News Category: Lumbar Spine

Aging isn’t always kind to us. Degeneration of the discs and vertebrae in the spine is all too common. Pain and loss of motion can limit function. Spinal fusion may be needed.

Spinal fusion at one or more levels restores alignment and stops motion at those levels. One new way to fuse the spine is with interbody fusion cages. These cages are often made of titanium, graphite, or bone and look like spiral-shaped barrels. They fit between the vertebrae where the disc used to be.

The surgeon can go in from the front of the body, remove the disc, and insert the cage. In this study a special “stand-alone” interbody cage was tested. These cages don’t need extra screws or metal plates to hold them in place.

The purpose of the study was to see what happens when the cages were subjected to an outside load. This kind of load or force occurs with muscle contraction. Increased force is also caused by the lifted position of the spine when the cages are in place. With greater distraction, the spinal joints are more open, allowing motion to take place when it shouldn’t. This puts more load on the fusion, too.

The results show that the stand-alone interbody fusion cages don’t limit spinal extension under low loads. This means the spine is not stable right away after surgery. The stability increases with increasing loads.

Lying down on the back is one example of a low load. Larger loads occur with standing and walking. The authors suggest anterior stand-alone cages may not be stable enough. Bone graft, metal plating, or extra screws may be needed to get a good enough fusion in the beginning. The authors predict greater stability will occur as the cages settle into the vertebrae.

A bout of low back pain (LBP) can start a vicious cycle. Fear of pain and further injury can make people avoid activity. Avoiding activity can make people depressed. It can also make the pain last longer. More depression and pain can lead to even more fear. And so the cycle goes around again.

It has been assumed that the cycle of fear and LBP leads to disability and low levels of fitness. This Dutch study tested patients with chronic LBP to see if that is true. Patients answered questions to rate their fear, depression, and disability levels. Their aerobic fitness and body fat percentages were tested. The authors then looked for relationships between fear levels, fitness, and disability.

There were some interesting results:

Don’t expect miracles with your spinal fusion. The goal is to get rid of pain, but the result is more often just pain reduction. This study shows a high rate of pain, even five years later.

Researchers used a series of questions and a pain drawing. They mailed them to patients who had lumbar spinal fusion. Patients drew their pain location and pain types on a figure of a human body (front and back, including feet).

The results were the same whether the patient had bone graft alone or bone graft and screws. Screws are used to keep the bones from moving while the graft heals. The authors report that women in the study were less likely to return to work and more likely to show signs of psychologic distress.

Only 21 percent of the patients surveyed were without pain. This means 79 percent reported some low back pain. Almost as many (69 percent) had some kind of leg pain, too. Ten to 15 percent complained of pain at the donor graft site (pelvic bone).

The authors conclude that only one in five patients who had lumbar spinal fusion were pain-free five years later. Pain drawings and questions about work, social status, smoking status, and function were reliable measures of outcome.

Scientists are working their way through a puzzling maze of information about bone fusions. A common place for bone fusion is in the spine. A common problem is fusion failure, when spinal movement happens where the fusion should be solid. Movement at a fusion site is called pseudoarthrosis.

Fusion has changed step-by-step as researchers find out more and more. We know that bone healing is delayed by smoking, diabetes, rheumatoid arthritis, and long-term use of some drugs. We know that using your own bone for the graft usually gives a better fusion result.

A new area of study centers on growth factor (GF) found in the platelets of the blood. GF increases bone growth. In fact, scientists found that GFs make more GFs. More GFs means more bone cells. Autologous GFs (AGFs) means your own GFs are used rather than GF from someone else.

Some studies are looking at what happens when AGFs are put right on the bone fusion. Other researchers are trying AGF with bone grafts. In this study AGF was used to enhance bone growth when fusion was done with a newer way of fusing the spine.

The newer procedure is called transforaminal lumbar interbody fusion (TLIF). TLIF with AGF is done by removing the disc from between two vertebral bones. Then bone chips taken from the patient’s pelvic bone and AGF, are packed into the front third of the empty disc space. A titanium mesh cage is placed behind the bone chips. The cage is filled with pieces of bone graft. Bone graft is added around the back half of the fusion site. Screws are then placed along the back of the spine.

