News Category: Lumbar Spine

The cause of most back pain remains a mystery. Researchers are trying to find clues to help doctors treat the problem. Knowing the cause would help direct treatment. Specific remedies could be provided.

There is a test called discography that can be used to see if low back pain is being caused by disc disease. The disc is an oval-shaped cushion located between the bones of the spine. Pain with disc disease can occur when there is a tear in the covering around the disc. The tear itself can cause pain. It may also produce inflammation and pain due to irritation of the nerves near the problem disc.

One group of doctors at the Stanford University School of Medicine used discography to test an idea. They wanted to see if this test could prove the disc was the source of back pain. A dye is injected directly into the disc. The patient’s pain response is charted, and an X-ray of the disc is taken. Two groups of patients were tested. One group had a mild but persistent backache. The second group had chronic low back pain.

The hope was to find a test that could detect disc disease when it is the primary cause of back pain. Current ways to image the parts of the spine tend to show a spectrum of degenerative changes, regardless of whether a person has pain or not. Also, psychological and social factors are known to influence back pain. Finding a single test to rule out one cause of back pain would be helpful.

After studying all the results, the researchers made several conclusions. Discography isn’t a reliable test for disc disease as the cause of the back pain. Both groups had equal amounts of positive test results. The group with chronic low back pain was more likely to report severe pain at many levels. However, this group didn’t have more disc damage when examined with magnetic resonance imaging (MRI).

The cause of chronic low back pain still remains a mystery. Discography couldn’t be used to separate those patients with back pain from those with disc disease. There was an equal number of positive tests, even among people who had mild back pain that went away.

An epidural steroid injection may be recommended for ongoing back and leg pain (sciatica). The steroid is a powerful anti-inflammatory drug that is injected into the area around the spinal cord (the epidural space). Epidural steroid injections have been used for more than 50 years. Although they can have complications, they are generally considered a safe way of dealing with back and leg pain–which is why this case report is so surprising.

This doctor’s report is about a rare complication that happened to a 39-year-old man after an epidural steroid injection for sciatica. The injection went well. However, the patient developed severe visual problems the next day, requiring him to start wearing glasses.

An eye exam showed that the man’s vision was now 20/400 in both eyes, which means he’d become extremely nearsighted. The cause was bleeding in the retinas of his eyes. The man also developed diabetes three weeks after the steroid injection and eventually needed insulin treatments.

A search of the medical literature showed that nine other patients–all women–had developed severe vision problems after an epidural steroid injection. This was the only case the doctor knew of in which diabetes developed along with vision problems after this type of injection.

The doctor determined that the man’s existing high blood pressure and extra weight had made it more likely for him to develop retinal bleeding and diabetes. This doctor warns that other doctors should be aware that high blood pressure and diabetes can put patients at a higher risk for vision problems after epidural steroid injections. The doctor also recommends that the smallest possible amount of medicine be injected very slowly into the epidural space. This is thought to cause less pressure in the spinal fluid in the head, which may make retinal bleeding less likely.

This scary tale has a happy ending. Over the following year, the man’s vision slowly got better. He still needed glasses a year later, but his vision improved nearly to normal (20/40). His diabetes also went away. And although it probably seemed like a minor problem by then, his sciatica did not come back.

Cricket might seem like a slow-moving, genteel sport to some. But this sport causes some serious back problems in “fast bowlers.” As many as 65 percent of young fast bowlers develop disc degeneration in the low back by age 18. It appears that different bowling techniques (“front-on” and “side-on”) can reduce injuries. Could coaching to improve technique make a difference?

This study, done in Australia, looked at the effects of an intensive training program on back and shoulder injuries among a group of school-aged fast bowlers. The boys were followed for three years. They went to a seminar every year. They also got six coaching sessions each year that specifically worked on the front-on and side-on techniques. The boys got physical exams each year to check on spine degeneration.

The results were impressive. After three years of coaching, the rate of bowlers using the better techniques had risen from about 20 percent to about 66 percent. The authors also note that their bowling speed remained the same as bowlers using the unsafe technique.

