News Category: Lumbar Spine

Spine surgery is trickier for people with diabetes. Problems can be harder to diagnose. Nerve problems and diabetes medications can make the surgery more difficult. Often, people with diabetes have worse outcomes after spine surgery. Surgeons need to understand as much as they can about how a procedure will affect a diabetic patient.

This study looked at results of decompression surgery for lumbar spinal stenosis. Sixty-two diabetic patients were followed for one to six years. The control group was 62 patients who did not have diabetes. All patients were over 65. The diabetic group had more pain and weakness before surgery. More patients in the diabetic group also had other health problems before surgery. The authors note that depression was much higher in the diabetes group before surgery. This is important because depressed patients tend to report more pain.

After surgery, both groups had about the same pain relief. Both groups were better able to do daily activities. The control group saw improvement in more activities. Within the diabetes group, patients who needed insulin and those who didn’t had the same outcomes.

However, the diabetes patients had many more complications during surgery. Sixty-seven percent had surgical complications, compared to 28 percent of the control group. There was also a big difference in patient satisfaction. In the diabetes group, 53 percent of the patients rated their results as satisfying. This compares to 78 percent in the control group. The diabetes group also had more additional surgeries to control pain.

All patients who reported dissatisfaction were more likely to report ongoing pain. The authors stress that pain relief is key to good outcomes after surgery. Overall, the authors conclude that decompression surgery can be effective in older diabetic patients.

Lumbar spinal stenosis is becoming a common problem among aging adults. What is it and what can be done about it? Lumbar refers to the low back area, and stenosis means narrowing. In spinal stenosis, the spinal canal gets too narrow, and the spinal nerves inside begin to get squeezed.

Treatment for lumbar spinal stenosis is often surgery. Part of the bony ring that covers the spinal nerves is removed to remove pressure. There’s been a trend over the past few years towards less invasive operations. Instead of taking the entire bone and nearby joints, only part of the bone is removed above and below the problem level. This operation is called laminarthrectomy.

Doctors are also looking for a way to predict which patients will get better with surgery. The aim of this study was to find a model to predict results. The model is based on information used before the operation.

Before the operation the surgeon examined 45 patients. History, symptoms, and strength were recorded. X-rays and CT scans were done. All tests and measures were repeated one year after the operation. Success was defined as improvement in three of four areas: general health, pain, function, and claudication (pain while walking).

The authors report a 58 percent rate of success by this standard. Most of the rest of the patients improved but only in two areas. They looked at the patients who had a successful result to see which factors might point to a good outcome. The model proposed by the author looks at gender and the presence of calcification in the aorta. They determined that a separate model may be needed for men and women.

The authors don’t think their model is ready for use yet. More study must be done. They advise the use of imaging studies to assess blood supply to the spine. Deposits of calcium and hardening of the arteries may be more important in the results than previously thought.

Spinal fusion has become increasingly popular as a treatment for chronic low back pain. Two or more vertebrae are fused together using bone grafts. Some procedures include metal spacers, plates, and screws. The success of the fusion varies from patient to patient. A fusion holds the spinal level stable and keeps it from moving. Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis.

Many factors can make a failed fusion more likely. Research shows smoking reduces the chances of a good fusion. So does the number of spinal levels involved. (The more levels that are fused, the less likely a patient will have a solid fusion.) Using bone graft from another person (an allograft) instead of the patient’s own bone can also slow down or stop the fusion process.

Doctors are looking for ways to improve the fusion rate. They are also studying ways to treat a nonunion. In this study, doctors used pulsed electromagnetic field(PEMF) stimulation to save the fusion site without doing more surgery.

Past studies have shown PEMF works well to increase bone formation after spinal fusion. This study shows it can also enhance bone formation in a patient with a failed fusion and nonunion. One hundred patients took part in the research. All had nonunion within the first nine months after fusion. Patients used a PEMF device at least two hours every day for 90 days or more. X-rays were taken to look at the fusion after PEMF. Doctors also used patients’ pain levels, medications taken, and return to work and activity as measures of success.

