News Category: Lumbar Spine

It probably wouldn’t surprise you to know that athletes have a much greater risk of low back injury than the average person. Can you guess which sports have the highest rate of low back injury? If you guessed, women’s gymnastics, you would be right. There are two others with equally high rates: men’s wrestling and American football.

It’s also interesting to note that athletes have a greater number of anatomic abnormalities (seen on MRIs) compared with nonathletes. But since a person’s symptoms often don’t match the imaging studies, clinicians examining athletes don’t rely heavily on this type of diagnostic approach.

Physical therapists have developed a method of examination for patients with low back pain called treatment-based classification. This three-step approach tries to match symptoms with a treatment approach that works best for those symptoms.

The therapist starts by making sure the patient doesn’t have a serious underlying pathology causing the low back pain. This process is called screening for referral. Anyone with signs of infection, inflammation, malignancy, or fractures must receive immediate medical attention before physical therapy treatment can begin.

Once the patient has been cleared, conservative (nonoperative) care under the direction of a physical therapist is next. During this second stage, the therapist evaluates the patient in order to decide which treatment approach will work best. As part of the process, the patient fills out several surveys that help identify levels of pain and disability.

The athlete is managed using treatments divided up on the basis of three stages. The goal of treatment is to reduce pain, improve function, speed up recovery, and prevent loss of practice and/or play time. Once the stage has been identified, then special tests are performed that have been found reliable in predicting which type of treatment will have the best outcomes. Let’s take a look at the three stages.

Stage I is more acute during the early days following an injury. Usually, this person has difficulty standing, sitting, or walking for very long or very far. Treatment during this stage is often with advice, manual therapy, and specific exercises. The athlete’s posture is modified when appropriate. Core training of the trunk and abdominal muscles help stabilize the lumbar spine.

Stage II describes the patient who can stand, sit, and walk but has trouble with basic daily skills (e.g., vacuuming, lifting, jogging, driving). Stage III means the patient can manage daily activities but isn’t able to participate in sports. Stage III is more of the chronic phase where patients experience recurrence of their low back pain that can be very limiting.

Treatment approaches for these two groups are still under investigation. Though the therapist has many treatment techniques available, predicting which one (or combination of techniques) will yield the best result remains unknown. Some of the treatment intervention will address pain while others focus on flexibility, strength, posture, and aerobic capacity. Endurance and neuromuscular control are also targeted in the more advanced levels of training (stage III).

Athletes in stage III are ready for sports-specific exercises. This approach is called functional training. It moves the athlete from limited practice time back to full participation in the sport of their choice. One of the long-term goals of treatment using this approach is to prevent future episodes of repeated back injury/pain.

In summary, physical therapists are busy researching, studying, and developing an evidence-based approach to low back pain in the athlete. Rather than applying treatment willy-nilly, they carefully examine each patient using a three-step classification-based approach. Staging the athlete (stage I, II, or III) based on level of pain, disability, and function helps direct treatment. This treatment-based classification yields a rapid return to the playing field and that’s the ultimate goal of every injured athlete.

Low back pain seems to be something most people experience at least once in a while. Many studies have confirmed this fact. Up to 90 per cent of all adults report an episode of back pain once in their lifetime. Despite a high level of fitness and even flexibility, athletes from young to old are not exempt from this problem.

In this article, experts in sports medicine review the way to evaluate low back pain in athletes. Patient history is a key feature — both the past medical history as well as the current history of the symptoms is important. Any recent or past injuries are recorded along with any medical conditions that could put stress and strain on the low back.

Physicians ask patients complaining of back pain many questions while listening for red flags that might tip them off to a more serious underlying problem. For example, extreme pain at night that is relieved by an aspirin or other antiinflammatory medication could be the sign of a bone tumor.

The presence of fever, chills, nausea, vomiting, diarrhea, blood in the urine, or chronic heartburn signals the need for a closer look. Anyone who is unable to stand and put weight on the legs without severe back pain requires immediate medical attention. Certain problems such as a urinary tract infection, cancer, or passing of a kidney stone can also cause low back pain.

Other factors that can contribute to low back pain include pregnancy, long-term use of corticosteroid medications, diabetes, or recent surgery. Infection or inflammation of any kind affecting the abdomen or pelvic area (e.g., appendicitis, diverticulitis, gastritis, pelvic inflammatory disease) may present as low back pain.

Sometimes the age of the athlete is a tip-off as to the cause. Children rarely have disc herniations or osteoarthritis. But these conditions are common in adults. Older adults tend to develop back pain as a result of spinal stenosis (narrowing of the space for nerve tissue). Unless present at birth, stenosis is not an issue with young athletes.

Trauma and repetitive motion (especially overextending the spine) are typical with younger athletes presenting with back pain. If you’ve watched any amount of sports or participated in athletic activities, you will agree baseball pitchers, football quarterbacks, and football offensive linemen are at risk for low back pain.

The type of physical movements repeated by throwers and the impact from tackles and falls on linemen is enough to increase the incidence of low back pain. Other sports participants are at risk too: gymnasts, divers, volleyball players, and dancers to name a few.

When the history and physical exam point to a possible problem that could be seen more closely with imaging studies, then X-rays, CT scans, MRIs, and sometimes ultrasound studies may be ordered. X-rays help rule out (or rule in) bone fractures. For infections, inflammation, and some types of tumors, additional lab work (blood tests or urinalysis) may offer helpful results leading to an accurate diagnosis.

For those health care professionals who conduct back evaluations (orthopedic surgeons, sports medicine physicians, physical therapists, chiropractors), the authors provide photos and descriptions of highly sensitive screening tests. Algorithms (flow charts) are provided for deciding when to order additional tests and when an inflammatory process may be present.

The bottom-line is to keep in the back of your mind that low back pain in anyone (including athletes) can be caused by mechanical, emotional, medical, or traumatic causes. Knowing what to look for in each age group can help speed up the diagnostic process. An early and accurate diagnosis is important when dealing with potentially serious health conditions. Early diagnosis and intervention is the key to a successful outcome for athletes young and old.

For this article, surgeons and physical therapists join together to present a current view on the diagnosis and management of sacroiliac joint (SIJ) pain. Anatomy (including nerve innervation) and biomechanics of the sacroiliac joint are reviewed. Drawings of the bones that make up the joint are provided along with photographs of test procedures and X-rays following surgical fusion.

Fusion of the joint is really a last resort effort and only used when all other approaches have failed. Surgery to fuse the joint is not guaranteed to end the painful symptoms. So, nonoperative (conservative) care is really the order of the day. The authors discuss both nonoperative treatment and surgical management.

Before treatment begins, a careful examination and evaluation are required in order to make the diagnosis. The patient’s history is a key factor in the diagnosis. Studies show that more than half of all cases of sacroiliac joint pain are linked with some form of trauma (fall, motor vehicle accident, direct blow to the low back/sacroiliac joint area).

Other factors that can increase the risk of sacroiliac joint problems include pregnancy (stretching of the pelvic ligaments leads to instability), scoliosis (curvature of the spine), polio, and hip arthritis. A previous spinal fusion and unequal leg lengths are two additional risk factors.

There isn’t one single test that is 100 per cent reliable in diagnosing the sacroiliac joint as the cause of the pain. But by combining the results of the history along with several other tests, the examiner is able to make what’s called a presumptive diagnosis. Here are a few of the diagnostic features:

Cats may be able to land on their feet when dropped from the second story of a building but humans are usually not so lucky. The force of the impact up through the spinal cord can kill a person. If the legs are bent and the person hits first on the sacrum — well that’s another story.

In this report, two cases of such injuries with sacral fractures are reported. The sacrum is a wedge- or pie-shaped bone that sits between the two pelvic bones. Above the sacrum is the lumbar spine.