The physical results were also impressive. At age 13, the bowlers showed the expected disc degeneration rate of about 24 percent. Four years later, only 33 percent showed disc degeneration. This was much less than would normally be expected. The bowlers who switched techniques stopped the progression of disc degeneration. The only boys whose disc degeneration got worse were those who continued to use unsafe techniques. 

The authors note that it took three years of intervention to see such good results. The coaching showed few results in its first year or two. They conclude that intensive training can be very effective in reducing injuries in young cricket players–but the training needs to be long-term, individualized, and intense.

By gathering the results of a particular type of surgery, health care providers are better able to guide back patients through an array of treatment choices. One procedure with few long-term studies is microsurgery for sciatic pain that hasn’t gotten better even after a lot of nonsurgical treatment.

Sciatica is the name given for pain that runs from the lower back down the leg. The cause of sciatica can be hard to pinpoint. If the nerve is being pinched from a herniated disc, surgery may be needed to remove the pressure. Microsurgery to remove part or all of the problem disc in the low back is categorized as lumbar microdiscectomy.

This study followed about 250 sciatica patients in Austria. All patients had some type of lumbar microdiscectomy. Although there are several reasons a person might need this procedure, the only factor for surgery in this group of patients was sciatic pain.

An average of seven years after surgery, one fourth of the patients were free of pain. Over 65 percent were much improved, leaving about 10 percent that were no better or were worse.

The authors also checked on the patients’ work history. About 65 percent of patients had returned to their jobs. Of the remaining patients, 15 percent had been forced to change jobs because of their sciatica, 14 percent were forced to take early retirement, and 6 percent were unable to work.

The authors noted that patients who’d had prior back surgeries and patients who had sciatica for longer than three months were the least likely to get better. They conclude that intensive conservative therapies are the front-line treatment choice when sciatic pain from a herniated disc is not causing worsening neurological symptoms. However, they balance this conclusion by commenting that if sciatic pain has been present longer than three months, the surgical results are generally not as good.

Surgery to fuse the spine is a well-known treatment for severe low back pain that just won’t go away. This surgery is done most often when the patient has changes in the discs such as thinning and tears, commonly called degenerative disc disease.

There are many studies comparing types of fusion and results of fusion. One important question is whether to approach the disc from the front or back of the body. There are so many factors to consider, it’s somewhat like comparing apples to oranges.

A new study compares fusion at one level when done from the front (anterior approach) versus the back (posterior approach). A single-level procedure fuses two vertebrae together. This type of spinal fusion is simpler than multi-level fusions. There are fewer problems during or after the operation.

According to this study, the anterior approach was the better choice for many reasons. There was less blood loss and less need for blood transfusion. The surgery time was shorter and the stay in the hospital was also shorter. Patients who had the anterior fusion had less need for transitional care after leaving the hospital.

In some cases, the patient’s condition requires one method over the other. This may be the case when there are many spinal levels involved. The posterior method may be used when there is a deformity that must be corrected. The anterior approach is best when a single level must be fused and there are no other problems present.

Medical experts know that an active rehab program after back surgery is helpful. Patients who have had a disc removed in the low back area tend to get better with active exercise. They often have less pain, more movement, and more function.

But what happens to these patients much later? How are they doing five years later? Doctors and physical therapists in Sweden studied this question. They divided patients into an early active treatment (EAT) group and a less active treatment group.

Men and women of all ages were part of the study. All the patients had symptoms caused by disc herniation in the low back. Treatment without surgery hadn’t helped these patients. Surgery to remove the problem disc was done on everyone in both groups.

A rehab program was started right after surgery for both groups. This was earlier than in most centers. The rehab lasted 12 weeks. It was started while in the hospital and continued at home during that time. The patients in the EAT group had fewer re-operations. The early rehab program didn’t seem to affect anyone negatively in either group. Both groups had the same number of sick days.

Returning to work after low back disc surgery is the goal of most patients. An active rehab program after surgery can help improve a patient’s chances of living without medications and getting back to work. According to this study, getting started early in a training program doesn’t increase the chances of reinjury requiring another operation.

Evidence is growing that low back pain is fairly common in kids. This study looked at almost 300 children between the ages of nine and 12 in Belgium. The goal of the study was to find factors that predicted which kids would develop low back pain.