The authors found an overall fusion success rate of 67 percent. This means two-thirds of the failed fusions became solid fusions using PEMF. The PEMF turned a failure into a success. It saved these patients from having a second operation. The authors say this is good news for patients who can’t have any more surgery because of poor health. PEMF is also a big cost savings compared to another surgery.

Computer searches are used in medicine to review changes and progress in treatment. Doctors from the Boston University School of Medicine conducted such a search. The topic of their study was lumbar spinal fusion.

Many changes have taken place in how spinal fusions are done. Advances in technology have also increased the number of fusions done. It’s time to ask the question, “What are the results of fusion now?” These researchers looked at the results of 84 studies on spine fusion over 20 years, from 1979 to 2000. All 7043 patients had degenerative spine disease requiring fusion.

There were some major gaps in the information collected. Many studies left out important variables. For example, some studies failed to include the design of the study. Others didn’t mention if they used braces after the operation. The location of the fusion and the rate of success weren’t always recorded.

From the data collected, the authors saw one trend. Fusions are done more often now using some form of hardware. The hardware can be metal plates, screws, rods, or other devices to hold the bones in place until fusion occurs. Fusion with these devices is called instrumented fusion.

Despite the changes in the last two decades, the results aren’t any better. The researchers were surprised to find the fusion success rate has stayed the same over all these years. The overall fusion success rate was 88 percent for all patients in the 1980s. The success rate was 87 percent in the 1990s. Fusion with instrumentation had a higher rate of success than no instrumentation. Fusion success goes down when more than one spinal level is fused.

The authors say the biggest thing they saw from this study is the need for a standard core of information collected and reported when doing studies of lumbar fusion. They suggest what types of information should be collected and placed in the database. The results will help surgeons choose the right operation for each patient in the future.

Most of the costs to take care of low back pain (LBP) patients occur in those who are on sick leave six months or more. The total costs of LBP remain high in Europe and the United States. Reports indicate that as much as two percent of the gross national product in the United States is spent on health care costs for LBP.

This study looks at the cost of lumbar fusion for LBP. Costs are compared to patients who haven’t had surgery. The number of lumbar fusions has increased 100 percent in the last 10 years. Is it worth the cost? Does it help? These are the questions researchers in Sweden looked at in a group of 284 adults with chronic LBP. Doctors at 19 clinics joined in this study.

The results of this study show that surgical treatment was much more costly than treatment without surgery. But it was also more effective. The group without surgery had nonoperative therapy that didn’t help. They were referred to as the therapy resistant group.

Patients were followed for two years after treatment. More patients could go back to work after lumbar fusion than in the nonsurgical group. Results didn’t seem to depend on the type of fusion used. Fusion patients all had equal results. Measures used to assess results included pain levels, level of disability, and return to work.

The authors reported all the costs for treatment of LBP. There were direct costs such as hospital care, drug use, and doctor bills. Indirect costs were also reported. These included lost days at work, lost productivity, and the cost of family support.

The cost of surgical care was about twice as much as nonsurgical treatment. However, twice as many patients in the fusion group improved, and twice as many returned to work full-time. More patients returned to work part-time in the fusion group, too.

The authors conclude that lumbar fusion is a good cost savings overall for society in cases of chronic LBP. The type of fusion didn’t matter in this study, so perhaps the simpler, less expensive fusion method should be used more often. More study is needed to look at this factor.

Taking out part or all of a lumbar disc increases the motion at that level. Increased motion can lead to an unstable spine. Studies show that it’s important to remove as little disc material during surgery as possible in order to limit this motion.

The increase in range of motion (ROM) may not occur right away. When only part of the disc is removed, loads repeated over time may lead to increased ROM and increased instability. These are the findings of a study at the Spine Research Center at the University of Toledo.

Researchers tested 28 lumbar spines taken from cadavers. Four different amounts of disc material were taken out. The spines were then tested in six different motions. The motions were repeated over 10,000 cycles.