Spinal fusion rate was 96 percent in the patients who had TLIF with AGF. Patients who had only one level fused had 100 percent fusion success. Patients with a two-level fusion had 90 percent success. The result of TLIF with AGF was compared to a group without AGF. The bone healed faster in the AGF group, but the pseudoarthrosis rate was the same. This means that spinal fusion is faster (occurs within the first six months) but not better with AGF. The authors conclude that more studies are needed before AGF is used for every spinal fusion.

When a disc in your spine thins out, the joints are affected, too. The small joints on each side of the back of the spine are called facet joints.

Degenerative disc disease causes a loss of disc height. The facet joints actually change shape. Decreased disc height leads to increased rotation in the spine. The load gets transferred to the facet joints. Increased motion at the joint from loss of disc height affects the joint capsule, too. The fibrous capsule changes to try to protect the joint.

The authors of this study took a look at the chemistry behind these changes. They studied the entire facet joint in 14 patients. Each patient had a spinal fusion with removal of the joint. The authors noticed that changes in the facet joints are often greater on one side than the other. The cartilage lining the joint and the capsule around the joint are also changed. The cartilage is worn away or cracked and fissured.

They also noted certain types of changes in the capsule. The capsule was hypertrophied, or increased in size. In this way, the capsule limits the increased rotational forces that occur with loss of disc height. Bone spurs form around the joint. This changes the joint shape even more and limits joint motion.

The authors conclude that damage to the joint occurs only after the capsule changes. Early signs of capsule changes might alert doctors to upcoming joint changes. In the future, CT or MRI imaging may help point out these early changes in time to do something about them.

The fusion dilemma: Fusing a part of the spine often gives immediate pain relief. But is it worth it if you end up needing another fusion later? There’s some debate over whether fusion at one level causes increased stress and load above and below the fusion. This can cause many problems, which the author of this study calls adjacent motion segment alterations (AMSAs).

AMSAs include dehydration of the disc, disc space narrowing, bone spurs, ligament bulging, and changes in alignment of the spine. But how often do AMSAs really happen? That’s the focus of this study from the University Hospital in Belgium.

Only patients with degenerative conditions of the spine were included. Everyone was fused for a minimum of five years. Some patients were in the study for up to 15 years. Besides having only one type of back condition, all patients were treated with spinal fusion by the same doctor.

The author found that the longer a patient has had the fusion, the greater the chance for AMSAs. After five years, the number of patients with AMSAs jumped from 29 to 41 percent. Reoperation was needed more often when the spine was fused at three or four levels (instead of just one or two levels).

Other risk factors may be linked to AMSAs, including age and obesity. Heavy work after fusion is a risk factor even in young patients with fusions at only one or two levels. AMSAs are less likely when the patient has a partial fusion or single-level fusion.

The results of this study point out the need to rethink spinal fusion for degenerative disc disease. More than one-third of the patients developed AMSAs, and half of those ended up having more surgery. The author of this study concludes that more research is needed to find better treatment options.

Spinal fusion may be moving over to make way for a new method of steadying the spine. When degenerative discs and aging bones cause chronic back pain, replacement parts may be the up and coming thing.

Artificial discs are now on the market. Replacing the discs with bone-filled cages is another new option. Cages with bone graft or metal plate is an example of an internal fixator. The nonfusion DYNESYS® Spinal System is used to stabilize one or more segments of the spine. Unlike the internal fixator, this new system restores spinal motion but leaves the discs and joints in place.

Researchers in Germany and Switzerland studied the internal fixator and the DYNESYS® system. The study was done on six cadavers (bodies preserved for study). The internal fixator and the nonfusion system were both tested in three planes of motion: bending forward and backward, bending side to side, and turning left to right. The results were compared to a healthy spine with normal motion. The researchers found that the DYNESYS® gave the spine more flexibility than the internal fixator. Still, the flexibility given by both systems is much less than the normal, healthy spine.

