News Category: Lumbar Spine

More and more low back surgery for disc problems is done with microsurgery. In microsurgery, a small incision is made, and a surgical microscope is inserted. The doctor can do the operation with only a small amount of blood loss, and with little or no trauma to the skin and nearby muscles.

The authors of this study say that open disc surgery is still the most common operation and should be studied until it’s no longer being used. This kind of research helps doctors choose the right surgery for the right patients and reduce potential problems after surgery. No one wants to see a disc patient end up with ongoing and severe problems, a condition called failed back surgery syndrome.

This report offers doctors a list of possible problems and ways to prevent them during or after disc surgery. Suggestions are given for all stages of treatment, from before the operation until the patient goes home.

Right before you stand on one leg, your abdominal muscles tighten. Then the deep muscles of the low back contract to stiffen and protect the spine. The muscles and ligaments work together in the low back and pelvic area to hold them steady. Your body weight can now shift over to the standing leg.

The central nervous system controls the timing and pattern of muscle contraction for movements of this kind. The muscles squeeze and hold the joints of the pelvis together. This allows the load of your weight to be shifted between the spine and the legs. Everything must work in a certain order to allow smooth movement.

But what if a person has sacroiliac (SI) joint pain? Do the muscles still contract in the same order to keep the pelvis stable? Researchers compared muscle patterns in 14 men with SI pain to 14 men with no SI pain. Muscle patterns of the standing leg were measured as each man picked one leg up to bend the hip 90 degrees.

Researchers found a delay in abdominal, low back, and hip muscle contraction in the men with SI pain. At the same time, part of the hamstring muscle behind the thigh contracted early compared to men with no SI pain. These changes occurred on both sides, not just the side of the painful SI joint.

It’s helpful to know that changes occur in how and when low back, hip, and abdominal muscles contract with SI joint pain. The authors of this study conclude that further research is needed to find out if exercise can restore normal muscle patterns as a treatment for SI joint pain.

Many patients with low back pain have increased symptoms after sitting for a long time (30 to 60 minutes). One patient in 70 will tell the doctor, “My pain comes on as soon as I sit down, and it goes away when I stand up.”

Doctors in France may be the first to link this pain pattern with lumbar instability. Instability means that there is abnormally increased motion at one or more spinal levels.

Finding the level of instability isn’t easy. The doctor uses palpation (feeling with the hands and fingers) and X-rays or other imaging methods to decide where the instability is located. Two kinds of motion of the lumbar vertebrae were measured in this study: translation and rotation.

Translation is the sliding motion of one vertebra over another. Rotation is a twisting motion. An increase of 10 percent or more of translation motion is a sign of lumbar instability. Patients with instability also had twice as much rotation as the control group (who had no back pain).

This study shows that pain while sitting that goes away by standing is a sign of lumbar instability. The unstable motion can be sliding or twisting. It’s unknown if the higher level of motion causes pain or if pain causes increased motion.

The authors of this study say it’s easier to measure translation than rotation. X-rays to find lumbar instability should not be taken with the patient in the painful sitting position. The X-rays are harder to focus and may cause error in interpreting the results.

Treatment for lumbar instability starts with physical therapy. Special stabilizing exercises are used. Changes in posture are made for many patients. If this treatment fails, surgery to fuse the unstable segment may also be an option.

You bend over for an hour of gardening and you can hardly get back up. Then once you’re up, it’s all you can do to bend back down and pick up your gardening tools.

Most people recover after just an hour in lumbar flexion. But spend the day bent over, and you’ll probably have pain and muscle stiffness the next morning. And if you have a job to go back to day after day, you’re at risk for back injury and other musculoskeletal disorders (MSDs). Doctors and engineers at the Occupational Medicine Research Center in Louisiana are using cats to understand this problem. This study looks at the effect of constant loads on the ligaments and muscles of the low back.

The scientists used computers and EMG (electromyographic) studies to measure the electrical activity in muscles. The length of the ligament between two vertebral bones was also measured before and after static loading.

The results showed that muscle activity goes down and the ligaments lose tension with a constant load. Under these conditions the spine is unprotected, and injury can occur. The researchers report this happens at more than one level of the spine no matter how much load is used.