The children were seen once at age nine and again at age 11. They filled out a survey about their health, activities, general well-being, and back pain. They also went through a medical exam that included a check of the spine and lower back. At age nine, about 36 percent of the children reported having low back pain at some point in their lives. At age 11, about 35 percent reported having low back pain.

The researchers found no good predictors of which children would develop low back pain. Only two factors seemed to have any relation to back pain. One factor was that children who walked to school seemed less likely to develop low back pain. The other factor was that children who see themselves as having poor health and who scored themselves lower on general well-being were more likely to report back pain–just like adults.

Notably, about 18 percent of the children who said they had low back pain at age nine reported never having low back pain at age 11. Researchers suggest that could be because low back pain in young children is not a big deal. It could be that it gets better quickly and is easily forgotten. It is also notable that most of the kids who reported having had back pain said they had it yesterday. So even if a third of young children do have low back pain, for most it doesn’t seem likely to become a long-term problem.

Talks about when to fuse the spine are ongoing among doctors. This is especially true for patients with a condition called spondylolisthesis. This problem occurs when a vertebral bone in the spine slips forward over the one below it.

Spondylolisthesis narrows the opening of the spinal canal. This is called spinal stenosis. This in turn may put pressure on the spinal cord and spinal nerves.

Surgery may be needed to take the pressure off the spinal cord and nerves. How much and what to do isn’t clear. The standard operation is to remove part of the ring of bone around the spinal cord. The disc between the bones may also be removed. The final step is to fuse the vertebrae together. This will prevent any further movement or slippage in the problem area of the spine.

According to the authors of a study in Germany, fusion may not always be needed. Taking pressure off the spinal cord may be all that’s needed. This is true when the spine is stable, and there isn’t any extra motion where the spondylolisthesis is located.

Taking the pressure off the spinal cord and spinal nerves without fusing the bones may be the best approach. The authors suggest this for older adults with spondylolisthesis. There are fewer problems after the operation without fusion.

Each decision must be made on a case-by-case basis. First, treatment without surgery is tried. When surgery is needed, only the smallest amount of bone is removed from around the spinal canal to take pressure off the spinal cord. Fusion is best when there is pain and extra motion in the spine at the level where one vertebra is slipping over the one below it.

What is known about back muscle strength and back pain? Patients with low back pain seem to have weak back muscles that get tired easily. Poor muscle endurance has a part in causing low back pain.

But there is a complicated interaction between the muscles that cover the back, buttocks, and hips. It’s hard to separate the actions of these muscles. They usually work together. When a load is placed on the back, the buttock muscles are quick to respond. Researchers find that to work the smaller muscles along the sides of the spine (paraspinal muscles), actions in the larger buttock muscles have to be minimized. The question is “How?”

Various styles of equipment and exercise are used. One type of machine used is the Roman chair, which can be adjusted to help work the back muscles.

But which equipment is best, and how much exercise is needed? Are three sets of 10 repetitions of each exercise needed? Is one set of eight to 12 repetitions enough? Do the number of sets and amount weight have to be increased in order to strengthen just the paraspinal muscles?

Researchers at an exercise science lab think that these paraspinal muscles are mainly used to hold the spine steady. They aren’t designed for moving higher loads. The buttock and hamstring muscles begin to kick in with higher loads. Adding more load to the spine while using the Roman chair may only increase the forces against the discs between the spine bones. This could put the person at increased risk for back injury.

Multiple sets of exercise to strengthen back extensor muscles are under question. According to these researchers, only one set of exercise is really needed. This is true for young, healthy people who participated in the study. Patients with low back pain may need a different amount of exercise.

In 1999, a new treatment for low back pain caused by disc disease was introduced. It’s called intradiscal electrothermal treatment) (IDET). IDET involves inserting a needle into the center of the disc. The needle is equipped with a heating coil that raises the temperature of the disc to 140 to 150 degrees Fahrenheit.

The idea behind IDET is that heat can destroy tissue. In this case, the part of the cell that registers pain is destroyed. At the same time, the tissue around the disc shrinks and tightens up. This area is called the outer annulus.

Studies must be done whenever a new treatment is tried. This means repeating the same research and comparing the results. When a treatment method works, other doctors in other centers can repeat this success.