The last lumbar vertebra (L5) has two extensions of bone sticking out (one from each side) called the transverse process. These bony wings actually form part of the sacrum and attach L5 and the sacrum to the ilium (upper portion of the pelvic bones). The narrow tip of the sacrum ends where it attaches to the tailbone or coccyx.

The force of the impact caused a U-shaped fracture. In the first case, the break occurred where the transverse process comes out from the fifth lumbar vertebrae. The fracture formed a vertical (up and down) line partway down the sacrum (labeled S2. Although the sacrum is one fused bone, there are five parts (S1-S5).

What makes this a U-shaped fracture is the horizontal (side-to-side) fracture connecting the two vertical fracture lines at the bottom of each fracture line. The second patient also had a U-shaped fracture but only affecting the left L5 transverse process with the connecting vertical fracture down lower at the S3 level.

Both patients reported low back/sacral pain, numbness in the legs, decreased muscle strength in the lower legs, and loss of reflexes. The force of the impact shifted the fractured bone into the spinal nerves that exit through tiny holes in the sacral bone.

There was tearing of the nerve roots and rupture of the dural sac (thin protective membrane around the nerves). In one case, there was further damage to the sacral nerves as the bone fracture fragments pushed into the dural sac cutting into the nerves. The damage set up an inflammatory response with bleeding, swelling, and eventual scar tissue formation from S2 to S4.

The nerves that come down the spinal canal end at the sacrum in a group called the cauda equina (literally “horse’s tail” because that’s what they look like). These are the nerves that help control bowel and bladder function as well as sensation and motor function of the groin and legs.

U-shaped sacral fractures like these two are rare. Optimal treatment choices are unknown because there are so few studies done comparing the results of one treatment to another. The goals of treatment are to move the bone off the nerves (a procedure called decompression) and nerve recovery.

It is agreed by everyone that the earlier surgery can be done, the better the results may be. Treatment within the first two weeks following the injury is ideal. There are fewer negative long-term effects with early decompression.

Besides moving the bone off the cauda equina, the surgeon can remove blood and bone fragments that might otherwise form a large callus (bump of bone) as the body tries to heal itself.

There are many different ways to approach a problem like this one. For both cases, the authors did not think screws would be enough to hold the transverse process in place. The skin is very thin over the sacrum so size of hardware used must be taken into consideration. They opted for an internal titanium plate to stabilize the sacral fracture.

This approach worked as both patients recovered with good bone union and no major complications. There were a few problems with regaining bowel function for one and bladder function for the other.

It was seven weeks before one patient could urinate (empty her bladder) by herself and six months before she was fully recovered. She had the higher-level (S2) U-shaped fracture. The patient with the S3 fracture experienced a longer course of bowel and bladder recovery but regained full function by the end of one year.

Patients and surgeons were pleased with the final outcomes. There was good bone fusion, no fracture displacement, and no need for additional surgery. The authors offer their experience with these rare U-shaped sacral fractures with cauda equina injury in hopes of guiding others who may treat this rare problem.

Despite the lengthy title of this news article, it doesn’t really begin to tell you about all the information contained within! First, the specific spine surgery in question is anterior lumbar (from the front of the low back).

This type of surgery is done for spinal instability that requires fusion, tumors that have to be removed, and infection that must be cleaned out. Not to mention disk degeneration, trauma, spinal deformity, and other causes of nerve impingement requiring surgery.

Whatever they are called — complications, problems, or adverse events — anything that occurs during or after the procedure that has a negative effect on the patient’s outcomes (results) is the focus. Any problems from the surgery that require additional treatment (e.g., blood clots, failure of the wound to heal, nerve damage) are also considered complications.

There are many different ways to classify or group complications. If we just look at it from a timeline point-of-view, then there’s intraoperative (during surgery) and postoperative (anytime after surgery up to six weeks) complications. But other categories of complications include problems that occurred as a result of the patient position, device-related (implants), or approach (anterior versus posterior incision).

Interbody implants (cages or bone graft placed in between the vertebrae where the disc was removed) can cause problems if they are too small, too tight, too loose, or too narrow. It takes a lot more skill and planning than we might realize for the surgeon to select and put in place the right-sized interbody fusion implants.

The anterior approach is necessary when the risk of spinal cord or nerve root damage is too great using a posterior approach. In the case of tumors or infection, the location of the problem may dictate the use of an anterior incision. But there are a lot of organs, arteries, veins, and deep muscles that can get nicked (cut) by accident during the procedure.

Adverse events linked with the anterior approach tend to be vascular (damage to blood vessels), visceral (injury to abdominal organs including the bowel), and neural structures (traction or cutting of nerve roots or nerve groups).

When removing the disk and replacing it with a metal cage and/or bone graft material, the surgeon must be careful not to over distract the two opposing vertebral bodies. Pulling the two vertebrae too far apart in order to get the disc out and put the cage in is the single most common cause of nerve root injury. Pull or traction on the nerve root causing nerve damage may be temporary but it takes a long time to recover.

Men are at risk for damage to the nerves controlling penis erection and ejaculation. Sometimes a problem called retrograde ejaculation develops. Instead of propelling the semen forward and out the penis, it goes backwards and into the bladder. Not everyone recovers from this problem. In fact, only about one-third regain complete sexual function. Young men should be fully informed about the possibility of this complication with anterior spinal surgery.

Of course, every surgeon does everything possible to avoid procedure, patient, or device-related complications. The use of fluoroscopy, a real-time, three-dimensional) type of X-ray helps guide the surgeon. Even with fluoroscopy, ileus (paralyzed bowel) can develop.

When any type of problem does arise, the next best thing is to manage it well and prevent the need for additional surgery. Management depends on what the problem is. For example, bleeding complications such as uncontrolled bleeding can result in serious complications (e.g., paralysis).

Blood clots can cut off blood supply in the legs or travel to the lungs and cause death. Watching for and recognizing early signs and symptoms is a key to prevention fatal blood clots. Pulses in the feet, skin color, and oxygen levels are measured frequently to assure proper blood circulation.

In summary, any type of surgery comes with its own set of potential complications. Spinal surgeons do everything they can to prevent and avoid such problems right from the start. Patients must be warned what to expect should something go wrong as a result of the surgery itself. Fortunately such adverse events are rare and usually temporary. With quick intervention, the problem can be managed quite well.

Patients with low back pain who are overweight or obese are often advised to lose weight. But is there any evidence that weight loss is linked with reduction of back pain? In other words, is it worth all the calorie restriction, exercise, meal replacement, and group therapy needed to accomplish the goal?

That’s what this pilot study was designed to find out. They used a medically supervised nonsurgical weight loss program and studied change in back pain. A group of 46 obese adults with mild-to-severe back pain and moderate-to-severe loss of function participated in the study.

Everyone followed a diet and exercise plan for a full year. The first 12 weeks involved a liquid meal program followed by another 13 weeks of reduced food intake. Throughout the first six months, everyone attended group therapy and educational meetings. Physical activity and exercise were a daily requirement (60 to 90 minutes).

Various aspects of the program were supervised by a variety of different health care professionals. This multidisciplinary team was made up of nurses, dieticians, physicians, and exercise specialists.

Before and after results were measured in three main ways: weight loss, pain intensity, and function. Weight loss is easy to measure with a scale. Pain is more of a subjective phenomenon so it can’t be measured directly. A pain scale called the numeric pain scale (NPS) was used in which patients rate their pain from zero (no pain) to 10 (worst pain).

A valid and reliable tool called the Oswestry Disability Index (ODI) was used to measure change in function. The ODI measures pain and level of physical activity at work and during leisure time. It is a self-report questionnaire, which relies on the patient to complete it either directly or over the phone with someone else asking the questions and taking down the answers.

After 14 weeks, 98 per cent of the group had lost a significant amount of body weight. Half the group reported major pain relief. Function improved for almost three-fourths of the group (73 per cent). But only one-third of the group who lost weight was able to maintain that throughout the rest of the study.