Doctors want to know what’s the best amount of tissue to remove from a damaged disc. The results of this study show the effects of repeated loads on the spine after various amounts of disc removal. The normal spine goes through one to three million cycles each year. Changes in spine motion were seen after only 10,000 cycles. This is equal to two or three weeks of normal movement, or one day of hard work with repeated bending and lifting.

The authors suggest using some type of lumbar support after even the smallest amount of disc removal in order to protect the lower spine. Support should be used for the first few weeks after surgery.

Imagine 100 billion dollars. This is the annual cost of back care in the United States. The high rate of repeat back pain and chronic disability accounts for much of this price tag.

There’s a new theory about why low back pain (LBP) occurs over and over in some people. It’s called the motor control theory. The theory says that patients with chronic LBP don’t use the trunk muscles with the same timing and force as patients without back pain. For example the muscles are slow to respond when there’s sudden trunk loading or increased trunk movement. Studies also show injuries to the spine can lower the set point so that pain receptors turn on sooner.

In this study, trunk flexion and extension were compared in two groups. Group one had LBP. Group two (the control group) had no back pain. The goal of the study was to see if patients with LBP flex and extend the spine with the same force and control as healthy subjects.

Isometric muscle contractions were used. This means each person pressed the spine against a resistance without actually moving. A special harness connected to an isometric testing device was used. Both groups used similar force in carrying out the two motions.

The researchers saw a pattern based on the patient’s pain level. Patients with more pain took less time to reach the maximum or peak muscle force. They also used a different pattern of muscle action or motor control.

The authors think the differences in motor control for patients with LBP occur as they try to limit pain during motion. It may be possible to use this type of information to see what form of motor control each patient uses. A specific exercise program can be prescribed based on this information.

What happens to muscle strength and size after back fusion? How do the results compare with the muscles of back pain patients going through an exercise program? Scientists in Norway are sorting this all out. In this study, back pain patients were divided into two treatment groups. One group received a lumbar fusion; the other was prescribed exercise and education.

The researchers used tests of muscle strength and CT scans of the muscle size and density as the main measures of outcome. They found the exercise group did better than the fusion group in all areas, including muscle strength, density, and endurance.

The authors suggest that weakness and atrophy of back muscles in patients with spinal fusion comes from the operation itself. Nerves are cut and muscles may be injured during the operation. Muscle tissues can generally recover with activity and exercise. Exercise has been shown to make muscle fibers larger.

The scientists aren’t sure why that didn’t happen in the fusion group. They had more physical therapy than the exercise group. And the exercise group didn’t exercise intensely. Patients were followed for one year and results were the same at the one-year checkup. Muscle strength was still greater in the exercise group. There was a significant decrease in the muscle strength of the patients with a lumbar fusion. Exercise therapy for chronic low back pain still seems to be the best treatment.

A new fusion treatment for chronic low back pain uses titanium cages inserted between the vertebrae. The disc material is taken out, and the cage is put into the same space. The cage gives the spine a strong support while fusion occurs. As with any new treatment, different cage designs are being tested.

The success of the fusion depends on the bone graft. Bits and pieces of bone are placed inside the cage. New bone growth around the area requires bleeding bone next to the graft. Usually the endplate is removed to get to the bleeding bone. The endplate is a flat piece of cartilage between the disc and the vertebral bone. The endplate keeps the disc tissue from pushing into the vertebral bone. It also keeps the bone away from the bone-filled cage. How important is the endplate? If it’s removed, will it put the cage at risk for failure?

This is the subject of a study by scientists in Switzerland. They inserted cages between the vertebrae of cadavers (spines saved after death for study). They measured the strength of the endplate and changes in the load on the endplate with cage insertion.

They used two different models of endplates. One was “soft” and equal to having part of the middle of the endplate taken out. The second model was a “hard” endplate with the center of the endplate equal in strength to the outer ring. The soft endplate mimics conditions when the endplate is removed. The hard endplate is more like the normal, live human endplate.