The researchers suggest that systems like DYNESYS® may give doctors another way to treat patients with chronic back pain. The device is implanted along both sides of the spine. It has screws, cords, and spacers. Such a nonfusion system provides the needed stability without losing all the motion.

More testing of this system is needed, with different loads placed on the spine. Applying a force like that of the muscles is one area for research. Finding a system that gives full stability and full motion is another area of study.

Whenever a new medical device comes on the market, doctors want to know when it can be used and what the results might be. Doctors in China are trying to answer these questions for the new prosthetic disc nucleus (PDN). The PDN replaces the inner portion of the disc (the nucleus), but it leaves the outer ring (annulus) intact. Disc herniation and degeneration are the two biggest reasons to use the PDN.

The PDN is made of a hydrogel core that absorbs fluid just like a real disc. Once it’s inserted into the disc space, it expands. This lifts the vertebral bone, giving normal disc height. The implant gives patients good pain relief. Increasing the space between the bones takes the pressure off the spinal nerve root.

Researchers have been looking for a way to replace the discs with an artificial device for years. The first attempt was made in 1966 in Europe. The new PDN design was invented by Charles D. Ray of Germany in 1991. The authors of this study report that inserting the new PDN is a fairly simple operation. This is especially true when compared with spinal fusion or using a total artificial disc. They advise using it for single disc replacement.

They found that the PDN seems to work best for early, painful disc problems in the low back. Other treatment should be tried first, such as drugs, rest, and exercise. Anyone with a fracture, damaged joints, or disc space that’s too narrow isn’t a good candidate for the PDN. The annulus must be in good condition, too.

Most patients in this study had pain relief. X-rays show normal disc height with the PDN. Patients had good spinal motion and could return to work. When only a single PDN was implanted, no problems occured with shifting of the implant.

Are you confused by the terms “manual therapy,” “soft tissue mobilization,” or “spinal manipulative therapy?” Doctors Swenson and Haldeman have taken the time in this report to define and describe each one of these treatments. They also looked at the research on spinal manipulative therapy (SMT). SMT is divided into three types of treatment offered by a chiropractor, osteopath or other medical doctor, or physical therapist.

Massage, mobilization, and manipulation (adjustments) make up the three broad groups of SMT. Massage is applied to the soft tissues around the spine. No joint motion occurs. Deep tissue massage, acupressure, muscle stimulation, and relaxation methods are all part of massage.

Mobilization stretches or puts pressure on the spine. This is done within the joints’ active range of motion. The joints, ligaments, and muscles are moved slowly. A regular rate of rhythm is usually used. Massage and mobilization help get the patient ready for manipulation.

Manipulation puts a sudden and quick force on one or more joints. There are several different types of manipulations. The type depends on where the force is applied and what position the patient is in.

The authors of this study review the theory for and uses of SMT. They conclude that studies show SMT is a common and safe therapy for low back pain. It’s best used with new episodes of low back pain. Consumer demand for SMT has made it a part of standard medical treatment in many areas of the United States. Medicare, HMO plans, and most health insurance now cover SMT in their plans.

Removing disc material from between two spine bones is not always easy. Doctors want to get in and out without damaging any of the nearby nerve tissue or blood vessels. Only so much disc material can be taken out when the surgery is done from one side of the spine. (Unilateral is the term for doing surgery on one side.) Can enough disc material be removed for a successful operation?

A new method of lumbar fusion that is quickly becoming popular is transforaminal lumbar interbody fusion (TLIF). TLIF can be done unilaterally. Only a small opening is needed to do the operation. Surgical tools are worked through the opening into the disc space. The surgeon must then remove enough disc material to implant a fusion cage filled with bone graft. (A fusion cage is a small device that goes into the disc space to help fuse together the bones just above and below it.)

With the disc out of the way, there’s more bone-to-bone contact between the two vertebrae. This is where the fusion is to take place. Scientists know that at least 30 percent of bone-to-bone area is needed for the fusion to support downward pressure on the spine.