Even a short time in lumbar flexion can lead to MSDs. The ligaments stretch or “creep” in response to the load. The larger the load, the greater the creep. The authors report that creep occurs within 20 minutes of bending over. The spine doesn’t fully recover even after seven hours of rest. Work activities for farm hands, mechanics, and floor, brick, or carpet layers can cause long-lasting creep in the tissues.

Workers can lose the ability to get back the normal tissue length of ligaments, discs, and joint capsules. Inflammation may occur and become chronic. Based on these results, the authors suggest using anti-inflammatory drugs instead of muscle relaxants for muscle spasm and stiffness after being in one position too long.

Many workers in industrialized nations are now seated workers. More and more jobs involve doing tasks while sitting down. Back pain may be linked to seated postures. In particular, the flexed curve in the low back and static muscle load are two major risk factors for disc problems.

Studies estimate that about 100 million workdays are lost each year in the United States due to low back pain (LBP). This study reports the results of a back support that lowers the pressure on the spine. It helps keep the low back in the proper position during sitting.

The support is adjustable. The back part of the seat can be tilted down and the backrest adjusted. The seat height and depth can also be changed. Measurements of load, force, and pressure were taken with and without the support. The support was tested on office workers with no previous history of LBP.

The authors report that the new seating device shifts the weight off the sit-bones (called ischial tuberosities) onto the thighs. With the seat tilted down, muscle activity is lower–especially in the low back area.

The load on the low back is maximally reduced when support is given to the low back curve and when pressure is off the ischial tuberosities. Using this new seating concept may help prevent problems of LBP. For patients with limited motion, changing body position is still the only way to change pressure on the buttocks.

Many muscles move the spine and help keep it stable. Researchers know that patients who have low back pain (LBP) often have problems in the muscles that work the spine. But do the muscle problems cause LBP, or does the pain and inactivity of LBP cause problems in the muscles? The answer may be different in different patients.

In this small study, researchers tested the effects of back strengthening exercises on patients with LBP. All patients had the size and density of the muscles around the spine measured. They also answered questions about pain and about what activities they avoided because of their pain. Then one group of patients was given specific exercises. In two to three one-hour sessions a week, these patients worked to strengthen thigh, back, and abdominal muscles, including some of the deep muscles that stabilize the spine. The control group did no special exercises.

After 15 weeks, the muscle size and density tests were repeated. Muscle differences were seen at a specific level of the lower spine (between the fourth and fifth lumbar segment, L4 and L5). The exercise group showed an increase in muscle, while the control group actually lost muscle in that area. The exercise group also scored better on pain and lifestyle questions than the control group. However, the researchers were surprised to find that the exercise group and the control group still scored about the same on strength tests.

The authors note that this study was limited by the small number of patients who took part. They also question whether the exercises were actually related to the decrease in pain and the increase in function in the exercise group. More research is needed to figure out exactly what kinds of rehabilitation help patients with LBP.

Back pain from spondylolysis can keep an athlete out of the game or sport. Spondylolysis is a defect in the pars interarticularis (pars) in the spine.

The pars is an area in the protective bony ring on the back of the spinal column. There is one pars on the left, and one on the right of each vertebra. A bony defect in the pars can actually create a separation in the bone. If the condition happens on both sides of the bony ring, the vertebra can slip forward over the one below it. This slippage is called spondylolisthesis.

Treatment with bracing and rest works for most people with spondylolysis. If treated early, many of these fractures will heal. However, young athletes with chronic pain from spondylolysis may have to quit sports.

This study presents the results of a new surgical treatment for spondylolysis. Bits and pieces of shaved bone are placed at the fracture site. This is called a bone graft. A wire is then tied around the broken bone. Patients wear a hard back brace called a lumbar orthosis for three months after surgery. Jogging is allowed at six months, and by 12 months the athlete is back to full sports activity. All the patients had complete healing of the pars. They were able to return to sports, although not everyone went back to the previous level of activity.

Not all athletes with spondylolysis can have this operation. Patients must be under 40 years of age. The spondylolysis must not have created a slip of the vertebrae (spondylolisthesis) greater than 25 percent, and there can be no nerve root irritation. Finally, the site of bone wiring must be large enough to pass a wire through.

Segmental wiring of the spine can get an athlete back to sports sooner. The authors think that if there’s a solid bone union, contact or collision sports can be allowed after this form of treatment in the patient with spondylolysis.