They found less stress on the bone when harder endplates are used. Increasing the stiffness of the endplate shifts the load to the center of the vertebral bone. Overall stress on the bone is less with a stiffer endplate.

The authors also report that cage insertion affects the bone more than changing the endplates. And they found that the strength of the place where the bone and cage come together is also affected by the condition of the bone.

Two common problems leading to cage failure are endplate fracture and the cage’s sinking into the bone. Based on the results of this study, these researchers suggest making a cage that doesn’t put pressure on the center of the endplate or bone. Contact should be with the outer edge or ring of the endplate. This design would also allow for more contact between the graft and bleeding bone in the middle.

Finally, doctors should check to make sure the bone is strong enough to support the load. This is important with the changes in load transfer that occur when the cage is inserted and before the fusion is complete.

Low back pain is a common problem as people age. There are probably many causes of back pain in middle-aged and older adults. These authors studied how bone mineral density (BMD) relates to low back pain in middle-aged women.

The study looked at BMD and low back pain in more than 2,000 women in Japan. BMD was measured in the forearm. These measurements have been shown to be related to BMD in the spine. The women also answered questions about their health, back pain, and habits. As expected, the women had more low back pain as they got older. The authors found that smoking and lack of exercise were linked to low back pain. These findings support other research.

The authors also found that high BMD was related to low back pain. That’s right, high BMD. Women with especially dense, strong bones were more likely to have low back pain. Women are used to hearing about the dangers of osteoporosis, which is a condition of very low BMD. It seems impossible that bones could be too strong! But this study suggests that might be true.

The authors say high BMD may make bones stiffer. Stiff bones may not be a problem in most parts of the body. But in the spine, stiff bones could put more force on the cartilage and soft tissues. This could explain why these women had more low back pain.

The authors say that more in-depth research is needed to prove a link between high BMD and back pain. They think that more attention should be paid to high BMD. The authors say that the healthiest levels of BMD need to be found. Doctors could then help their patients avoid both osteoporosis and low back pain.

Doctors and therapists have very little success finding an exact cause for many patients’ back pain. Without a known cause of pain and dysfunction, everyone gets lumped into one big group. Finding the right treatment is a challenge without a clear diagnosis.

Some researchers think patients with low back pain can be put into subgroups. One of those groups is called lumbar segmental instability (LSI). Each spinal segment has an ideal amount of passive and active motion. With LSI the spine doesn’t move within this range. Active motion comes from the spinal muscles. Passive movement is supplied by the elastic stretching of discs, ligaments, and joints. Too much motion at any segment can cause extra wear and tear, pain and deformity, or pressure on the spinal nerves.

Patients with LSI may get better with a specific rehab program. Therapists think it’s a good idea to identify these patients early on. In this study, physical therapists checked how reliable tests are for LSI when more than one person does the test. A reliable test means the same response is seen no matter who does the test. And the same result is observed each time the test is given.

Tests included trunk motion, joint laxity, and two special tests: the posterior shear and prone instability tests. The therapists also looked at segmental mobility testing. They rated each patient as normal, hypomobile (too little motion), or hypermobile (too much motion).

They found ligament testing and the prone instability test were the most reliable for LSI. Observing trunk motion was also a reliable test. The posterior shear test had fair reliability. Segmental mobility testing had the poorest reliability. The authors suggest reasons for the poor results with segmental mobility testing. They think it may be due to how hard it is to know what lumbar level is being tested. Lack of training in conducting the test may also be a factor.

The authors conclude that therapists can expect to get similar results every time when using the three most reliable tests for LSI. They say the next step is to look for tests that are valid, meaning that the test really shows if LSI is (or isn’t) present.

Surgery to fuse the lumbar spine is changing all the time. Early operations made a long cut from behind to open the back (posterior approach). There are problems with this method. The spinal cord or spinal nerves can get damaged. Scar tissue can wrap itself around the nerve tissue, causing chronic pain. The muscles on either side of the backbone can be injured, too.