The authors of this study wanted to find out just how much of the disc can be removed during unilateral TLIF. They also wanted to know whether it’s enough to get the bones to fuse. Doctors worked from one side of the spine and took out as much disc material as they could. The amount was measured. Additional disc material was then taken out by entering the spine from the other side. The researchers found that more than enough disc material could be removed by working only from one side. In fact, nearly twice as much area was made available in the disc space to get a good fusion.

For people facing lumbar spine fusion, this is good news. Doing surgery from only one side means that fewer muscles and nerves need to be moved around during the operation. This means fewer problems and faster healing.

This study raises another question these researchers want answered. Does unilateral TLIF create enough area for the fusion to stay solid during all other types of loads that impact the spine?

Spinal fusion is an important treatment for low back pain. Many studies have been done since the 1950s on how to do this operation. Today there are many different ways to fuse the spine — and many opinions about the results. Doctors don’t always agree on the best way to fuse the lumbar spine.

Researchers haven’t given up on studying spinal fusions. This study was done in the military. Thirty-five men with disc disease at one level in their low back were chosen. The problem disc was removed, and bone graft was placed in all patients. The bone graft was first put inside a fusion cage. Surgeons implant the cage into the disc space between the two vertebrae where the disc is removed. This makes it an interbody fusion (one that occurs “between two vertebral bodies”). When the surgeon does this surgery from the back of the spine, the operation is called posterior lumbar interbody fusion (PLIF).

One group received a single fusion cage; the other group got two cages. Fusion cages are usually made of bone, titanium, or graphite. They help hold the two spine bones apart while the bone graft fuses. The cage also helps distribute the load on the spine.

The authors wanted to know whether one or two cages work best for PLIF operations. Results of this study were based on patient satisfaction, pain levels, and function. X-rays were also used to measure the fusion. There were no differences in length of hospital stay between the two groups. Complications were about the same, and no one had a deep infection after the operation. Four of the 35 patients had a tear of the lining around the spinal cord. Three of these four were in the two-cage group. Both groups had increased function after the fusion. Pain was decreased the same in both groups. Patients were equally satisfied whether one or two cages were implanted.

The authors conclude that there is no difference in results with PLIF using one or two fusion cages. Using only one cage is less expensive and involves fewer dural tears. The authors say to keep in mind, that this is a small study. The results are only a beginning in the quest to know which choice is best — one cage or two.

Have you ever hurt your back (maybe even had back surgery)? Were you afraid to move afterwards? Perhaps afraid you’ll reinjure your back? Fear of movement is a real problem after back injury and surgery for disc problems. A rehabilitation program might help.

The problem is that not much is known about exercise and rehab programs after lumbar disc surgery. Do they work? A group of physical therapists from the Netherlands did this study to measure the effect of treatment on fear of movement.

The researchers also looked at “catastrophizing” pain (making it seem worse than it is). Two types of treatment were compared: usual physical therapy care, and behavioral graded activity (BGA). Only patients having their first lumbar disc surgery were included in the study.

Usual physical therapy included exercise training, instructions for lifting, massage or soft tissue mobilization, and electrotherapy. BGA gives patients positive feedback for trying and completing activities. The exercise starts slowly and gradually builds up in time and intensity.

Patients were checked six months after surgery and again at one year. The researchers found no difference between the two groups. They had the same motion, strength, pain, and function.

The authors thought BGA would decrease patients’ fear of movement and pain, allowing them to recover faster. The authors also thought the patients would have improved function after BGA.

These predictions were based on how patients with chronic back pain respond to BGA. Since the results weren’t the same, the researchers suggest that patients having lumbar disc surgery are different from chronic back pain patients.

What are the opinions and practices of osteopathic doctors about the treatment of disc problems? Do they use the common straight leg raise (SLR) test to diagnose disc herniation? Does the result of the SLR figure into their treatment decisions?

These questions were asked in this study. A survey was sent to all the registered osteopaths in the United Kingdom (a total of 1,030). About half the osteopaths returned the survey.

Everyone agreed about when and how to use the SLR test. Half the group said they use spinal manipulation for disc herniation. They said that putting a force on the spinal joint restores motion in the spine. The other half thinks this treatment is dangerous.