Point

Most people know what drugs to take for back pain: anti-inflammatory medicines such as ibuprofen. Ibuprofen and many other over-the-counter and prescription anti-inflammatories are known as NSAIDs (non-steroidal anti-inflammatory drugs). COX-2 inhibitors are a relatively new class of NSAIDs. They work by blocking the COX-2 enzyme, which triggers pain, inflammation, and fever. One of the benefits of COX-2 inhibitors is that they tend to have fewer effects on the digestive system than other NSAIDs.

These authors tested a specific COX-2 inhibitor in patients with long-term low back pain (LBP). Almost 700 patients, who had LBP for an average of 12 years, reported their levels of back pain and function. They were then divided into three groups. The first group got a standard dose of the drug, the second group got double that dose, and the third group got a placebo pill. Everyone the medication once a day in the morning.

After one month, all the patients were retested. Both COX-2 groups had significantly less pain than the placebo group. They also showed better back function. There were no significant side effects, although patients on the smaller dose had fewer problems. The authors conclude that this drug is very safe and effective at the lower dose for patients with long-term LBP.

Counterpoint

A doctor from the University of Washington wrote a commentary following the original article. He points out some limitations of the study. First, all the patients were already taking NSAIDs. That means the researchers already knew that NSAIDs helped these patients’ condition and that the side effects weren’t too bad for them. People who tried NSAIDs and either didn’t get pain relief or had bad side effects were automatically not part of this study. Testing COX-2 inhibitors in the general population of people with LBP would almost certainly show less success and more side effects.

Second, this was a “flare” study. That means that patients had to come off of medications they were already taking, which typically causes pain to flare up for awhile. Then the patients began taking the study drug. This makes the study drug seem to be especially effective because it relieves some of the worst symptoms patients have had for a long time.

The doctor also questions whether a one-month follow-up is enough in patients who have had LBP for an average of 12 years, and whether the pain relief was really good enough to consider making COX-2 inhibitors the treatment of choice.

The bottom line according to this doctor is that there need to be further studies of COX-2 inhibitors to really tell how well they work for all patients. He does not consider this article to be proof that this drug is a better treatment for patients with chronic LBP.

Researchers know that low back pain (LBP) is often linked with anxiety or depression. The relationship is especially strong in patients whose LBP doesn’t get better. No one is exactly sure how this relationship works. Does the pain and inactivity of LBP cause anxiety and depression? Or does anxiety and depression set patients up for low back pain? The answer probably depends on the patient. But either way, it has become clear that doctors and therapists must deal with the psychological distress associated with LBP in some patients.

These authors in England questioned more than 200 patients with recurring LBP who were referred for physical therapy. The authors used a standard survey for rating distress in LBP patients. They found that one-third of the patients showed significant signs of distress. And earlier research shows that these patients have three to four times as many poor outcomes after treatment as LBP patients who have lower levels of distress.

The authors conclude that all health care professionals, especially doctors and physical therapists, need to be aware of the psychological needs of their patients with LBP. Most importantly, health care workers then need to help their patients get the care they need to shake the blues–and their LBP.

How are low back muscles linked with the discs located between the vertebrae? This is a question researchers are eagerly studying. They would like to identify types of exercise that would help patients with herniated discs.

Discs between the bones in the spine have two parts: the nucleus in the center, and an outer ring called the annulus. If the nucleus pushes completely through the annulus, it is called a disc herniation.

Most patients with low back pain from disc herniation also have muscle atrophy (wasting) in the back muscles. Weak and atrophied spine muscles may put these patients at increased risk of overload and more back pain.

Surgery is one way to treat disc herniation. The operation may relieve painful symptoms, but it doesn’t always change atrophy of the muscles in the low back. Muscle atrophy and weakness can go on for months. The patient is often delayed in getting back to daily activities.

This study from the Nippon Medical School in Tokyo, Japan, focuses on one muscle group in the low back called the multifidus muscles. The primary job of this muscle group is to hold the spine steady during regular activities.

A small piece of the multifidus muscle was taken from both sides of the spine in 17 patients with disc herniations. The pieces of muscle were looked at under a microscope. The muscle cells were markedly different in the muscles examined on the same side as the disc herniation. Smaller fibers and changes in the shape of some muscle fibers were found. The researchers also checked the activity of the muscles using electromyography (EMG). The EMG changes were greatest in patients who showed the largest changes in the fibers of their multifidus muscles.