Today the operation can be done from the front of the body. This is called an anterior approach. The disc is removed and an implant or cage is put between the two vertebrae. This operation is called an anterior lumbar interbody fusion, or ALIF. It avoids the problems with the posterior approach.

Now doctors are using a laparoscope to do this surgery. This tool allows them to enter the body with one puncture hole. The doctor can fuse the spine without cutting open the body. The authors of this study report the results of ALIF using the standard mini- open operation versus the newer, laparoscopic method. They want to know if there’s any real advantage to the laparoscopic method.

A few other studies have looked at the results of laparoscopic ALIF. Only a small number of patients were included over a short amount of time. In this study, 54 patients were followed for two years. Everyone had a fusion of the L5/S1 level. One group had the mini- open fusion with a five-centimeter incision. The laparoscopic group had one puncture near the belly button.

The authors report no difference in pain levels between the two methods. Patients in both groups were equally satisfied with the results. The same number of problems occurred after the operation in both groups.

The laparoscopic ALIF is a more difficult operation. Since it doesn’t give better results, the authors wonder if it’s worth using. Advanced technology makes the laparoscopic ALIF possible. It’s not necessarily better than the open-mini method. More study is needed in this area to guide physicians in making this decision.

When a doctor treats a patient with low back pain, there are two main goals: control pain now, and prevent chronic pain. We know from research that most episodes of back pain go away in six weeks. We also know back pain returns for many people.

Guidelines on assessing and treating back pain are available. National groups put these out after reviewing all the studies on the subject. In the United States, the Agency for Health Care Policy and Research (AHCPR) has issued such guidelines. In Europe the Royal College of General Practitioners has offered similar advice.

How do most doctors handle back pain patients? DO they do it “by the book”? According to this study, doctors in Spain may not be doing such a good job following the guidelines.

The guidelines point out how important the history and exam are in making a correct diagnosis. These steps are initially more important than X-rays or other tests. Yet, in this study, doctors spent less than 10 minutes with each patient. With so little time, they may have gotten important information, but didn’t write it down. X-rays weren’t used as often as they should be. The guidelines suggest ordering X-rays for back pain in adults over 50 with signs of fracture, infection, or cancer.

Patients are given advice and education, but it may be the wrong kind. Studies show patients get better faster when told back pain usually goes away in a short time no matter what treatment is used. Giving patients advice about what to do works better than talking about anatomy, posture, or giving specific exercises.

These authors conclude that most patients aren’t given an exam according to published guidelines. They think if doctors aren’t following the guidelines then something must be done to change this practice. Perhaps finding out why some doctors don’t follow guidelines will help us change this. Clearly the situation must be improved.

There’s a well-known way to surgically treat chronic low back pain caused by disc degeneration–spinal fusion. In recent years, doctors have used titanium cages as part of the fusion process. The disc material is removed, and the cage is inserted between the two vertebral bones. The cage keeps the same disc height and gives the spine balance and support.

The cages can be inserted from the front of the spine. This is called anterior lumbar interbody fusion (ALIF). When inserted from the back, it’s called a posterior lumbar interbody fusion (PLIF).

There are problems with both methods. For example the success rate with the ALIF varies too much. The PLIF may not work if the disc itself is the cause of pain. Doctors are trying to find ways to overcome these problems. A new titanium cage has been designed with these issues in mind. It’s horseshoe-shaped and held in place with screws. The cage is also filled with bits of bone to form a bone graft for better fusion.

In this study, doctors in England compared the ALIF with the PLIF using the horseshoe-shape cage. Before the operation each patient had X-rays, MRIs, and a discography. During discography, fluid is injected into the disc to see if the disc is the source of pain. The results after surgery were measured by changes in imaging, back pain, and work capacity. All patients were active at work.

The authors report no difference in the overall results between ALIF and PLIF using the horseshoe cage. Measures included function, return to work, compensation rate, and disability benefit. Problems after the operation were about the same in the two groups.