There’s a lot of debate and not much agreement on this point. Some say spinal motion can damage the disc. An already injured disc could be harmed even more during a manipulation. Others think manipulating a nearby segment is helpful and can be done without shocking the damaged disc.

The authors report common and correct use of the SLR test by osteopaths. Use of spinal manipulation for disc herniation isn’t so clear. They suggest another study to look at whether or not spinal manipulation should be done for lumbar disc herniation.

Chronic low back pain affects many adults in the United States every year. In fact, it’s the second most common cause for a visit to the family doctor. It’s the most common reason for treatment by an osteopath.

Osteopaths use spinal manipulation to treat back pain. The Agency for Healthcare Research and Quality agrees with spinal manipulation in the first month of low back pain. Many studies support the use of manipulation. Research shows the best effect comes with the first treatment.

Every group treating patients with low back pain wants to know if their method is working. This includes doctors, surgeons, osteopaths, physical therapists, acupuncturists, and chiropractors. This study was done by several osteopathic colleges and centers. It looks at the results of osteopathic manipulative treatment (OMT). The three patient groups studied include 1) OMT, 2) sham or pretend OMT, and 3) no treatment.

Osteopaths in this study looked at general health, back pain, patient response, and function. The results show equal results between osteopathic manipulation and sham treatment. Patients who had no treatment didn’t do as well.

The authors think the lack of difference between the group receiving osteopathic manipulation and the group getting sham treatment brings up questions about the effects of OMT. They suggest reasons why the results turned out this way. A larger study with doctors who have been osteopaths for a longer time is advised.

Most people know it’s better for their back to squat down than it is to bend (flex) over. Even so, most of us bend over to pick something up or to look in the refrigerator. Why? Because it’s easier. Why is it easier? Because of something called the flexion-relaxation phenomenon (FR).

FR is the pattern of muscle activity in the back when bending over. First the muscles contract. But when the spine reaches a certain point, the muscles relax. At this point (the FR point), there is no muscle effort. The back is using ligaments to hold the position. People find that it’s easier to hang on the ligaments than use active muscle control to hold a bent posture.

Scientists have known about FR since the early 1950s. They hope to find out enough about FR to use it during rehab for back injuries. This is the first study to show that people with chronic low back pain can get a normal FR back with treatment.

It turns out that full flexion motion of the low back occurs at FR. In this study patients who are work-disabled because of chronic back pain were tested for FR. The FR was compared to their range of motion measurements. All measures were taken before and after treatment.

The authors suggest that once a patient regains FR, rehab can move right into strength training and endurance. This will reduce costly and lengthy treatment programs. Suggestions were made for treatment to restore the FR. Doctors can also use FR in making decisions about disability ratings.

I don’t know what happiness is.
When I get a box of chocolate turtles, I’m happy.
When the turtles are all gone, I’m unhappy. (Katherine Hepburn)

Whatever happiness is, we know that it is linked to our general feelings of health and well-being. In this study, Japanese researchers tried to find out if low back pain is linked with happiness as well as function, general health, and social activities. They found some of these factors were linked to back pain. Some were linked to each other, but not to back pain directly.

The results of this study show that function is affected most by general health. Happiness and enjoying social events are closely linked to physical health. Since function is linked with how severe the back pain is, then general health must have an impact on back pain.

The authors also reported that a patient’s happiness is linked with health status. The authors suggest using happiness, general health, and social activities as measures of outcome for people with back pain. This may help predict who will get better after an episode of low back pain.

Physical therapists often treat patients with acute low back pain (LBP). Yet no one really knows what works best for this problem. According to the Agency for Health Care Policy and Research (AHCPR), watchful waiting is best in the first four to six weeks.

Using these guidelines, doctors and therapists give patients advice and assurance, but symptoms are not treated. Patients are told to stay as active as possible. Low-impact aerobics are okay but nothing stronger until after four weeks.