Two doctors in the Netherlands used IDET with 20 patients. Results were measured after six months. Several variables were measured such as pain, physical and social function, and overall health. There was some improvement in pain, but no other changes. The authors feel that there isn’t enough pain relief with IDET.

These doctors suggest that the actual temperature increase in the disk is limited with IDET. It’s probably not enough, the believe, to destroy cells or shrink tissue. According to the results of this study, patients may still have low back pain after IDET. Because of the method of needle insertion, only patients with mild disc disease can have this treatment.

Do athletes who have injured their backs run slower after the back is healed? These researchers set out to answer this question. They thought it might show if there are leftover problems even when the back pain is gone.

A timed 20-meter (66 feet) shuttle run was conducted. This short distance stressed the back and legs but did not cause cardiovascular fatigue, which could affect the results. Twenty-seven athletes with resolved back pain were compared to athletes who had never had back pain. The athletes who had back pain were in fact slower.

This is important information because many athletes suffer back injury or pain. They usually return to their sport when the symptoms are gone. Unknown changes may be affecting their performance. Other studies have shown that injuries in one part of the body can result in other injuries. For example, a knee or hip injury can lead to a future back problem. This phenomenon appears to be especially true for women.

Changes in function and performance may be present in athletes long after their injury has healed. This has been shown in cases of athletes with low back pain. For example, when the pain is gone and the athlete returns to his or her sport, running time is slower. According to researchers, this confirms the idea that the function of the hips, legs, and feet is affected by a previous back problem.

More research is being done to see if the 20-meter shuttle run can be used as a screening tool. Identifying athletes with residual changes from a previous injury could be an important part of training.

Back pain in athletes is common. Gymnasts, divers, weight lifters, golfers, and football players report back pain the most often. College students on rowing teams (called crew teams) are also at risk for back pain. In fact, back pain among rowers has increased a lot in the last 20 years. This is true for both men and women crew teams.

There are many possible reasons for this increase in back pain among rowers. The style of rowing has changed, and training is much more intense. Athletes who use many different training tools have higher rates of back pain. This may include weight machines, free weights, and indoor rowing machines referred to as “ergometer rowing.”

Ergometer training has made it possible for more rowers to practice for longer periods. Training on the ergometer is more difficult than rowing in a boat. The longer a rower uses an ergometer, the more his or her rowing technique declines.

Other changes in the sport of rowing have included taller and heavier athletes. Increased height is linked with back pain in female rowers. The shape of boat oars has also changed and may be adding to strain on the back. The use of a “hatchet” oar blade is a also risk factor for back pain.

There are several suggestions for preventing injuries in college rowers. Training type, frequency, and intensity should be monitored carefully. Ergometer training should be done for less than 30 minutes at a time. The focus should be on cardiovascular training rather than strength training. Early training must be on strengthening for the back, hamstring, and shoulder blade muscles. Novice rowers should use tulip-oar blades until they are strong enough to handle hatchet oars.

Spondylolysis is a term used to describe a defect, or crack, that forms in the bony ring on the back of the spinal column. It is especially common among certain younger athletes, including gymnasts, weight lifters, and football linemen. Most of the time it doesn’t require surgery.

Because so few patients undergo surgery, it is unclear what to expect afterwards. Are athletes able to return to their sports? These doctors looked at four of their patients who had surgery for spondylolysis. All four were competitive athletes, ranging from 13 to 22 years old. All four had at least six months of conservative treatment before opting for surgery. They all had the same type of surgery and the same type of rehabilitation.

Within six months, all four patients were working toward going back to competition. By one year after surgery, all four were competing at their former levels. Only one patient reported ongoing problems. He had low back pain, but he continued with his sport.

Such a small study doesn’t prove much. But it does suggest that surgery for spondylolysis can have a good result and may help active adolescents get back to their sports.

Some boys and girls involved in sports seem to be at risk for a certain kind of back problem. Ballerinas, football players, and weight lifters are the most likely to develop this problem. It’s called spondylolysis. This is a term used to describe a defect, or crack, that forms in the bony ring on the back of the spinal column. The area affected is called the pars interarticularis, so doctors sometimes refer to this condition as a “pars defect.”

