News Category: Lumbar Spine

Movement. Posture. Control. It all seems so easy. In fact, the healthy body is on “automatic” most of the time. The body senses movement and responds to it. The muscles protect from injury by contracting at the right time. Sensors in the trunk and legs signal the body to hold still or stand upright.

All of these actions are part of a system called the central movement control system. Low back pain (LBP) can throw a monkey wrench in the system. Suddenly, muscle control and posture isn’t so automatic.

Scientists are studying the link between chronic LBP and the central movement control system. In this study, researchers looked at impaired postural control in patients with sciatica before and after surgery. Normal adults without back pain were compared to back pain patients with sciatica from a herniated disc. The back pain patients all had an operation to remove the disc (discectomy).

A special machine was used to measure motion in the low back. A separate device measured postural control. Reaction time of muscles in response to unexpected movement was also recorded. In this small study (20 patients), low back and leg pain decreased after surgery. Disability and depression also improved.

The authors think the impaired sense of movement present in sciatica patients can be restored. Regaining control of posture isn’t so easy. They found that full recovery of the movement control system isn’t automatic after discectomy. A longer follow-up study is needed to find out how long it takes before healing occurs.

Low back pain results in a huge number of missed workdays and millions of dollars in health care costs each year. Health care professionals are always looking for ways to lower the cost of low back pain. These researchers tested the effectiveness of a “mini-intervention” and a work site visit in helping keep people with low back pain on the job.

The study involved 164 employed patients in Finland who had low back pain for four to 12 weeks. The patients were divided into three groups. All three groups got a brochure explaining how to deal with low back pain. The control group got standard medical care.

The mini-intervention group had a 1.5-hour session with a doctor and physical therapist. These patients were given positive messages about their ability to get better. They were told about the importance of staying active and shown ways to modify their work and home activities to protect their backs. They were also given up to five exercises to do at home.

The third group had the mini-intervention, too. Each patient in the third group also got a visit from the physical therapist on the job. If possible, the physical therapist included the supervisor and company medical personnel in the meeting. The physical therapist spent over an hour helping the patient modify work tasks to help keep the back healthy.

All three groups answered questions about their back pain after three months, six months, and one year. The researchers looked at the number of sick days the patients took and the health care services they used. All three groups reported similar levels of pain, disability, and quality of life. However, both intervention groups had less daily pain and less interference with regular activities. They were more satisfied with their medical care. They also used fewer sick days and used less health care services. The work visit didn’t seem to make a significant difference in the outcomes between the two intervention groups.

The economic analysis showed that the mini-intervention alone resulted in significantly lower health care costs. Factoring in fewer sick days, it had an even bigger economic impact. The authors conclude that putting some money and energy into early treatment of low back pain can help keep costs down in the end.

An episode of back pain is common for most adults. For 90 percent of these patients, the problem goes away within six to eight weeks. The results aren’t always so good for the 10 percent who experience ongoing back pain.

Researchers around the world are trying to find out the best treatment for back pain. Two groups are looked at: patients with acute pain (lasting less than eight weeks) and those with chronic pain lasting more than eight weeks). The focus of this study was patients with chronic low back pain (LBP).

Chronic LBP patients were divided into two groups. Both groups were treated by a physical therapist. One group received exercise therapy (ET), while the other group was treated with manual therapy. Manual therapy (MT) is a form of manipulating or moving the joints in the spine.

Both groups got better with these two methods. Results were measured on the basis of pain level, range of motion, sick leave, general health, and function. Patients in the MT group had twice the pain relief and improved health when compared to the ET group. Patients in the MT group went back to work sooner, too.

This study adds to the growing proof that exercise and manual therapy are both helpful for patients with low back pain. Manual therapy improves all areas measured. The gains are typically made in the first eight weeks of treatment. The authors report that these positive results are still present a year later.

More and more people are having lumbar discectomy worldwide. This surgery is used to remove damaged disc tissue from the low back. However, there is only limited evidence of the surgery’s effectiveness in treating low back problems. Some research even suggests that it has poor results.

These authors did a large-scale review of medical records in Finland to make some sense of the controversy surrounding this procedure. They looked especially at the risk of needing further back surgeries afterward. Over 10 years, more than 35,000 patients had a lumbar discectomy. The researchers noted several interesting facts about the patients who needed further surgery.

Doctors have found a new way to fuse the low back. Surgical fusion cages can be implanted between the vertebrae to be fused. Made of bone, graphite, or titanium, these cages are placed between the vertebral bones of the spine. The surgeon first removes the disc that sits between the two vertebrae and then inserts the cages. Usually, one cage goes on the left side and one on the right.