These researchers conclude that the horseshoe cage can be used with good results for lumbar fusion. Either approach (ALIF or PLIF) can be used with equal success. There were no failures and a good fusion rate for both methods.

What we don’t know about back pain could fill volumes. Back pain of unknown cause can be acute (lasting up to three weeks), subacute (four to 12 weeks), or chronic (lasting more than three months). Our understanding and treatment of back pain is based on these three groupings.

Studies have shown that some factors can predict absence from work after an acute episode of low back pain. Knowing what factors predict recovery from chronic back pain would also be helpful. Right now, it’s still a mystery. These researchers in Finland are trying to help solve it.

Doctors from the Department of Occupational Medicine recruited 164 adult workers with disabling back pain for this study. All subjects had subacute back pain. The workers were put in one of three different study groups.

Everyone answered questions about sick leave, pain levels, and quality of life. They also told the researchers about their overall satisfaction with medical care. Cost of health care visits was calculated. This included visits to the doctor, nurse, or physical therapist, as well as drugs, hospital care, and X-rays and other imaging studies.

Here’s what they found:

There isn’t a “best” rehabilitation program for lumbar spinal fusion patients. Different clinics use different programs. And none of the programs has been shown to work especially well. Two years after surgery, as many as 40 percent of lumbar fusion patients aren’t much better.

These authors tested three different types of rehab programs for lumbar fusion patients. The 90 patients were divided into three groups. The training group had intense physical therapy twice a week for eight weeks. Therapy included muscle training, overall conditioning, and stretching. The video group watched a video of rehab exercises. They went through the exercises with a physical therapist one time. They were then told to exercise at home. The “back café” group did everything the video group did. But the back café group also met with a physical therapist and other lumbar fusion patients. The café groups met only three times over eight weeks. The meetings were casual. The group talked over a cup of coffee or tea about whatever subjects they wanted. They also got to ask the therapist questions.

All three groups were followed for two years. All groups were checked six months, one year, and two years after surgery. Researchers looked at back and leg pain, activities, and function. All three groups got better after surgery. And all three groups looked about the same early on.

However, two years later there were remarkable differences in the back café participants:

“Fear of pain and what we do about it may be more disabling than the pain itself.” This is a quote by a well-known doctor and researcher, Gordon Waddell. Dr. Waddell studies pain, especially back pain. His idea helps explain why some people with low back pain get better while others get worse.

Studies show that a person’s fear of pain is the most important factor in how he or she responds to low back pain. Fear of pain commonly leads to avoiding physical activity. Physical therapists often treat patients with back pain. Perhaps physical therapy treatment can be used to reduce the fear and avoidance behaviors that occur in some patients.

In this study, 66 first-time back pain patients were divided into two groups. The first group got standard back care. The second group had fear-avoidance physical therapy. Before treatment started, each patient answered some questions. Pain levels, disability, and fear-avoidance beliefs were included in the questions. These same measures were looked at again one month and six months after treatment.

Standard care included reading a pamphlet with information about spine anatomy and what can go wrong. Patients were given a home program of exercises. The therapist kept a log showing how often and what exercises were done.

Fear-avoidance care also included reading a pamphlet. This booklet encouraged the patient to take an active role in rehab and recovery. Anatomy was not the focus. Back pain was presented as a common problem, not a serious disease. The patients in this group received exercises, too. However, the exercises were started slowly and gradually increased in number and intensity. They did these at home and kept a log, just like the other group.

Results from this study confirm Dr. Waddell’s statement. The amount of disability patients had after one month and six months was linked to the level of fear-avoidance. Only the patients with fearful beliefs improved with the fear-avoidance physical therapy.

The authors conclude that back pain patients should be screened before treatment begins. If they show signs of fear-avoidance beliefs, then fear-avoidance treatment is advised. All other patients do just as well with standard care. Patients who don’t have fear- avoidance beliefs aren’t helped and may actually be hindered by the fear-avoidance treatment.