It remains unknown what causes this defect to occur. Doctors think that repetitive stress on the bone is the most frequent cause. Others include weakness of the nearby soft tissue, a defect in the bone that is present at birth, and traumatic spine injuries.

In young athletes, this problem can be treated with temporary changes in activities. For example, the athlete is instructed to avoid overextending the back or repeating spine motions in any direction. Physical therapy treatment and pain medication can also be helpful.

Any young athlete who develops painful back symptoms should be seen by a doctor. Early treatment can help young people avoid serious injury later.

There is new research information about herniated discs. It seems that disc herniation may be the result of inflammation. In fact, the sciatica and low back pain that are symptoms of disc herniation may really be caused by a chemical process.

Disc material, present between the bones of the spine, may be able to respond to damage or injury with an inflammatory response. One substance in the center of the disc, called PGE2 may be able to cause pain. It does this by irritating the nerve roots leaving the spinal cord. PGE2 may be linked to sciatica and low back pain.

Scientists in Japan studied the disc material taken from patients with disc disease. In some cases, the disc had herniated or pushed into the spinal canal. Other discs included in the study had broken off and were floating in the spinal canal. These samples were compared to normal disc material taken from patients with vertebral bone fractures.

This was just one of several studies to confirm the idea that inflammation is part of the herniated disc process. It’s a bit more complicated than just an increase in PGE2 causing herniated discs. There’s also an enzyme called COX-2 that helps the PGE2 along. The more COX-2 is present, the greater the amount of PGE2 that becomes part of this inflammatory process.

Researchers think that keeping COX-2 levels down will reduce the use of PGE2. This, in turn, means less inflammation, less irritation of the nerve roots, and fewer symptoms for disc pain patients. Antiinflammatory drugs designed to stop COX-2 have recently begun being used to treat the symptoms of disc herniation. It seems that these drugs are effectively limiting the effect of COX-2 and thereby helping to reduce the symptoms and the underlying cause of the problem.

There’s some new thinking going on among doctors and researchers about back pain. Doctors used to think back pain that went below the knee from a disc problem was always caused by pressure on the spinal nerve root. When the disc pushes out of its normal space, it can come up against the spinal nerve as it leaves the spinal cord.

This pain from an irritated nerve is called radicular pain. Radicular pain begins in the low back and spreads or “radiates” down to the buttock, hip, knee, and lower leg (below the knee).

A separate and different cause of pain is called referred pain. Referred back pain from disc disease occurs in the low back but is also present in the hip, buttock, thigh, or lower leg. It doesn’t spread from place to place. It is usually present in one or more locations at the same time.

Several new studies now show that the disc itself can refer pain into the lower extremity. Pain below the knee can be from the disc or from pressure on the nerve. This is important information because different treatment may be needed. Treatment depends on the actual cause of the pain.

More studies are needed to help doctors understand the exact pathways of pain. Better tests are needed to diagnose the exact cause of back pain. Studies are also needed to show which treatment works best for each type of pain.

People in many countries are living longer in good health. They are staying active, but many age-related diseases can get them down. One of these is a back condition called spinal stenosis. This is a narrowing of the spinal canal. The spinal cord travels down this canal from the brain to the low back.

Spinal stenosis can cause severe pain that keeps the patient from walking more than a few feet without stopping. There’s an operation that can help open up the space and reduce the symptoms. But if you’re over age 75, the risks that go with surgery can increase. And if you also have other problems, such as heart disease or diabetes, you may decide to skip the operation and just live with the pain.

A recent study from Israel offers some new hope. One doctor operated on 122 patients with spinal stenosis. All were 75 years old and older. Many of these patients had more than one medical condition. Careful records were kept to see how well these patients did.

There were some problems after surgery. Problems included chest pain, heart failure, and wound infection. No one had to stay in the hospital longer because of these problems. Patients were much better after the operation. There was less pain, and they could complete more of their daily activities. Walking distance increased greatly.

The author of this study concludes that older adults can benefit from surgery for spinal stenosis. Even with other diseases present, the results can be good. Patients report reduced back and leg pain. They can do more and walk farther. It’s not necessary to avoid this surgery just because of age and age-related conditions.