According to the authors, rehab exercises for lumber disc herniation should include tonic and dynamic exercises. During tonic exercises, the muscles contract at low level for a period of time. This builds muscle endurance. Dynamic exercises for the multifidus muscles involve exercises that move the trunk through a range of motion, requiring the multifidus muscles to hold the spine steady while moving. This builds the muscle fibers that are responsible for muscle power and quickness. Including both forms of exercise in a rehab program for disc herniation may help halt atrophy of the multifidus muscle fibers.

The most successful surgery starts by choosing the right patients. In the world of low back care, doctors want to find a good way to choose the right patients for disc surgery. One way to do this is to use a system called the McKenzie test.

The McKenzie test involves arching the low back to its end point over and over. The test can be done while standing or lying down. Several studies report that the results of this test can be helpful when deciding for or against disc surgery. The McKenzie test helps show who will recover without surgery. The test can even be used with patients who have failed to get results with at least one month of other nonsurgical treatments.

Doctors from the University of Chicago Spine Center and Dartmouth Medical Center conducted a study with 63 patients. None of the patients had successful treatment. Treatment had included medication, spinal manipulation, and a quick return to regular activities. Bed rest was avoided. Each patient was sent by his or her doctor for surgery.

The authors think the results show that it’s possible to find patients with disc pain who will recover without surgery. Some patients can get relief from pain by doing McKenzie exercises. This form of treatment is called mechanical therapy. Surgery can sometimes be avoided by using postures and exercises that support mechanical therapy.

Everyone wants to get “back to normal” after a bout with back pain. Athletes are especially eager to return to play after back surgery. This study may give some help to professional and Olympic athletes.

This study looked at 59 athletes who had a microscopic lumbar discectomy (MLD) for a herniated disc in the low back. MLD removes any loose pieces of the disc with only a tiny incision. Part of the bone and nearby ligament may be removed if the disc is pinching the spinal nerve root.

All the athletes had an intensive rehab program that started a few weeks after the operation. Physical therapists and sports trainers showed the patients stabilization exercises. The focus of the program was to hold the spine in the middle, or “neutral,” position.

Once the spine was stable, exercises were added to gain control in balance, coordination, and strength. There were five levels of trunk stabilizing exercises. Each level moved up in intensity. Athletes also did aerobic exercises that built up in intensity. Then athletes began a series of exercises to regain skill in their sport.

This study shows that MLD plus a rehab program gets athletes back to a high level of sports competition. This faster return to preinjury level of play is especially important in seasonal sports.

Proprioception is our sense of position. It’s an essential part of the way we control our movements. In proprioception, information from receptors in the skin, ligaments, tendons, muscles, and joints is sent to the brain and spinal cord about the location of our joints.

Position sense is part of our system of movement control. Position sense tells the body about its position. Researchers use position sense to measure proprioception. This particular study used repositioning error (described below) as a means of measuring lumbar spine stability.

Thirty patients were divided into two groups. One group of 15 adults had chronic low back pain (LBP) and a loose (unstable) spine segment in the low back. The second group of 15 adults was free of LBP. Each subject was helped into a neutral spinal sitting posture. A neutral position is defined as the mid-position between full flexion and full extension of the low back. Each patient then had to get back into this position without help. A missed attempt at getting back to the starting position is a measure of repositioning error.

The lumbar spine was generally less stable in the “neutral zone” of motion. Motor control of the spine seemd most affected here. There was a deficiency in lumbar proprioceptive awareness. And this problem was present at all spinal levels tested in this group, not just at one segment. These results agree with conclusions of other studies.

The authors think that even small errors in position sense and movement control can overload the soft tissues in the spine. When the lumbar spine can’t find its own neutral position, pain can develop. When this happens, movement of the spine takes place toward the extreme ends of motion rather than in the middle. Chronic LBP develops when the spinal tissues are overloaded time and time again in these end ranges of movement.

Traffic accidents cause low back pain for many people. Recovery time may be linked to insurance benefits for pain and suffering. In other words, it may take longer to heal when there’s a chance of getting some money from the insurance company. This kind of system may delay recovery from back pain.