Those who did lose weight and kept it off had the greatest amount of back pain relief. But this study did not evaluate whether the decrease in back pain could have been the result of the natural course of back pain (i.e., it gets better over time for many people without doing anything).

In summary, one-fourth of all adults in Canada and the United States are considered obese by medical standards. Studies have shown that obesity and low back pain go hand-in-hand together. But whether or not weight loss would reduce low back pain has not been clearly established.

This pilot (small) study did show a change in back pain but the program used did not involve just weight loss. There was also exercise, group support, individual attention, and behavioral changes as part of the whole package. Using a comprehensive program like this did yield some promising results.

More study is needed to find out if all parts combined are really required for change in back pain or if some individual components have a greater impact than others. The authors suggest a larger study with longer follow-up comparing different programs as the next step in this process of discovery around weight loss and low back pain.

Surgeons do everything they can to help reduce postoperative pain for patients having spinal surgery. With good pain control, patients can get up and move around sooner. This helps prevent complications and reduces the number of days in the hospital, not to mention the costs.

In this study, anesthesiologists compare different dosages (amounts) of a drug called pregabalin for postoperative pain control after lumbar spine fusion. This drug is already in use but the optimal dosage for this purpose is unknown.

Three groups of patients were formed. All patients in the study were male with a one- or two-level lumbar spine fusion. Anyone with a serious health problem was eliminated from the study. Likewise, anyone with an alcohol or other drug history was also excluded from participating.

Patients were assigned to one of the three groups randomly. One group received 75 mg of pregabalin one hour before surgery and again 12 hours after surgery.

The second group was given twice that amount of drug (150 mg) at the same time periods. The third group was the placebo (control) group. They were given fake pills. No one taking the pills knew which group they were in.

Normally, patients are given narcotics (opioids) to manage pain after lumbar
spine fusion surgery. But these medications have some very unpleasant side effects (nausea, vomiting, difficulty breathing).

Pregabalin has been selected as a possible adjunct (helper) treatment because the drug is quickly absorbed and acts in a predictable and safe manner. It works because it blocks the release of neurotransmitters (chemical messengers) that tend to overexcite the nervous system, ramping up pain messages.

The results of this experiment were measured in terms of pain intensity,
amount of opioid medication used after surgery, and frequency of rescue
analgesics required in the first 48 hours after surgery. Rescue analgesics
refer to additional pain relievers needed to get control of pain because pain intensity has increased too much and the patient is very uncomfortable.

For any anesthesiologists or other health care professionals involved in
administering anesthesia to spinal fusion patients, the authors describe the procedures they used in this study. Type and amount of anesthesia are provided along with method of drug administration, monitoring during the procedure, and end-of-surgery procedures.

Patients were observed carefully during the postoperative period for any adverse effects such as nausea, headache, inability to wake up (sedation), blurred vision, dizziness, and pain intensity. Patients were also asked to rate their level of satisfaction with the anesthesia and treatment for pain.

After collecting and analyzing all the data, they found that the higher dose of pregabalin (150 mg) was much more effective in controlling postoperative

pain. The group receiving the higher dose used much less narcotic for pain
control in the 48 hours after surgery. Symptoms after surgery were similar in
all three groups, so clearly the pregabalin at any dose did not compromise the patients in any way.

The need for additional rescue medications was also reduced in the 150 mg group. With less pain after surgery, there is an added benefit: reduced risk of becoming a chronic pain patient.

The authors conclude that although 150 mg of pregabalin before and after lumbar fusion surgery reduced postoperative pain, they still don’t know if this is the optimal dose. Likewise, there’s room for further study of the timing of the drug administration. This study only reviewed lumbar spine fusion, so other studies looking at other surgeries may yield different results.

For now we know that 150 mg of pregabalin is more effective in pain control than 75 mg (or placebo). The 75 mg dosage was about as helpful as the placebo, so it may be possible to reduce the amount of pregabalin given but not down to 75 mg.

The optimal dose may be somewhere between 75 and 150 mg — or it could be at a level greater than the 150 mg tested in this study. Future studies with different doses while monitoring side effects are still needed. And repeating the same study with an all female group of patients is necessary before recommendations can be given for all adults.

No matter what the problem, treatment for health problems has the best results when it is aimed at the underlying problem — not just the symptoms. Back pain is no different in this regard except there can be a lot of different reasons why someone has back pain.

Physical therapists who see the majority of people with back pain have started classifying patients with low back pain into specific subgroups or categories to help in this process.

One of the most common subgroups is called lumbar segmental instability (LSI). Lumbar refers to the low back region composed of five large vertebrae numbered one through five (e.g., L1, L2, L3, and so on).

Segmental means a specific one of those vertebrae is involved. And instability describes too much movement or translation of the bone. The shift of the bone can be seen on X-ray when the spine moves — especially at the end of the spinal movement (e.g., bending forward/flexion or bending backward/extension).

The patient suffering from back pain as a result of lumbar segmental instability experiences a “catching” sensation when standing up straight after being bent forward. Another sensation described is one of the spine “slipping out” during spinal motion.

The pain is usually worse in the morning. Pain and slippage are key features when the person tries to roll over. And like a weather gauge, changes in the barometric pressure also increase painful symptoms.

What can cause lumbar segmental instability? Age-related disc degeneration, surgical spinal fusion, surgical removal of a disc, or a history of trauma affecting the spine. The reason spinal fusion causes instability may have to do with the increased load and stress on the segments above and below the fused level.

The condition is diagnosed based on the patient’s history, physical exam (clinical tests), and imaging studies. But X-rays expose the patient to radiation, so physical therapists are trying to figure out which tests currently being used are accurate and valid enough to use without X-rays to confirm the results.

This group of therapists from New Zealand at the University of Otago conducted a systematic review of the literature. They looked back over the past 60 years worth of data entered on six different electronic databases.

Articles testing the accuracy of clinical tests for lumbar stability/instability were read and evaluated. There were 11 tests in all that met the criteria for high-quality research.

Physical therapists will recognize some of the tests included such as the posterior shear test, the prone instability test, the Beighton hypermobility scale, the prone leg extension test, and tests for the instability catch sign, the painful catch sign, and the apprehension sign.

They found that the tests were all specific enough (able to identify when lumbar segmental instability was NOT the problem). But the tests had low sensitivity meaning they weren’t very good at identifying patients who DID have segmental instability.

One test did stand out as being the most sensitive (84 per cent) and with high specificity (90 per cent) — the passive lumbar extension test. But in the end, the patient’s symptoms (pain with certain movements like rolling over or standing up straight) and the timing of those symptoms (worse when the weather changed) actually had the highest sensitivity/specificity (88 per cent/93 per cent).

In summary, this systematic review to evaluate evidence for clinical tests used to diagnose lumbar segmental instability found limited diagnostic use for those tests. In the future, it will be necessary to compare tests for accuracy and reliability when used with different age groups and when performed by different examiners.

Once the condition can be accurately diagnosed, then finding the most effective treatment strategies will be the next step. The goal is to develop noninvasive testing methods and treatment approaches that don’t involve exposure to radiation or surgery.

People with chronic low back pain often have to learn to live with it because all efforts to get rid of it or control it have failed. Psychologists who study chronic pain patients attempt to understand what’s going on in an effort to find better ways to treat pain or help patients manage their chronic pain.

There seem to be two different ways people with chronic low back pain respond to their situation. They either avoid activities that might cause pain or they persist in being extremely active despite their pain. Pain experts suggest these behaviors called avoidance and persistence are the result of self-discrepancy.

Even without pain, you have probably experienced self-discrepancy at times in your life. Some people refer to this as the “split-mind.” You perceive yourself one way but think you should be (or think) different. There are several different ways self-discrepancy plays a role in our lives.

There’s the actual self or how you really are in your natural state. That is compared with your ideal or perfect self — the way you would like to be. Then there’s the “ought” self (i.e., I ought to be …you fill in the blank here). And finally, the “feared” self. The feared self is the one you are most afraid of being like or becoming (i.e., becoming someone you do not want to be).