Back pain is an old problem that’s been with us from the beginning of time. Solomon once said, “There’s nothing new under the sun.” It’s a good thing he wasn’t talking about treatment for this problem, because he would have been wrong. Doctors, researchers, and scientists continue to move forward with new studies everyday.

This study involved placing a spacer between the bones of the spine. This oval-shaped implant is made of titanium and is used to treat painful lumbar stenosis. Stenosis in the low back is a narrowing of the opening for the spinal nerve roots. Pain, numbness, and weakness in the legs occur when there is pressure on these nerves as they leave the spinal column.

Patients with stenosis often get relief by bending forward. This position opens the space for the spinal nerves. It’s usually difficult to stand up straight with this condition. The implant holds the spine in a slightly forward bent position. This relieves the symptoms of stenosis while allowing the patient to stand up straighter.

The spacer also decreases pressure on the discs between the spine bones (vertebrae). The load is transferred from the disc to the vertebrae. This occurs at the level where the implant is placed. No changes occur in the discs above or below the spacer. This is important because other studies have shown that increased pressure on a disc can cause damage.

There is a reason that calcium is most often combined with vitamin D in supplements. Vitamin D is needed for the body to be able to use the calcium to build bone. Too little vitamin D can be almost as bad for your bones as too little calcium. Vitamin D deficiency causes a condition called osteomalacia. Osteomalacia makes the bones soft, which can cause deformities and weakness. Luckily vitamin D is easy to get: just step into the sunshine. Direct sunlight causes your body to make its own vitamin D.

In some places, soaking up the rays is just not possible–for example, along the Arctic Circle during winter. But sunny desert countries see problems with vitamin D deficiency, too. People who live there commonly cover up and try to avoid the outdoors because it is just too sunny and hot. This is especially true of women in Muslim countries such as Saudi Arabia, who traditionally wear full body coverings every time they go outdoors.

A group of Saudi Arabian doctors checked vitamin D levels in 360 patients, most of them women. All of the patients had low back pain with no specific cause (idiopathic low back pain). Idiopathic low back pain is known to happen in people with osteomalacia caused by too little vitamin D. All the patients had X-rays to rule out other causes of back problems. They had a blood test to determine their vitamin D levels. The doctors found that 83 percent of the patients had low levels of vitamin D. The doctors then put all the patients on three months of vitamin D supplements.

After three months of taking vitamin D, the blood tests were repeated. All 360 patients had normal levels of vitamin D, and 95 percent of them reported that their low back pain was gone. This is a dramatic response to a simple treatment. The authors recommend that doctors in areas where people may not get enough sun exposure should be sure to check the vitamin D levels in patients with idiopathic low back pain.

Foot drop is a condition in which muscles can’t lift the front of the foot. The muscles or nerves in the ankle that lift the foot are not working correctly, possibly because of nerve damage. Foot drop can make walking and climbing stairs awkward and difficult.

Foot drop also has several spinal causes, including disc herniation and spinal stenosis in the lower spine. Foot drop in these instances occurs due to pressure on the nerves that go from the spine to the foot muscles. When such spinal disorders are the cause of foot drop, surgery may be the chosen treatment.

However, there is very little follow-up research on how well surgery on the spine works to correct foot drop. These authors reviewed the records of 55 patients who had spine surgery for foot drop. The patients had foot drop for an average of three months before spinal surgery. Most of the patients also showed some other muscle or nerve problems, such as weakness in the muscles of the hips, decreased sensation, and weakness in the muscle that lifts the big toe up.

After surgery, foot drop improved in all but one patient; 71 percent of the patients had a full recovery. Most patients saw their other symptoms improve as well. However, weakness in the big toe muscle was the problem least likely to improve. The one patient who saw no improvement was one of the oldest patients who also had other significant health problems. The authors noted no connection between improvement and a patient’s age, severity of foot drop, or length of time before having surgery.

The authors conclude that spinal surgery can be an effective way to correct foot drop. They suggest more research on bigger groups of patients to help determine the best timing for surgery. They also note that all the patients in this study had leg pain along with foot drop. So patients with painless foot drop may have different results.