On January 1, 1995, Canada changed from tort law (compensation linked to pain and suffering) to a no-fault form of insurance. Under the new no-fault law, payments for pain and suffering were stopped. Having a lawyer on the case is limited.

Researchers measured the effect this change had on the time it takes to close a claim after traffic collisions. They also looked at how long it takes patients to recover under both tort and no-fault laws.

The results of this study show that the total number of claims went down under no-fault insurance. This was true even with more accidents and more miles traveled. Fewer people went to the hospital after an accident under no-fault insurance. Under the old tort law system, more people reported intense pain and pain over a large part of the body than did no-fault accident victims. Recovery time was also longer when accidents were covered under tort law.

Under both systems, the final result was based on a mix of factors. These factors included pain, legal issues, and the patient’s social background. Recovery time tended to be longer when the patient was female, had a large area of pain, or had numbness in the arms or legs. Patient depression and hiring a lawyer were two other factors that predicted a longer time to close the claim.

Closing a claim after motor vehicle accidents appears to be faster under no-fault insurance. The authors of this study think that giving payment for pain and suffering also lengthens recovery time.

How do we know if back surgery is the right choice? Take microdiscectomy, for example. Microdiscectomy is the removal of disc material from between two vertebrae. In microdiscectomy, a needle is guided by X-ray into the disc space. The damaged part of the disc, including outer and inner layers, is removed.

There are many ways to define and measure success. Researchers at the University of Vienna (Austria) gave 809 back patients some simple questions to answer. A scale called the Prolo Functional Economic Outcome Rating Scale was used. Results were rated from two (poor) to 10 (best).

As the name suggests, the survey looks at functional, social, and economic status. Questions are asked about pain, physical and social activities, and return to work. The Prolo Scale is getting increased attention by surgeons. It has a simple rating scale that doctors can use to judge outcome.

The authors of this study say that having one scale to use in all studies of the same kind would be very helpful. They used the Prolo scale with microdiscectomy patients. The operation is shown to be a low-risk treatment method with good results.

According to these researchers, a scale like this could be used to judge the outcome of other spinal operations, making comparison between different methods of treatment easier.

Many studies over the years suggest that low back pain can be caused by lifting an unexpected weight or a load that shifts suddenly. Now the question has been raised: if the load is uneven, is the risk of injury even greater?

The authors of this study say, “No and yes.” No, unexpected mass to one side doesn’t increase the compressive force on the spine. In other words, the bones in the spine don’t press down on each other with the new load. But, yes, there may still be an increased risk of injury from another source.

The muscles of the trunk pull to one side in response to an unexpected load placed on one side. Lifting objects while bending to the side or twisting increases the risk of injury. The muscles generate a high force to offset the load. The resulting forces may be damaging to the spine.

In this study, a video-based recording system was used to show the effects of expected versus unexpected loads. Tiny lights placed on various joints marked the starting posture. As the person lifted the weight, the lights moved and any change in the posture was recorded.

At the same time, electrical activity in the muscle was recorded for the back and abdominal muscles. Muscle force and spinal compression were measured. The results show that total muscle force was decreased when lifting uneven weight loads.

While the load on the spine wasn’t increased, delayed muscle contraction or too little muscle contraction may still lead to spinal rotation. The rotation combined with pressure through the spine may be enough to cause injury to the ligaments or disc.

According to these authors, the bottom line is this: unexpected weight shifts when lifting loads can increase the risk for injury– just not for the reasons we might expect!

Muscles rarely contract one at a time. When one muscle contracts, the opposite muscle must relax or contract at the same time. In the trunk, groups of muscles work together to hold the back upright. The same is true during movement. In fact, these muscles have a certain pattern to their work together.

These patterns are called trunk muscle recruitment patterns (TMRPs). Researchers think TMRPs are different in patients with low back pain than in adults without back pain. Patterns of muscle recruitment in both groups are the subject of this study.

Many studies have been done to show the level of muscle action with back movements. This study looks at patterns of muscle action during tasks such as bending forward, bending sideways (right and left), and extending backwards. Sixteen adults with chronic low back pain of unknown cause and 16 healthy adults were compared.

The authors say that the differences in the two groups points to a TMRP that tries to increase spinal stability in the subjects with back pain. The muscles appear to be trying to make up for a loss of stability. Or it could be that an increased amount of muscle activity is needed because back muscles have begun to shrink (atrophy) in patients with back pain.