Any of these discrepancies or conflicts can result in emotional distress such as anxiety, depression, and pain. In addition to emotional experiences, the person may develop these other behaviors mentioned earlier (avoidance or persistence).

In this study from the Netherlands, the researchers try to explain avoidance and persistence in terms of self-discrepancy and behaviors designed to “self-regulate” (or change). They proposed that people who engage in “I ought to do or be this way” kind of thinking are more likely to be driven to be their “ideal” or “perfect” self. Their behavior would tend toward persistence. And fear-based behaviors are more likely to result in avoidance.

The 83 patients included all had chronic low back pain lasting at least three months. Anyone who was pregnant or had a known psychologic problem was not allowed to participate. Everyone in the study filled out various surveys and questionnaires designed to measure self-discrepancy. The tools used have been tested and found to be valid, accurate, and reliable measures of ideal, ought, and feared sides of ourselves.

Other factors were measured using surveys specific to depression, anxiety, activity patterns, disability, pain intensity, and health-related quality of life (QOL). All of the survey tools were self-report (patients answering questions about themselves and how they think, feel, and act.

Any good study analyses patient characteristics to see if there are any differences based on age, sex (male versus female), education, or income level. In this study, none of those patient variables had an effect on results. So they turned their attention to their real area of interest: self-discrepancies and emotional and activity patterns.

They found that patients who perceived themselves close to who they wanted to be were happier and less depressed. On the other hand, patients who saw themselves more like the person they didn’t want to be or were afraid of becoming had higher levels of anxiety and depression. Patients in the “ought-to-be” category weren’t really more depressed than anyone else.

On the behavior side of the equation, there weren’t major links between self-discrepancy and patterns of behavior (avoidance or persistence). Avoidance was associated with a lower quality of life and greater disability. The patients who saw themselves as becoming the person they feared or didn’t want to be increased their avoidance of activities that might increase pain.

Further analysis of the data did show that people who engage in “ideal-other” thinking are more likely to demonstrate persistence behavior. No matter whether they felt close or far away from what they thought was “ideal” for themselves, they worked hard or demonstrated behaviors referred to as overdoing it.

In terms of working with chronic pain patients, this study makes some interesting points. One is that patient behaviors (whether towards avoidance or overdoing it) have underlying reasons. One of these reasons is the role of self-discrepancy as either a protective or motivating factor. It might be helpful to guide patients to achieve personal goals with an understanding of how emotions and behavior are driven by how patients see themselves.

Persistence behavior doesn’t seem to have any negative effect on outcomes, disability, or quality of life. Therefore, it might be best to gear future research efforts around preventing (or stopping) avoidance behaviors. The final outcome may be to improve function, decrease disability, and increase quality of life for people who suffer from chronic pain, especially chronic low back pain.

There have been quite a few studies showing that chiropractic care (specifically spinal manipulation) is effective for the treatment of acute low back pain. But there aren’t too many patients who go to the chiropractor and only have a single spinal manipulation (often called an adjustment).

In this study, the type of combined treatment really received in a chiropractic clinic is the focus. Combined treatment refers to the spinal manipulation along with patient education, massage, heat or cold, exercises, bracing, and pillows. Advice on nutrition and lifestyle changes are also part of the patient education piece.

Does combined treatment work as well (or possibly better) than spinal manipulation alone? How does chiropractic care compare with other interventions? What short-, mid-, and long-term outcomes are seen with combined care? Are there any adverse effects of combined chiropractic care? And finally, how do the results of chiropractic care compare with having no treatment?

To make these comparisons, the researchers had to find studies that used the same or similar time frame and outcome measures. Short-term results were measured during the first month after treatment was started. Medium-term follow-up included results obtained between one and six months after the start of treatment. Long-term refers to anything achieved six month after treatment began (or later).

Pain, disability, and general health status were used to measure progress. Studies included in the analysis had to describe patients in such a way that comparisons could be made between studies. The treatment or plan of care used had to be clear enough to make the same type of comparisons from one study to the next.

This criteria was met in 12 of the studies reviewed. There was a total of 2887 low back pain patients in those 12 studies. Each study was a randomized controlled trial (RCT) meaning patients were assigned to treatment groups randomly (usually generated by a computer).

A special table summarizing all the information gathered is presented. You can look at this table and see at a glance the type of chiropractic care given in each study. Treatment given for each of the other groups (compared with the chiropractic care) was placed in the adjacent columns.

After collecting all the data from the 12 studies and making comparisons, there simply wasn’t a significant or measurable difference in results between combined chiropractic care and other interventions when used alone. Other interventions included heat, cold, massage, education, medications, bed rest, and exercise.

Some patients got pain relief faster in the chiropractic care group at the start (short-term) but the improvement in pain over other treatment wasn’t considered statistically significant. At the end (long-term), this edge was no longer present. That’s pain, what about disability? Same story: no significant difference in disability at any point between combined chiropractic care and other treatment approaches.

The final outcome measure (general health) was no different between combined chiropractic care and other types of care in the short- and mid-term. Long-term results weren’t available in any of the studies published so far. That leaves rate of improvement and adverse effects.

Once again, no difference in rate of improvement in the short-, mid-, or long-term. And no major or serious adverse effects of chiropractic care were reported. There were some cases of increased pain and other symptoms with chiropractic care but nothing was permanent or lasted more than a few hours to a few days.

In summary, according to this systematic review, chiropractic care does not provide any long-term benefit over other types of conservative care in terms of pain relief, disability, or general health. Whether or not chiropractic care is better than no treatment has not been explored yet. This would be an important area of future study along with using return-to-work or daily activities as specific functional measures.

This review studied how treatment (mixed therapies) is typically delivered in a chiropractic clinic. But it didn’t help determine if one modality would work better than another or if all are truly needed to get the desired results. The studies included did not look at subgroups of patients (i.e., treat groups of patients differently because of specific characteristics). That’s another area for future research.

Patients with pressure on the spinal nerves from two conditions (listhesis and stenosis) are the focus of this study. Both sets of patients have leg and/or back pain. Previous studies have shown that patients with either of these spine problems have better results if their symptoms are mostly leg pain (as opposed to back pain or both leg and back pain). But those studies combined patients with both conditions. So we don’t know if patients with listhesis get better (or worse) results than those with stenosis.

Let’s make sure we know what is being referred to as listhesis and stenosis. You may have heard of a condition called spondylolisthesis where one vertebra (spine bone) slips in front of another. With listhesis, one vertebral bone starts to slide off to the side of the next vertebra. Spondylolisthesis is more of a front-to-back shift of the bones. Listhesis (also known as lateral listhesis is a shift from side-to-side.

Spinal stenosis is a narrowing of the spinal canal. The spinal canal is the opening where the spinal cord and nerve roots travel from the brain down to the limbs. Many degenerative changes common with aging can cause this space to get smaller. Bone spurs, thickening of the ligaments, and flattening of the discs reduce the space in the spinal canal putting pressure on the nerve tissue. The result is often leg and/or back pain.

In this study, results of surgical and nonoperative treatment were compared for each diagnosis (listhesis versus stenosis) separately. Within each diagnostic group, the patients were further divided into leg pain (predominant), back pain (predominant), and both leg and back pain equally. The groups were fairly evenly distributed with about one-third with just leg pain, slightly less than one-third with back pain, and slightly more than one-third with equal leg and back pain.

Outcomes were then measured following treatment for each group separately and compared. Treatment was either surgery or conservative (nonoperative) care. Surgery consisted of decompression (removing bone pressing on nerves) with or without fusion to stabilize the spine. Conservative care included physical therapy, education, and medications. Everyone was followed for two years.