Some experts feel the cages work best when placed in pairs. However, researchers havn’t known if the two cages share the loads that are placed on the spine. This study was done to help find the answer.

These researchers placed tiny sensors inside titanium cages before implanting them in the spine of nine human cadavers. (A cadaver is a human body used after death for scientific study.) Once the cages were in place, the spine segments were tested through 1500 cycles of movement.

A special testing system compared forces and motion from one side to the other and from front to back. The authors found that the load sharing wasn’t even.

At first, there was a higher load on the back of the vertebra. Later, the load shifted from the back to the front of the cage in all spines. There was also a measured difference in load from side to side. It’s unclear if this uneven load sharing will cause any problems in the adult patient who has a lumbar fusion using cages.

The authors also saw that when the ligament ring around the disc (called the annulus) is cut in the front, there’s more motion when the spine is bent backward (extension). Since the fusion is supposed to hold the spine still, this could be a problem. The authors suggest using a brace to restrict extension when the fusion procedure using cages is done from the front (anterior approach).

The best treatment for chronic or long-term back pain is still a mystery. When pain doesn’t respond to drugs, exercise, or rest, doctors may consider fusion as a possible option. Fusing the problem part of the spine together doesn’t always relieve pain either. Generally, only half the patients get better with spinal fusion.

The authors of this study compared two methods for fusing the vertebrae of the low back area. Posterolateral and circumferential are the two types of fusion reviewed. The doctor uses tools to enter the spine from the back of the body in both these methods.

With posterolateral fusion, pieces of bone, called bone graft, are placed alongside the back surfaces of the spine. The disc remains in place. In the circumferential approach, the disc is removed from between the vertebrae. Then a cage filled with bone chips is placed inside the disc space. The cage lifts and holds the vertebrae apart, regaining the disc height. In both types of fusion, screws and rods are usually applied to hold the spine in place.

Patients in both groups had less pain and numbness and could walk further. Patients also reported psychological improvement. Some tests showed no difference in the results between the two groups.

More patients with the circumferential fusion returned to work. The authors think this is because the disc height was kept the same with a more even load distributed through the spine. Fusion rates were slightly higher in this group.

Even with a good fusion, patients don’t always get better. The authors report that lower results sometimes occur because of psychological, social, or economic reasons. They advise careful selection of patients before doing spinal fusions, regardless of which type of fusion is to be used.

Walking is often recommended as good exercise for people recovering from low back pain (LBP). But doctors are not sure how LBP affects walking. This research tried to shed some light on the mechanics of walking in people with LBP.

These authors tested people with acute LBP (LBP that had just come on within the past week) and people with healthy backs. Researchers used reflective markers and video cameras to track the movement of subjects’ hips and bodies while they walked on a treadmill. Researchers also measured stride length. First the subjects walked at whatever pace felt comfortable to them. Then they walked at a pace 40 percent faster. People with LBP did the same tests again six weeks later, when their back problems had resolved.

The group with active LBP walked differently. They took shorter strides and had less movement in their hips and bodies while they walked. The authors felt that they were trying to avoid pain. Subjects with LBP actually reported significantly less pain after walking at speeds they chose. Their pain levels stayed about the same even as they walked faster and were forced to take longer strides and use their hips and bodies more actively.

The authors conclude that walking can be an effective way for people with LBP to stay active. They recommend further research to understand how speed and stride affect the back. They also suggest that walking tests might be useful in diagnosing back problems, since walking can make certain back conditions more painful and yet seemed to lessen pain in these patients, whose LBP resolved in six weeks.

What’s the definition of “back pain?” And how do you know if or when you’re “recovered?” The authors of this study searched medical journals on-line looking for answers. They found 36 articles reviewing cases of back pain in the general public.

According to the results, 62 percent of adults who have back pain still have painful symptoms one year later. One-third miss work due to relapses of pain. Even patients who return to work aren’t always fully recovered. Many leave their jobs, reduce their workload, or find less demanding work.

Studies reporting patients “recovered” within one month may really only be showing that patients stopped seeing their doctor. Back pain may change, but absolute recovery occurs in only one of every four patients. This is much lower than the currently reported 80 to 90 percent recovery rate.

The authors report that a standard definition of back pain doesn’t exist. In the overall picture, low back pain doesn’t go away by ignoring it. Future studies are needed to find a precise definition of LPB, which can further guide health providers to even better solutions.

Doctors and researchers are still unsure about the best way of doing spinal fusion. Using special devices called fusion cages to support the bones has become very popular. The implanted cages are usually placed next to each other in the disc space (after the disc is removed).