Heat can be used to treat chronic low back pain (LBP). But it’s not in the form of a hot pack or hot tub. Electrical signals are used to heat the nerve tissues enough to damage some or all of the nerve fibers. The goal is to block pain messages traveling from the painful area to the brain. This form of treatment is called radiofrequency (RF).

Lately there’s been some question about the use of RF for LBP. Some studies report short- term pain relief only lasting four weeks. Other studies show better results with pain relief for years afterward. Researchers in Israel studied the results of RF in 122 patients with back pain located anywhere in the spine from the neck down to the low back.

RF was applied to the spinal nerves according to the location of the pain. An instrument with a heat probe on the end was inserted under local anesthesia. The doctor used fluoroscopic X-rays to guide the probe. The nerve tissue was heated up to 175 degrees for 60 to 90 seconds.

Patients were followed for one year after the treatment. Four weeks later, three-fourths of all patients had a big improvement in their pain. They still had the same good results three months later. By six months, two-thirds of the patients still reported relief of pain. They continued to have good pain control at the end of one year.

The authors conclude that RF doesn’t seem to work better in one area than another. All levels of back pain (neck, midback, or low back) were affected equally. The results of this study suggest RF is safe for use, but may only give relief to some patients. It doesn’t work for everyone. They advise using it for patients who have not been helped by other treatments such as drugs, rest, and exercise.

Steroids are powerful anti-inflammatory drugs. They are sometimes used to help ease inflammation after surgery. Earlier studies have shown that steroids may help patients who have spinal discs removed. The steroids seem to work by controlling swelling and limiting the growth of scar tissue.

These authors tested how well steroids work during disc surgery. Eighty patients were divided into two groups. All patients had lumbar disc herniations. All had surgery to remove the problem discs. The first group had extra steroids during surgery. Steroids were given through an IV line and by injection into the muscles. Tissues soaked in steroids were also placed on the area before stitching it up. The second group had the usual surgery, without large doses of steroids.

All patients were followed for two years. Researchers looked at patients’ recovery time, pain levels, function, and return to work. Both groups got better. However, the steroid group had better outcomes. On average, the steroid group had shorter hospital stays. They returned to full-time work earlier. They also had lower pain levels and better function. These good results lasted over the two years of the study.

They authors saw no side effects from the steroids. Steroids can have bad side effects when taken long-term. But a one-time dose doesn’t seem to cause lasting problems. The authors conclude that steroids given during disc removal surgery improve the results.

You may have heard of extreme sports. But have you ever hear of “extreme disc herniation?” That’s a term used to describe a condition called extraforaminal lumbar herniation (EHL). Extra means outside, and foramen is a hole or opening. EHL refers to disc herniation in the lower spine that occurs in a spot just beyond where the spinal nerve goes through the opening in the bone.

Most disc herniations press against the nerve root before it leaves the foramen. Only about four percent of the patients with disc problems have EHL. Most of them occur at certain spots in the spine.
Surgeons who remove the disc fragment must pay attention to both the foramen and the herniation. The problem disc is located above the nerve it’s pressing on. Doctors try to avoid removing bone from the vertebra. Loss of bone can cause the spine to become unstable.

These researchers in Italy report on their method for removing the disc without removing the bone or damaging nearby soft tissues. They use a tool with binocular magnification lenses. Another device called a retractor helps them move muscle aside without cutting it. This approach helps the surgeon operate in such a small space. The extraforaminal piece of disc is easily removed. Patients in this study all had good results. Most symptoms went away right away and everyone returned to work without any nerve pain. There were a few cases of persisting mild low backache.

In this report, the doctors carefully describe the steps they took in completing the surgery. They give the exact location of bone, joint, ligament, and muscle involved. The surgeon must move carefully between nerve and blood vessels to avoid damage there as well. Other doctors will find this helpful information when faced with a patient who has EHL. Knowing where and how to enter to get to the site is the key to this operation.