Comparing painful symptoms between degenerative listhesis and spinal stenosis, the authors report patients had the worst pain if it was present in both the back and the leg. That was true for both diagnoses. And the results of treatment were less successful for this pain group for both diagnoses, too.

Just as other studies showed, patients had the best results when leg pain was their main symptom. Surgery yielded better results than nonoperative (conservative) care for patients with predominant back pain. The group with the poorest overall treatment results was the equal pain group. The equal pain group did have an intermediate response to treatment but it wasn’t nearly as good as the results for patients with leg pain only or back pain only.

The authors conclude that this is the first study comparing treatment results for degenerative listhesis and spinal stenosis based on pain location. The benefit of surgery for patients with low back pain only was reinforced by the results. Results were even better with surgery for the patients with predominant leg pain. For both diagnostic groups and in all pain types, outcomes were better for surgery compared with conservative care.

Those conclusions may lead surgeons to think surgery is the answer to the problem of pain associated with degenerative listhesis or spinal stenosis. But the authors suggest these results point out the need to find better ways to treat these two problems with conservative approaches.

It’s possible that some nonoperative treatment (or combinations of nonoperative care) might work better than others based on the location of the pain. Finding the treatment path that gives the best outcomes by diagnosis and by pain location is the next goal.

We know now from many studies done over the years that back pain is a common problem among adults the world over. Disc degeneration and herniation seem to be the most common diagnosis among back pain sufferers. Efforts to understand disc degeneration and pain associated with the problem are ongoing.

Many people have disc problems and never know it. They have no symptoms of back or leg pain.There is no numbness in the back, buttock, or leg and no change in reflexes or weakness that are commonly reported by patients with symptomatic disease. Is there a reason why some patients develop symptoms and others do not?

In this study, researchers use information collected in a genealogical database from the University of Utah to determine the influence of heredity on symptomatic lumbar disc disease. Genetics has long been suspected in this disease process, but no one has been able to pinpoint the specifics.

This study may be the first step in getting closer to our understanding of inheritance as a possible etiology (causative factor). Over a million patients are included in this database. The software makes it possible to search for patients with lumbar degenerative disc disease within the same family.

Results of treatment were compared for patients in the family clusters against a very similar group of patients (same diagnosis, age, gender, socioeconomic background) who did not have other family members with the same back problems.

Two statistical tools used in this study included the estimation of relative risks (RR) in relatives and the Genealogical Index of Familiality (GIF). The results showed a definite genetic link to lumbar degenerative disc disease in symptomatic patients. And because the condition was present in the first- and third-degree relatives, we know it’s not just a matter of shared environment or exposure.

For clarity, we should define the degrees. First-degree refers to siblings (brothers and sisters). Second-degree includes relatives in a different generation such as parents, uncles, aunts, grandparents (or grandchildren). Third-degree relatives can be within the same generation such as first cousins. In fact, first-degree and third-degree relatives are usually in the same generation, whereas, second-degree is a different generation.

Twin studies have previously shown the impact of genetics on lumbar degenerative disc disease and disc herniation. Other studies have shown that people who have a family history of disc herniations have more severe disc herniations themselves. Now this study adds support for a familial predisposition to lumbar disc disease.

The next step is to find out exactly what is the genetic link or abnormality. Is it in the cellular material that makes up the discs? Is there some miscoding on a particular gene that alters the biochemistry of the disc? Perhaps there is a genetic abnormality that changes the collagen protein in the disc.

The authors conclude that lumbar disc disease isn’t always caused by heredity but in some people, there is a definite inherited aspect. By studying genes that might be involved, it may someday be possible to prevent disc disease before it ever develops or becomes symptomatic (painful).

When it comes to treating chronic low back pain, there still remains quite a bit of debate and controversy. That’s because it can be very difficult to tell what is the problem and where the pain is coming from.

Even when studying the same problem (e.g., low back pain from disc disease), researchers often come up with conflicting results. For example, some will show conservative care is effective when dealing with degenerative disc disease. Others conclude surgery gives better results.

In order to narrow the playing field, this group of researchers from Chiba University in Japan studied a very select group of patients with painful disc disease. Each one had confirmed disc disease at one lumbar level (either L45 or L5S1). No one had leg pain — just low back pain.

No one involved in a worker’s compensation claim was included. Likewise, anyone who had previous back or spine surgery was not allowed to participate either. The presence of any other spine problems also excluded some people.

The goal was to get patients with disc degeneration and only disc degeneration and at only one lumbar level. It’s easier to tell if treatment is effective if everyone has the same exact problem.

The diagnosis was made using MRIs, pain provocation on discography, and pain relief by discoblock. You are probably familiar with MRIs (magnetic resonance imaging) as a diagnostic tool. MRIs use radio and magnetic waves to show details of internal structures like discs and ligaments. Discography and discoblock may be more unfamiliar terms.

Discography is the use of a radioactive dye injected directly into the disc. The patient’s response to the injection is telling. An increase in or reproduction of their pain suggests the pain is coming from the disc. CT scans of the area also show areas where the dye has gone where it shouldn’t indicating tears, fissures, holes, or other damage to the disc and/or its outer covering.

Discography isn’t always reliable and even if it’s positive, that’s not a sure sign that the patient will develop back pain or experience chronic problems because of the damaged disc. That’s why discoblock was developed.

With discoblock, an injection of a numbing agent like bupivacaine (similar to novacaine) is used. Immediate pain relief signals the disc is the problem. The test is accurate and reliable.

The surgeon uses a special real-time X-ray called fluoroscopy to make sure the injection gets to the exact right place (inside the disc). Studies show that patients who have a discoblock and then go on to have disc surgery have improved results from the operation when compared to patients who had a discography instead.

All that was just to diagnose the problem as accurately as possible. Now for the treatment. There were three groups. Two groups had surgery (two different approaches to spinal fusion) and the third group received minimal treatment (conservative care, a nonoperative approach).

The conservative approach was daily walking and stretching prescribed and supervised by a physical therapist. The program was carried out everyday for two years. Patients had to report monthly to their physicians. If they did not do the exercise program, they were not included in the study.

In order to measure the results, the authors assessed pain levels, function, and disability before and after therapy. Patients were followed for two years before the final “after” results were measured.

They found that the patients in the surgical groups had better overall results compared with the exercise group. The results were actually reported as significantly better for surgery.

When comparing the two types of fusion procedures used, the patients who had an anterior (from the front of the spine) approach had significantly better results than those who had a posteriolateral (from the back and side) fusion.

The anterior interbody fusion (ABF) procedure involved removing the disc and placing bone taken from the patient’s pelvic bone and using that to fuse the bones together. No hardware was used in this procedure.

The posterolateral approach was used when MRIs showed important blood vessels were too close together and couldn’t be avoided using an anterior approach. Screws and bone graft were used in the posterolateral fusion procedure.

Patients expressed their overall satisfaction with the treatment they received using a four-point scale: 1) treatment met expectations, 2) not as much improvement as expected, 3) treatment helped but not enough to do it over, and 4) same or worse than before treatment. More patients in the exercise group rated their results as poor (worse than before treatment). Patients in both surgical groups gave their results a fair-to-good rating.

The results of this study show that when patients truly have a degenerative disc as the main reason for their pain (carefully verified with testing), surgery yields better results than nonoperative care. The preferred fusion technique is an anterior approach. But when there is sufficient reason to use a different method, then a posterolateral approach offers good results as well.

If you were 80 years old (or older) and had chronic low back pain, would you consider a spinal fusion? What if you knew you would live another 10 years, 15 years, or even longer? More octogenarians (80 years old and older) are making that decision. And with the new minimally invasive surgeries, the option of a simple spinal fusion to stop the pain may be available for more seniors than ever before.

The first question that comes up when thinking about spinal fusion surgery in this age group is: safety. No matter how the procedure is done, there are some risks. But with improved surgical techniques, better surgical tools, and more advanced imaging available during the procedure, the risk of complications and problems has declined.