A physical therapist uses a new model of treatment for acute low back pain. Patients are classified by their symptoms. This guides the type of treatment that is given. This is a classification-based model. In contrast, treatment that is based on clinical practice guidelines (like those given by the AHCPR) is more like following a recipe. The treatment doesn’t vary over time or according to patient response.

The authors report greater patient satisfaction after four weeks using the classification-based method. Patients are also more likely to return to full-duty work. After one year, this group showed a trend toward improved function.

The best timing and methods of treatment for patients with acute LBP remain unknown. Physical therapists are comparing current standards with treatments that target individual patients with specific symptoms. More research is needed to find the right exercise program for the first month after back pain begins.

Patients getting a spinal adjustment have come to expect a popping sound. But a study by a group of physical therapists reports that this popping is not necessary for a successful treatment

The popping or cracking sound that comes with a forced thrust at the joint may be caused by cavitation. Cavitation is an engineering term. It refers to the buildup and collapse of gas. Cracking the knuckles is an example of cavitation. However, scientists aren’t sure that the same thing happens when the knuckles are cracked as when the spine pops during manipulation.

Military therapists studied a group of patients between the ages of 18 and 60 who had low back pain. Each therapist had advanced training in spinal manipulation. Range of motion was measured before treatment and again two days later. There was no difference in motion between the group with a pop and the group without. Pain and disability levels were also unchanged. A pop occurred in about 70 percent of cases. The researchers aren’t sure where the popping sound came from.

It turns out there’s no link between a pop that can be heard and better spinal motion. Neither pain nor motion is affected by an audible pop during spinal manipulation. The authors conclude that health professionals who do spinal manipulation don’t have to depend on a popping sound when treating patients.

You’ve probably heard the saying, “They really put the screws to that guy.” That’s what happens to some patients with a lumbar spinal fusion. Pedicle screw fixation (PSF) is one way to help fuse the spine. The pedicle is a bridge of bone in the vertebral arch around the spinal cord. In PSF, screws go through the bone to hold it in place.

Doctors have used pedicle screws since the 1960s. The screws increase how stiff or rigid the spine is at that level. This study looks at the long-term results of fusion with PSF.

Why study this issue? Because PSF has used by many doctors for over 40 years with very little information about the results years later. There have also been questions about possible bone loss around the fused segment. This study reports results after 10 to 15 years for 94 adults who had fusing with PSF.

At least 80 percent of the patients were pleased with the results. Pain and physical function were used as measures of outcome. Doctors report a low rate of failure based on X-ray findings. They also say that improved function 10 years later in patients over 50 years of age is an impressive result.

The authors conclude that PSF is a good method to use when fusing the lumbar spine. Patients get better and have more function even many years later.

Scoliosis describes an irregular, sideways curve of the spine. The condition is most common in adolescent girls, but it can develop in adults too. There are two types of scoliosis that affect adults. Idiopathic scoliosis develops for no obvious reason. Degenerative lumbar scoliosis happens along with degenerative changes in the lower spine and its supporting tissues. This second type most often occurs in people older than 50. This author reviews the medical literature on degenerative lumbar scoliosis. The article is a good overview for anyone who wants to understand current medical thinking about the condition.

The research shows that degenerative lumbar scoliosis most often appears with three types of degenerative changes, in a different pattern than idiopathic scoliosis. The condition seems to have different causes in different patients, and patients have a wide variety of symptoms. Some people have no problems at all, while others develop extreme pain and disability. Most people are somewhere in the middle.

The author notes that degenerative lumbar scoliosis can be difficult to diagnose in a physical exam. X-rays or other imaging tests are needed to give a clear picture of the condition of the spine. The author also notes that doctors must tailor treatments for the individual’s symptoms, taking into account age and other medical conditions. The article lists the many nonsurgical treatment options, stressing the importance of regular exercise and detailing the drugs that can be helpful. The authors note that braces and physical therapy are useful only in some situations.

The author also summarizes the different surgical procedures that have proven effective in treating the symptoms of degenerative lumbar scoliosis. The author notes that, while surgery is often necessary, complication rates in studies range from 20 percent to 40 percent, and there is a high rate of revision surgery.