One way to put the cages in place is a surgical procedure called posterior lumbar interbody fusion (PLIF). “Posterior” means the operation is done by opening the spine from the back. “Interbody” is the disc space between the vertebral body above and below. The surgeon removes a small piece of bone off the back of the vertebral column, making it easier to get the disc out and the cages in.

But taking out part of the bone can cause weakness in a spine that already needs more stability. Studies have compared the use of one cage instead of two. A single cage placed at an angle inside the disc space results in greater stiffness after the operation. Increased stiffness or loss of motion is actually the goal of a fusion.

The authors of this study used the posterior approach with one cage for spinal fusion. A minimum amount of bone was removed to make room for the cage. Screws and rods called instrumentation were also used to support the spine at that level.

A single cage lowers the risk of nerve damage. It’s an easier way to do the operation. Other good things about a single-cage PLIF are less blood loss, less time in surgery, and a shorter hospital stay.

These authors conclude that a single cage with instrumentation is a good choice for fusing two vertebrae in the low back. This method shows better results than doing a PLIF with two cages.

Symptoms of numbness, tingling, pain, and weakness in the legs and feet are common in older adults. These symptoms can be caused by several different problems. Narrowing of the opening around the spinal nerve root is one of the causes.

The spinal cord travels through the spinal canal. Nerve roots leave the spinal cord and exit through a small opening on the sides of each vertebral pair. Narrowing of these openings in the low back area is called lumbar spinal stenosis (LSS).

Most often, symptoms of LSS appear in the low back, buttocks, and legs. The most common symptom of LSS is calf or leg pain (or cramping) with walking that goes away when walking is stopped. This is called neurogenic claudication.

Diabetes is another potential cause of painful numbness and tingling. Damage to the nerves from the disease result in a condition called diabetic neuropathy. These symptoms can affect the arms and hands as well as the legs and feet.

Many older adults have one of these problems, or sometimes both at the same time. The treatment for each condition is different. Therefore, finding out what is causing the symptoms is important. This study looked at various tests used to diagnose LSS and neuropathy, including the exercise treadmill test (ETT) and electromyography (EMG).

Walking on the treadmill was the most helpful for identifying LSS. It showed that patients who had neurogenic claudication covered much less distance and at a slower pace than those who didn’t have claudication.

EMG studies show that nerve messages to the muscles are slowed down for both groups (LSS and diabetes). However, this change was greatest for diabetic patients with problems in both the arms and legs. EMG changes are only present in the legs for patients with LSS.

The authors of this study advise that the exercise treadmill test has some limitations. Walking may end early because of other problems such as shortness of breath or joint pain. Patients who stop walking early should be evaluated carefully before being diagnosed with LSS.

We use our “position sense” when we have to quickly adapt our body to changing or unexpected demands. It’s the body’s way of helping us stay upright when we run on uneven ground or jump into a floating canoe. It also helps keep our joints steady and safe from injury.

We use the position sense of our spines when we lift and carry heavy items. These researchers were interested in seeing how good the spine’s position sense is in situations when it is at highest risk of injury. The spine is especially likely to be injured when it is twisted to the side or when it is bent far forward. (This is why we’re supposed to lift with our legs, using a straight back.)

Eleven people were tested to see how well they could sense and control the position of their backs. The subjects did pretty well with bending to one side or the other. But the further they had to bend over, the more difficult it was for them to match the test posture. If this is true of most people, it would help explain why lifting with the back stooped over seems to cause so many spine injuries.

The authors recommend that people take extra precautions when they need to bend down deeply to lift objects or do their daily tasks. They say if someone needs to stoop over, they should be make sure they have firm footing and to be especially careful of shifting loads.

Low back pain is like the common cold. Lots of people have it, but it is almost impossible to cure. Doctors don’t fully understand the causes of low back pain, and they aren’t always able to diagnose the exact problem.

These authors tried to shed some light on the mystery of low back pain. They compared spine MRIs with low back pain history in 115 pairs of male identical twins. The men ranged in age from 35 to 69. Using twins helped the authors control for genetic factors and family influences. The authors also took into account the men’s jobs and lifestyles and whether or not they smoked.

The authors found only two MRI variables that seemed related to problems with low back pain. Both variables showed up more often in men who reported significant low back pain. The first was a loss of disc height. The disc is the soft cushion that sits between each of the spine bones. An MRI can show if a disc becomes thin and narrow.

The second finding on MRI was tears in the annulus (the outer portion of the disc). Annular tears showed up even more often in men who had done heavy lifting in the past year.