In this study, surgeons from Spine Midwest, Inc. in Jefferson City, Missouri performed a lumbar fusion on 40 patients 80 years old or older. Half the group had an open incision procedure. The other half was operated on using a minimally invasive approach. Minimally invasive means a smaller incision is made. Using a special retractor system, the muscles and soft tissues can be pulled aside instead of cutting away from the spine.

Many studies have shown that the minimally invasive approach reduces bleeding, length of stay in the hospital, and postoperative pain. The results of this study confirmed those findings and more. Just like younger patients, the older adults in this study benefitted from a surgical approach called the extreme lateral interbody fusion (XLIF).

With an XLIF, the surgeon passes surgical instruments to the spine from the side rather than from the back of the spine. By doing so, it is possible to avoid hitting blood vessels and nerve tissue that can result in serious complications. The XLIF has been compared with the more traditional approach to lumbar fusion (called posterior interbody lumbar fusion or PLIF). This may be the first study to compare them in octogenarians.

Most of the patients in the study (25) had a single-level lumbar fusion. But there were some (seven) who had two-levels fused, and eight others who had a three-level lumbar fusion. The risk of blood loss and need for transfusion increases with multi-level fusions. Any complication increases the risk that the patient won’t be able to go directly from the hospital to home.

And in this study, hospital stay was four days shorter for the minimally invasive group. Not only that, but only three of the patients who had the minimally invasive approach were sent to skilled nursing facilities. Those who had the open posterior lumbar interbody fusion (PLIF) were all discharged to the skilled nursing facility for further care and rehab. They were unable to return home.

The PLIF group had more serious complications such as infection, poor wound healing, and bone fracture. Even the number of deaths in the first six months after surgery was higher in the open PLIF group (six deaths in the PLIF group compared with only one in the minimally invasive group). Infection and blood loss were the reasons most patients died.

The surgeons also found that with the minimally invasive extreme lateral approach to fusion, they could insert a larger implant into the disc space compared with the posterior approach. A larger implant helps maintain the proper disc height between two vertebrae and improves spinal alignment. And with larger implants and greater stability, they could reduce what might have been a multi-level fusion down to only one-level.

The authors conclude if you are an older adult with disabling, degenerative back and/or leg pain, don’t give up. Your function and quality of life matter — maybe even more now than ever before! The results of this study suggest you could be a candidate for a procedure like the minimally invasive lumbar spinal fusion. Talk to your doctor today about your options, including the risks and benefits of minimally invasive surgery.

Long, open incisions to perform surgery on the lumbar spine (low back area) are no longer needed. New surgical tools and techniques make it possible to complete decompression and fusion procedures with several smaller incisions. This new approach is referred to as minimally invasive surgery (MIS).

The main advantage of the minimally invasive approach is less trauma to the bones, muscles, tendons, and other soft tissues of the spine. There is less bleeding and a faster recovery time. But even so, this technique requires the use of retractors to pull the tissues apart in order to give the surgeon access to the spine.

Even with a smaller incision, there is still the risk of trauma (cutting or crushing) to the soft tissues when using a minimally invasive approach. There is a learning curve that may contribute to problems. Studies show that surgeons have much greater success as their level of experience with this procedure increases. Reports of complications and problems are much higher at the beginning when surgeons are just starting to use this method.

In this article, a surgeon from the Spine Institute of San Diego, California reviews and summarizes studies published to date on the minimally invasive surgical technique for lumbar spine surgery. The goal was to report on ways to prevent muscle injury when using the posterior minimally invasive approach.

Even though the minimally invasive approach creates less trauma, injury, and damage to soft tissues when compared with an open incision, there have still been problems with this technique. At first, the procedure was done using an incision along the middle of the spine. But this midline approach cut through an important spinal muscle (the multifidus). Muscle weakness resulted in loss of function of this important spine stabilizer.

As a result, surgeons started making incisions on either side of the spine in order to avoid cutting the attachment of the multifidus muscle to the spinous process. The spinous process is the bump you feel along the spine, often referred to as your “back bone”.

A second change that has come about is the use of tubular retractors used to hold the soft tissues apart after the incision is made. The retractors are attached to the table. There are two advantages to this tool: 1) a surgical assistant no longer has to hold the retractors steady for the entire length of the operation and 2) pressure on the soft tissues, nerve, and blood vessels can be minimized.

These new table-mounted retractors are a great improvement over the self-retaining retractors used before. During long periods of retraction, pressure from the table-mounted retractors can be released from time to time. This feature reduces force and load on the muscles and tendons and helps maintain good blood supply to those areas. With shorter retraction times and periodic release of pressure, there are also fewer nerve injuries contributing to muscle weakness.

In summary, minimally invasive lumbar spine procedures have reduced the effects of muscle cutting and stripping that normally takes place with an open incision approach. But problems can still develop so surgeons have found even better ways to perform the minimally invasive technique.

Change in location of the incisions and safer ways to retract the soft tissues are now advised. Anything that can be done to reduce trauma to the soft tissues will provide a better result with fewer complications and problems. The patient benefits from the minimally invasive procedure without the added loss of spinal stability as an unfortunate side effect of the technique.

When it comes to lumbar spinal fusion, surgeons have more than one choice in how they do this procedure. Interbody fusion has become a commonly used technique that continues to change and improve over time. In this study, results from surgeons’ own experience as well as studies available are summarized for extreme lateral interbody fusion (XLIF). It might help if we explain a few terms before bringing you up-to-date on the study outcomes.

An interbody fusion refers to the removal of degenerative disc material from between two vertebrae (spine bones). The empty space is supported with a metal cage filled with bone chips. Long screws placed horizontally on either side of the disc space hold the segment stable until the fusion is complete. In this way, the body of one vertebra is fused to the body of another vertebra next to it (either just above or just below).

As far as lumbar fusions are concerned, the field of spine surgery has changed quite a bit. One of those changes has been the shift from a strictly anterior (from the front of the spine) or posterior (from the back of the spine) approach to a lateral approach.

A lateral approach means the surgeon enters the body and spine from an angle between the front and back. With an extreme lateral approach, the surgeon comes in from the front and side of the spine. A special tube is placed through the lateral abdomen, through the psoas (anterior hip muscle), and to the spine. With this portal (pathway), the surgeon avoids major blood vessels, organs, the spinal cord, and nearby spinal nerve roots.

Many people with chronic, severe low back pain from degenerative spinal conditions have come to depend on a lumbar fusion procedure to reduce pain, restore function, and improve quality of life. As you can imagine, open spine surgery can result in additional pain at the incision site, infections, and delayed or poor wound healing.

Surgeons have worked hard to find alternate ways to do lumbar fusions without using open incisions (e.g., minimally invasive). The studies included in this review involved patients who had lumbar fusion using the interbody technique. Different approaches were used (e.g., XLIF, XLIF and posterior, just posterior, just anterior) making it possible to compare results. All fusions were done using an open incision or minimally invasive technique so these two could be compared as well.

Results were measured by comparing surgical time, rates of complications, length of stay in the hospital, and use of narcotics after surgery. X-rays and CT scans were also used to verify that the fusion was solid. Patient reports of pain and function were compared at the one-year follow-up appointment.

The investigators behind this study found that there were wide ranges for many of the factors. For example, surgical times were as short as 67 minutes up to seven hours. Patients were in the hospital anywhere from one day up to six days. The more complex the procedure (e.g., combined XLIF and posterior fusion), the longer the surgical time.

Complication rates were all over the map from as low as two per cent up to as high as 30 per cent. Of course, it’s important to divide those figures between minor and major complications. Problems that are mild or don’t last long and go away completely are considered minor. Major problems such as dural tears, blood clots, and heart attacks can present many more long-term health issues.

Dural tears refer to damage of the very thin lining around the spinal cord. This can be a serious complication resulting in cerebrospinal fluid (CSF) leaking out. Cerebrospinal fluid is the fluid that bathes and protects the brain and spinal cord. Any leakage can lead to much more serious problems. Dural tears were most often reported in association with posterior lumbar fusion.