Whatever the cause, it’s clear there are changes in TMRPs for patients with chronic low back pain. These changes may even persist after the pain is gone. Therapists working with back pain patients to restore normal muscle activity must be careful. There may be some TMRPs that are still needed to hold the spine stable.

Low back pain can be a long-term problem. Studies of low back pain need to be long-term, too. Repeated clinic visits over periods of several years can be inconvenient and expensive. These authors did a test using questionnaires like those used in clinic visits, but they sent them through the mail.

The authors sent out a questionnaire by mail to patients with long-term low back pain. They sent the same questionnaire a second time two weeks later. The questionnaires addressed back pain, work status, medications, and other factors. The authors also sent out some of the most widely used questionnaires for low back pain.

Almost 90 percent of the patients returned both questionnaires. The results showed that one particular type of questionnaire, called the Oswestry Disability Index (ODI), was reliable in the mail. Questions about work, back satisfaction, and pain medication also showed reliable results. The rest of the results were not so reliable. Rating pain seemed especially unreliable on the mail-in survey. This could be because pain varies quite a bit from day to day in patients with chronic low back pain. It could also be a problem with the survey.

This preliminary study shows that questionnaires by mail may be effective in helping researchers do follow-up studies with low back pain patients. More research is needed, especially in understanding the way questionnaires by mail reflect real pain levels.

Low back pain (LBP) on the job is so common that large companies have come up with many policies to help protect workers–and company profits. LBP is costly in terms of productivity, insurance claims, and missed work. In fact, LBP is one of the most frequent causes of sick leave.

One of the policies that companies use to limit the effects of LBP on the job is to give employees “work restrictions.” Work restrictions are specific to the job done by the employee with LBP. For instance, a worker with LBP may come to work but not be required to do the usual heavy lifting or climbing. Work restrictions allow the employee to get back to work and stay active, which is important in managing LBP, while still giving the back time to heal.

These authors studied whether work restrictions decrease sick leave and get people back to work faster. They looked at the records for 240 workers who missed work due to LBP at a large utility company in New York. Of the 240 workers, 43 percent were given work restrictions, mostly to limit lifting, pushing, and pulling. The workers who had work restrictions and those that didn’t took about the same amount of sick leave. Almost all of the workers in both groups had returned to work within a year. The workers with restrictions went back to work a bit sooner than the other group, but 22 percent of them never had the work restrictions lifted. Workers without work restrictions were also somewhat less likely to have LBP come back.

The results seem to show that work restrictions aren’t especially helpful in cases of LBP. However, the authors don’t know exactly what the results mean. Work restrictions may have been given only in the worst cases of LBP, or workers may not have followed their work restrictions carefully. The authors recommend further research that is more specific about how and when work restrictions are used. They also recommend looking into job modifications for all workers to help prevent LBP.

Muscles in the back that extend or straighten the spine are often weak in patients with chronic low back dysfunction (CLBD). CLBD is not a single disease or disorder. It’s a group of disorders that occurs with back pain. Patients with CLBD report a wide range of history, symptoms, and disability.

Scientists around the world are trying to find a valid way to measure muscle performance. They’d like to tell if a patient is giving his or her best effort during testing. Sometimes, and for different reasons, people pretend to contract the muscles fully. This is called feigned effort.

In this study, physical therapists in Israel and Australia measured trunk extension strength (TES). They used a special piece of equipment for testing muscles called a dynamometer. The dynamometer has computer software to make calculations. DEC is the math term used when measuring strength at different speeds during muscle contractions. Previous studies have measured maximal muscular capacity in normal adults. This group measured TES in patients with CLBD.

They found that the strength scores in patients with CLBD followed the same patterns as for normal adults. However, the scores were greatly reduced from normal. The DEC scores in 89 percent of the patients showed full effort was given during testing.

It is nearly impossible to know if a patient is giving his or her best effort during muscle strength testing. Physical therapists can use a dynamometer and DEC scores to look for less than full effort. A DEC score greater than 1.02 in women and 0.95 in men strongly suggests feigned effort. The score shouldn’t be used to support or discount a person’s symptoms, however. Instead it offers another useful bit of information in a thorough evaluation.