However, neither MRI finding related very well with low back pain. The authors conclude that these MRI findings are of little use to doctors who are trying to understand the riddle of their patients’ low back pain.

The “tailbone” in humans is called the coccyx. Most of us aren’t even aware that we have a coccyx. Coccygodynia is a painful tailbone. Because of the location of the pain, this condition often makes a person sit up and take notice!

Symptoms of coccygodynia are pain or tenderness in the tailbone area. Pain is made worse by sitting, especially on a hard chair. The pain may be coming directly from the coccyx or from the nearby tissues. Poor posture and long periods of sitting may bring it on. Pressure on any of the nerves that travel to or near the coccyx can cause a painful tailbone.

Pain in this area can also occur as a result of falling on the tailbone, from tumors, or as a result of referred pain. “Referred pain” comes from some other back problem, such as a herniated or damaged disc. A problem in the sacroiliac joint can also cause coccygodynia. The sacroiliac joints are formed where the triangular-shaped sacrum at the bottom of the low back fits between the two pelvic bones.

Researchers at the San Francisco Spine Institute reviewed the charts of 10,750 new patients over a five-year period of time. There were 77 cases of coccygodynia. Most of the patients got better with steroid injections or physical therapy, or by making changes in their workplace. Twenty percent had severe pain that didn’t go away with treatment.

This study shows that surgery to remove the coccyx can help some people. Before doing the operation, doctors inject the coccyx area with a steroid drug. This can be done two different times. Relief may last days, weeks, or longer. If the symptoms return, the patient will likely benefit by having the tailbone removed. Pain is often reduced or gone afterward, allowing the patient to sit with greater comfort.

The American Medical Association (AMA) uses range of motion to decide which back patients are ready to go back to work. The same low back (lumbar) motions are used to agree on disability. Lumbar flexion or forward bending is the test used most often. Well-known researchers in Canada question this method.

The concern is that decreased lumbar range of motion (LROM) and actual back tissue problems aren’t connected. In fact, more than one study reports there’s no link between tissue changes due to low back pain and LROM. This study agrees with those findings.

These Canadian researchers found that LROM isn’t any different in workers going back to work from those on disability. What the workers thought they could do and what they could actually perform didn’t match either. Scientists also note that while the AMA’s method looks for motion in the spine, research shows that too much motion is a risk for injury.

These authors conclude that it may be time to rethink the AMA’s way to decide disability. The authors suggest that function be measured by a worker’s ability to carry out tasks, rather than using LROM. Functional ability to do the job can be tested using grip strength, heart rate, lifting and carrying loads, and time spent seated or standing.

Heads or tails? Flip a coin and there’s a 50-50 chance you’ll get one or the other. The odds are only slightly better for a good result after low back (lumbar) fusion for degenerative spine conditions. Doctors would like to find a way to improve the odds for these patients.

This study reports the results of one method called temporary fixation as a possible way to predict success of lumbar fusion. The patient goes to sleep under general anesthesia. Screws are placed through the skin into the bones on the back of the lumbar spine. A special brace called an external frame is attached to the screws on the outside of the back. This keeps the spine from moving in the area that is braced.

The frame and the screws are removed eight days later. Pain and function are measured before, during, and after the brace is in place. Function is measured by speed and distance the patient can walk.

Improved pain and function after a short period of fixation are signs that spinal fusion will work. In these cases, it is thought that patients will get at least as much pain relief with a fusion surgery as they did with the brace. Some patients get even better results with fusion surgery.

The authors report that this method can be used to help predict which patients can benefit from a spinal fusion. Using such a device can save thousands of dollars for patients who might not be helped by having lumbar fusion. Researchers conclude that even better methods of patient selection for low back surgery are needed.

People with chronic low back pain may see a physical therapist for treatment. The therapist uses tests of movement and strength to find out what’s wrong. Changing the position of the spine is one way to help reduce painful symptoms.

The therapists in this study looked at 14 different tests of trunk and limb movements. They measured the change in patient symptoms as being better, worse, or the same after each test. The goal was to find positions or directions of movement that improved symptoms. Therapists can use this information to teach patients better ways to move at home, work, and play.

Bending forward in the standing position was the test most likely to increase symptoms. Getting down on hands and knees (quadruped position) was the most comfortable. Rocking back in the quadruped position was even more likely to bring relief from low back pain.

The authors of this study also report that moving the arms and legs while keeping the trunk still can make symptoms worse. For example, lifting a leg up while lying on the back tended to cause complaints of back and leg pain. Some patients also had increased back pain when lying face down and bending the knee or turning the hip in or out.