There were isolated cases of major and minor problems in all groups. The most common complication present with the XLIF approach was muscle weakness of the psoas muscle. The psoas muscle is a hip flexor that the surgeons pass their instruments through when using the XLIF approach. Fortunately, all patients who had this problem recovered fully within the first two months after surgery.

The best news of all were the fusion rates: between 91 and 100 per cent success. Pain and function were significantly improved after fusion with the extreme lateral approach. Outcomes for this new approach continue to improve over time as surgeons’ technical skills improve. Complication rates were lowered with the XLIF fusion method. We can expect to see more results reported in the coming years as the lumbar fusion procedure is performed more often using the extreme interbody method.

If you see older adults bent forward, you may wonder to yourself, “Why don’t they just stand up straight?” The answer may be simple: lumbar spinal stenosis (LSS). Stenosis (SS) is the narrowing of any opening. In the case of the lumbar spine, spinal stenosis refers to a smaller diameter of the spinal canal where the spinal cord or spinal nerve roots are located.

In the aging spine, bone spurs, thickening of the ligaments, and disc degeneration can all contribute to a smaller opening. Any narrowing of this opening for spinal nerves to pass through the bone from the spinal cord on its way down to the leg can result in painful symptoms.

Bending forward gives a slightly larger space for the neural tissue, taking pressure off the nerves, and reducing back and leg pain. The stooped forward position becomes an unconscious choice of comfort. Treatment is often nonsurgical with antiinflammatory medications, physical therapy, and steroid injections.

When conservative care is unsuccessful in reducing pain, improving posture, or restoring function, then surgery may be the next step. The timeline for successful treatment of spinal stenosis requires quick action — conservative care for three to six months. For best results, surgery is recommended when nonsurgical care is not effective and within a year of the start of their symptoms.

The most common surgical procedure for lumbar spinal stenosis is called a decompression and involves removing bone and soft tissue from around the neural opening (called the foramen). The lamina (the back portion of a protective circle of bone around the spinal cord) is often removed (called a laminectomy).

Decompressive laminectomy works well most of the time. But in some cases, poor results from a failed decompression can leave the patient with the same painful problem. Now in addition to the pain and stooped posture, they face recovery from the procedure as well. And if too much bone is removed, the spinal segment can become unstable.

Surgeons are exploring the use of a new tool called a microblade shaver to get inside the neural canal. This instrument allows the surgeon to carefully remove just the right amount of soft tissue, thereby reducing pressure on the nerve tissue without losing spinal stability.

The shaver has the added advantage of being flexible enough to go forward and back, where the standard tool only allows side-to-side motions. The shaver is inserted into the foramen and pulled back and forth almost like using dental floss. The end-result is removal of impinging tissue while preserving the lamina and facet (spinal) joint. Saving the facet joint is important because without it, motion of the vertebra is altered. Increased shear and rotational forces develop adding to spinal instability and putting added stress on the disc.

When the microblade shaver system was first developed, a pilot study with nine patients was done. The preliminary results were very positive — encouraging enough to repeat the study with a larger number of patients. This time there were 67 patients included in the study. Some of the patients had more than one level decompressed so there was a total of 132 levels treated with this shaver system.

Again, the results were very promising with successful decompression of the spinal nerve root that was being pinched. Pain relief and return of function were reported by everyone in the study. All patients remained stable and no one needed any further surgery in the first 12 months after the procedure.

The authors suggest the use of a flexible shaver system like the microblade used in this study will become very important in the near future. With 38,000 decompression procedures done each year in Medicare patients and the next wave of senior citizens from among the Baby Boomers, spinal stenosis is likely to become an even bigger problem than it already is for this age group.

The next step in the investigation of this flexible microblade shaver system is to follow-up the stenosis patients who have already been surgically treated with this tool. Long-term results are needed before declaring the technique an absolute success.

As more patients are treated for stenosis with this system, any risk factors will become clear. Predictive factors (factors able to predict success or failure) may also help guide surgeons in choosing the best surgical treatment for patients with lumbar stenosis — and choose the right patients for each procedure.

Patients are clamoring for less invasive surgical procedures. But before surgeons leap from open incision spinal fusions to the minimally invasive technique, it might be helpful to compare the results from these two approaches.

If the minimally invasive procedure yields better outcomes, then great — surgeons will want to get trained and pursue that method. But if there’s no difference between the two, then some experts suggest maybe it’s time to slow down and think about the direction spinal fusion surgery is headed.

One of the most popular fusion procedures used for the lumbar spine is called atransforaminal lumbar interbody fusion or TLIF. It is quickly replacing the posterior lumbar interbody fusion (PLIF). What’s a TLIF and what is the difference between TLIF and PLIF?

Let’s start with the basics. An interbody fusion refers to removal of damaged disc material between two vertebral (spinal) bones. The space is filled with a tiny metal cage that helps hold and support the diseased spinal segment. That’s what makes it an interbody fusion (between two the main bodies of two vertebrae). The cage is filled with bone graft material that will become part of the solid bone fusion holding the spinal segment in place without movement at that level.

Transforaminal and posterior are words used to describe the location where the surgeon makes the incision to gain access to the spine. Transforaminal comes in at an angle from the side, whereas posterior is from the back of the spine. The transforaminal approach has gained in popularity because it reduces the possibility of cutting through important nerve structures such as the spinal cord or spinal nerve roots.

As the technique for lumbar fusion has changed and progressed, so have the surgical instruments used in fusions. It is now possible to use small incisions yet still get the full view of the spine being operated on. That’s what we mean by minimally invasive surgery. Special tubular retractor systems hold the skin and soft tissues open over the segment being fused. Real-time (3-D) X-rays called fluoroscopy make it possible to see inside the spine and aid in the procedure.

The minimally invasive approach has been shown to reduce blood loss, speed up recovery, and shave off the number of days patients spend in the hospital. But there’s a steep learning curve for the surgeon. It takes a while before the procedure has been done enough times to gain the expertise and accuracy needed for the best possible outcomes. That’s probably the biggest drawback to minimally invasive interbody fusion.

The question then is: if all things are equal, which procedure has the best results: minimally invasive posterior lumbar interbody fusion (MI-PLIF) or minimally invasive transforaminal lumbar interbody fusion (MI-TLIF)? And how do these two surgical approaches compare when the surgery is done using an open incision technique?

To find out, the authors of this article reviewed all the studies published so far comparing these two fusion techniques. They took into consideration the ability of new technology to provide the surgeon with better lighting and magnification of the surgical site.

They discussed the improved fusion rates with interbody fusions and the muscle damage that’s done when open incision is used instead of a minimally invasive approach. But they also bring out the fact that the retractor tube used in minimally invasive spinal fusion surgery has the potential to compress and damage tissue being pulled out of the way.

A summary of clinical studies published comparing minimally invasive TLIF with open TLIF and PLIF was presented in table form. Most of the studies had a small number of patients (less than 50). Not everyone performed the procedure in the same way or collected the same data on patients. That makes it difficult to make meaningful comparisons.

But from the available information and analysis performed on the data collected, it looks like minimally invasive lumbar interbody fusion surgery is as good as (if not better) than open procedures. There is less blood loss and shorter hospital stays.

Postoperative problems appear to be about the same in type and number between minimally invasive and open procedures. Use of narcotic medication is less for patients having the minimally invasive surgery. Length of time in the operating room under anesthesia was slightly longer when a surgeon with little experience was performing a minimally invasive procedure. As such, patients with longer operating times are often exposed to longer periods of radiation from the fluoroscopy.

Patients who should not have a lumbar fusion no matter what type of approach is used include those who have bones too weak or brittle to support a cage. Fusion rates do not appear to be as affected by type of surgical approach as by the patient’s age and condition of bone. Concerns that the minimally invasive method doesn’t give the surgeon enough room to prepare the graft site or get enough bone graft to the area were set aside.

