advises surgeons to take the time to make a calm and deliberate treatment choice.

A previous history of low back pain (LBP) increases a worker’s chances of having another episode. How can we change this? Studying the forces through the spine during lifting might offer us some helpful clues when retraining a worker after the first injury.

The object of this study was to show how spine loading compares between workers with and without low back pain. Everyone lifted four different weights in five positions. Electrical activity of 10 muscles was recorded. The muscles included trunk and abdominal muscles. A computer monitored the speed, direction, and force of trunk and back motions.

Signals were collected using special software developed by the Biodynamics Laboratory at the University of Ohio. The program made it possible for patients with LBP to lift without using maximum exertion. The researchers could still get the needed readings for the study.

In this study they measured downward pressure and sideways (shear) forces when lifting in patients with LBP compared to subjects who’ve never had back pain. In some positions there was more than twice as much pressure through the spine for the back pain group. Shear forces were much higher for LBP patients when lifts weren’t in the center or midline. These lifts required combinations of movements like bending and twisting. They are called asymmetric movements. The greatest differences in force between the two groups occurred when lower weights were lifted.

The authors of this study have spent the last 20 years developing a three-dimensional model that shows how much the spine is loaded during motion. Movements tested so far include forward bending, side bending, and twisting. This study is a first step toward matching a patient’s ability to lift with the amount of load that goes through the spine during asymmetric lifting.

This information will help workers prepare to return to work safely. The results of this study will help find ways to train muscles to contract with the right amount of force and with the right timing. Workers need to be able to lift weights from the center and from off center.

In 1997, a new treatment for disc pain in the low back was developed called intradiscal electrothermal therapy (IDET). In IDET, a flexible electrode is inserted into the inner disc and heated to around 190 degrees Fahrenheit.

IDET has been around long enough to find out if it works. Is it better than a rehab program? Is it just a placebo effect (meaning the patient would get just as much relief with a pretend treatment)? Researchers at the Texas Spine and Joint Hospital took a look at IDET compared with a placebo.

Thirty-seven patients with low back pain from a disc problem were treated with IDET. A second group with 27 patients thought they were getting IDET, but once the needle was placed inside the disc, no heat was applied. Both groups were monitored afterwards by a physical therapist. Everyone wore a lumbar corset for six weeks. All patients in both groups started special exercises after six weeks. The exercises were done for six weeks, until week 12 of the study.

Both groups got better after treatment. However the IDET group had better results than the sham group. In the IDET group 40 percent of the patients got at least 50 percent better. Patients with poor physical function and with greater disability did best with IDET treatment. Healthier and less disabled patients had equal results with IDET versus the sham treatment.

This study confirms a finding from another study. The results at six months after IDET were stable. The patients with pain relief continued to have good results after 12 and 24 months, too. The authors conclude that the benefits of IDET are more than just a placebo effect. Only patients with a posterior tear of the inner disc were included in this study. Therefore the authors say the results can only be applied to this particular type of disc lesion.

Exercise is still the best treatment for chronic low back pain. Studies show it’s safe and doesn’t increase your risk of future injury. In fact, it’s likely that a regular exercise program prevents future episodes of back pain. These are the results of a review of many studies done on exercise as a treatment for chronic back pain.

Doctors at The Spine Center in Boston did a computerized search of studies on exercise and back pain. They found regular exercise decreases the risk of future back pain or spinal degeneration. Exercise improves flexibility, strength, and function. Exercise doesn’t increase the risk of another injury or episode of back pain. In fact, there’s some evidence that it can protect against back pain.

The authors conclude exercise is safe for people with back pain. It can be used to overcome fears of re-injury. Strength and motion can be improved. Pain intensity can be reduced. Regular stretching should be done, and even within the painful range of motion. Muscles of the spine, trunk, hips, and legs should be included. The stretches must be held for at least 30 seconds and done at least three times each week.

If you stand on a flat surface with your feet fully supported, your ankles do the work of keeping your body centered over your feet. But if you stand on a surface that is smaller than your feet, then the hips work extra hard to keep you upright on your feet.

Postural control is the term used to describe what goes on in the body to keep us up and centered. Scientists think this postural control is affected in people with low back pain (LBP).

It’s possible that pain causes changes in postural activity of the trunk muscles. This leads to a backwards shift of weight on the feet in the quiet standing position. It’s like standing on a surface that is smaller than the feet. This is called a short base of support.

In this study, researchers started out with the idea that people with LBP have trouble keeping their balance because of this weight shift. A short base of support forces them to use the hips more than the ankles to stay centered in the upright position.

They compared the postural control of people with and without LBP. This was done while standing on a short and a long base of support with eyes opened and eyes closed. Several different positions were used with both feet and standing on just one foot. Each subject was marked successful if he or she could hold the position for 70 seconds (both feet) or 30 seconds (one foot).

The results showed that patients with LBP have poor balance compared to adults the same age and gender without back pain. Balance is worse with eyes closed and when standing on a short base of support. The authors think this is caused by decreased shear force from front to back at the hip. They suggest a closer look at improving balance during rehab. Specific training should focus on the hip.

Most patients with low back pain (LBP) get better with spinal manipulation. But some don’t, and physical therapists are wondering why not. In this study, six factors were found to make a difference. Patients who don’t get better with spinal manipulation have symptoms longer, back pain with buttock or leg pain, and normal lumbar spine motion. Hip motion and the results of a special test for the sacroiliac joint are also important.

Therapists used manipulation on the lumbar spine of 71 patients with LBP. The goal was to study patients who didn’t get better with this treatment. If therapists can identify why these patients didn’t improve, then future patients with similar symptoms can be treated with a better method.

Each patient received two treatments of spinal manipulation. Improvement was based on several measures. First, the patients reported they were at least 50 percent better. Spine and hip range of motion were also measured. Patients filled out a survey to assess function. Again, 50 percent or more improvement on these tests was needed to say the treatment was a success.

About two-thirds of the patients improved with manipulation. The rest didn’t get better. The results of this study helped therapists find patients who should not be treated with manipulation. A longer duration of symptoms and pain down the buttock and leg signal that a poor result is likely with manipulation.

The authors say this is a first-step study. A second study is needed to repeat these findings. Long-term results of manipulation must also be studied. These steps are needed before clinical practice guidelines for the use of spinal manipulation can be published.