Finding positions of comfort allows patients with chronic low back pain to safely increase their movement. Therapists help their patients find these positions and use them when they sit, stand, and move in everyday activities. The results of this study help therapists know which tests to use with each back pain patient. Finding positions and movements that are comfortable may help speed up the recovery and rehabilitation process.

Electric heating pads and other heat treatments can soothe low back pain. However, they either get too cold in the wee hours of the morning, or they get so hot that they can burn the skin.

These authors tested a new type of wrap that keeps a low level of heat on the back muscles, and the wrap can be worn all night. The results were promising.

Patients with moderate to severe low back pain were tested for pain, muscle stiffness, flexibility when bending over, and disability level. The patients either took a fake pill and wore a heat wrap overnight, or they took ibuprofen and wore a sham (unheated) wrap.

All patients went through three days of treatment and two more days of measurements. Patients who wore the heat wrap did better overall in every category. Nearly everyone in the heat wrap group (90 percent) showed improvement in morning pain relief. They also had about 25 percent less muscle stiffness, an 18 percent increase in flexibility, and a 40 percent decrease in disability.

The group who wore the heat wrap also reported better and more restful sleep. The researchers suggest that this is one of the reasons the continuous heat therapy was successful. Good sleep can be very important in healing and recovery, and patients with low back pain often report problems sleeping. The authors suggest more research is needed combining night and daytime continuous heat wrap treatments.

Heat can soothe aches and pains. However, in the case of low back pain, heat treatments have never been shown to provide lasting pain relief. This is true of heating pads and other short-term heat treatments that patients use for a half-hour or so while resting. But these researchers tested what would happen if patients wore a 104-degree heat wrap for at least eight hours during normal daily activities. The results were impressive.

The study involved patients with moderate to severe low back pain. Measures were taken for patients’ pain, muscle stiffness, flexibility when bending over at the waist, and back function. The patients were divided into different treatment groups, including one group that took ibuprofen and one group that wore a sham heat wrap. The groups followed their treatment plans for three days, and testing continued for another two days.

The heat wraps showed significantly better results. The heat wrap gave about 67 percent greater pain relief over all five days. Patients getting heat wrap treatment had less muscle stiffness, better flexibility, and better function. Only one patient reported problems with red skin, but the problem went away by itself.

The authors think the some of the benefits of continuous therapy is because patients can wear the heat wrap while they are active. Much research has shown that bed rest can make low back pain worse. If continuous heat wrap therapy holds up in future research, it could be an important new treatment when genralized low back pain first hits.

Are you having low back (lumbar) surgery for disc problems for the first time? Wondering what’s best after surgery? So are the experts! Little is known about what treatment works best to get patients back to activity and back to work while avoiding reinjury.

Doctors and physical therapists in the Netherlands took a look at the “big picture.” They reviewed studies done around the world from 1966 to 2000. They put patients into three groups. These included back patients who had treatment right after surgery, those who had treatment four to six weeks after surgery, and those who waited more than 12 months after surgery.

For each group, active rehab was compared to no treatment. Active rehab was also compared to other kinds of treatment. Some of these studies also looked at a specific treatment added to active rehab versus active rehab alone. Which group had the best result?

Getting treatment right after surgery didn’t seem to change the final results. Strikingly, those patients who received exercise programs four to six weeks after surgery went back to their routine activities and work sooner. Proof for the effectiveness of other treatments was limited.

The authors of this review say it won’t hurt to return to activity after lumbar disc surgery. In other words, patients don’t have to remain quiet or passive after this operation. For those patients who are afraid of reinjury, there’s no proof that this happens as a result of safely returning to an active lifestyle.

Muscles of the low back fatigue easily, especially in patients with low back pain. What happens to low back muscles as they get tired? Fewer muscles fibers fire, so other muscles must take over. This is different from the way other muscles in the body respond to fatigue.

Electromyographic (EMG) studies of most muscles show that as they become tired, they usually increase their firing activity. Not so with low back muscles. Back muscles work hard until about 55 percent of the muscle is active. You might say the muscle is only “half tired” before it gives up and turns the job over to another muscle.

Muscles in the buttocks and hip work with the low back muscles. A thick, tough fibrous covering holds them together. They share the ability to move the spine into an extended position. Muscles that work together in this way are called synergistic.

Studies of normal human movement using EMG are being done at the Musculoskeletal Research Lab in Syracuse, New York. Researchers say this information can affect how the low back muscles are strengthened. Doing repetitions beyond the 55 percent fatigue level won’t increase activity in the muscles of the low back. More studies will help determine better methods to target the low back muscles once they start to fatigue.