In summary, although the studies were small, the results confirm the benefits of minimally invasive interbody lumbar fusion. Minimally invasive surgery yields just as good of results as the open incision technique and with some advantages in terms of less blood loss, shorter hospital stay (cost savings), and less postoperative pain.

What remains to be explored are the long-term effects and differences between these two surgical techniques. Larger studies comparing equal groups of patients are also needed to generate statistical validity for results. Hopefully over time, trends in one direction or another will replace current conflicting data. This type of information will help surgeons choose patients more carefully for minimally invasive lumbar spinal fusions in order to get the best outcomes.

For almost 30 years surgeons have been fusing the lumbar spine using the popular transforaminal lumbar interbody fusion (TLIF) technique. The surgeon approaches the spine from the side rather than from the front (anterior approach) or the back (posterior approach).

The TLIF method of lumbar fusion has many advantages. The lateral approach gives the surgeon access to the disc and disc space without applying excess pull or traction on the nearby spinal nerve(s). With a lateral approach, it is only necessary to remove one spinal joint (rather than the joints on both sides of the spinal level being fused) in order to get to the disc space.

The procedure was first done with an open incision approach called an open transforaminal lumbar interbody fusion or oTLIF. This procedure required cutting through the spinal muscles to get to the spine.

Over time, surgical technology and equipment have improved and advanced so that the procedure could be done as a minimally invasive (MI) approach. Minimally invasive means a very small incision is made.

In a minimally invasive TLIF (referred to as mTLIF), a long thin tube is passed down through the skin, fascia, and muscle down to the spine. It is not necessary to dissect (cut through) all these layers of soft tissue. Surgical instruments and hardware (cages, screws) used to fuse the spinal segment are passed through this tubular retractor system.

In theory, a minimally invasive approach reduces blood loss during the procedure and postoperative pain afterwards. Hospital stays are shorter with the mTLIF, which means lower costs. Other advantages of the minimally invasive approach have been reported. For example, there is less damage to the muscles and less tissue trauma overall. The surgeon uses 3-D navigational (surgical) tools that allow him or her to see the correct pathway and avoid injury to nerve tissue.

That all sounds good in theory, but how do the results of these two different ways to perform a TLIF compare? A study was done to compare fusion rates and complications for the open transforaminal lumbar interbody fusion (oTLIF) with the minimally invasive TLIF (mTLIF). The method used to do this comparison was a literature review.

By conducting a computer search, the authors of this study found 23 studies including a total of 1028 patients who had the TLIF procedure. There were an equal number of men and women in the total database. Ages ranged from 38 to 65 years old. There were twice as many oTLIF (open) procedures compared to the mTLIF (minimally invasive) approach.

Most of the studies were case series (a lower level of evidence). But by combining the results of multiple studies like this creates a meta-analysis. This research tool is helpful when the number of patients in each case series is too small to achieve significance on its own.

The results of this comparison showed nearly equal fusion rates between the two procedures. Open TLIF had a 90.9 per cent fusion rate. Minimally invasive TLIF had a slightly higher rate at 94.8 per cent. Rates were determined in follow-up at least six months after the surgery. Some fusion rates were for follow-up periods as far out as 46 months (almost four years) after surgery.

What about complications? The types and numbers of problems encountered by patients in both groups postoperatively were also similar. For example, complications after the open TLIF were calculated at 12.6 per cent. Complications after the minimally invasive TLIF were reported at 7.5 per cent.

Typical complications in both groups included dural tears (lining of the spinal cord) with leakage of the cerebrospinal (CSF) fluid, leakage of the cerebrospinal fluid, infection, misplaced screws, and radiculopathy (pain down the leg from irritation or compression of the spinal nerve root).

As predicted, the minimally invasive (mTLIF) method may be slightly safer than the open procedure. The difference in complication rates may be due to the more frequent use of bone morphogenetic protein (BMP) in the mTLIF group. Bone morphogenetic protein was developed as a grafting technique to help speed up bone healing.

Half of all the mTLIF procedures were done with bone morphogenetic protein (BMP) and may be the reason why complication rates were lower with the mTLIF procedure. But the intent of this study was not to assess the BMP technique as a factor in results. The authors suggest future studies are needed to compare lumbar fusion with and without BMP for oTLIF versus mTLIF.

For now, they concluded that fusion rates are good-to-excellent for both open and minimally invasive TLIF. Efforts to reduce complications from soft tissue trauma and dissection using the mTLIF seem to be successful. This is the first study to make these comparisons. As such, the results provide a “benchmark” or baseline for future studies to verify or add to these findings.

In today’s evidence-based medicine, efforts are being made to develop standard ways to treat problems. The goal is to find treatments that yield consistent, effective results. Such a research-based treatment protocol is referred to as a clinical practice guideline (CPG). Not all conditions have clinical practice guidelines yet but there are such guidelines for the treatment of acute low back pain.

It’s clear that not all patients receive care following these guidelines. So the purpose of this study was to compare results for patients who are treated in the usual manner against those who receive treatment based on the published clinical practice guidelines.

It might be helpful to define a few terms. Acute low back pain is the pain that develops early on (first four weeks). The patients in this study had low back pain lasting between two and four weeks. They ranged in age from 19 to 59. There were no patients included who had a fracture, infection, or tumor causing low back pain. Patients were randomly placed in one of two groups.

Patients in the study group (SC) were cared for following the clinical practice guidelines (CPGs). The CPGs recommend giving patients reassurance that the back pain will go away. This type of counsel is based on known research regarding the natural history (what happens over time) of acute low back pain. The proven natural history of acute low back pain is that more than 80 per cent of all adults with this problem do get better within days to weeks.

The study group also received advice to stay out of bed, stay active, and start walking. Chiropractic care (spinal manipulation) of the lumbar spine was administered two to three times a week for up to four weeks. Things that were NOT allowed included: braces or corsets, muscle relaxants or opioid drugs (narcotics), core stability exercises for the trunk or extension exercises for the back, and (as already mentioned) bed rest. They were allowed to take Tylenol (acetaminophen) for pain relief.

Patients in the second group (called the usual care or UC group) did not all get the same standard care. Some were treated by a physical therapist while others saw a massage therapist, their family doctor, or a kinesiologist (the study was done in Canada where kinesiologists who are movement experts practice).

Outcomes were measured at regular intervals (time periods) of eight, 16, and 24 weeks after treatment. Results were compared to baseline (before treatment) measurements. And improvements in pain, motion, and function were assessed at each of these points using standard tests such as the Roland-Morris Disability Questionnaire and the Short Form-36 (measures pain and physical function).

How did the two groups compare? Overall, there were more patients in the study group (those who received spinal) manipulation who did better than the patients in the usual care group. Those improvements were seen at each of the check-points but were most pronounced at the 24 week mark. An equal number of patients dropped out of each group so that aspect of the study was similar between the two groups.

The a
uthors say the significance of this study is three-fold. First, it shows how using the Clinical Practice Guidelines already outlined for the treatment of acute low back pain really are successful (and more effective than other approaches).

Second, it is the first study to look at all the components of the Clinical Practice Guidelines (CPGs). Many previous studies have just used one or two parts of the CPGs, not the entire package. And third, the results again show physicians the importance of switching from the usual care they are prescribing to a more effective and proven approach.

This last piece (physician compliance with CPGs) is a bit of a trick. Other studies conducted by these same authors have already shown that primary care physicians are resistant to changing the way they treat patients with acute low back pain. The reasons for this attitude remain unclear at the present time.

More study is needed to find reasons for physician resistance to adopting published clinical practice guidelines for the treatment of acute low back pain when the evidence is clear about the superiority of this program over others. The authors also suggest a future long-term study to see if recurrence of low back pain occurs in one group more than the other.