News Category: Lumbar Spine

Sometimes, surgery is needed for back pain. Two or more bones may be fused together to prevent movement at that level. This is called a spinal fusion. There are some problems that can occur after spinal fusion. Disc herniation is one of these rare problems.

The disc is a spongy material between each vertebra in the spine. It is encased in a protective material and held in place by ligaments and fibrous tissue. Injury or damage to any of these structures can cause disc herniation. The disc material pushes out of its normal space and can begin to press on the spinal cord or spinal nerves, causing low back and leg pain.

When two or more bones of the spine are fused together, movement between the fused bones stops. The segments just above and below the fusion have to move more than normal. This extra movement can cause wear and tear on the discs above and below the spot where the spine is fused. The result can be a disc herniation.

Anyone with a previous fusion in the low back can have a disc herniation later. Returning symptoms of back and leg pain after a fusion surgery should be checked by a doctor. This could be the first indication of disc herniation. Early treatment with physical therapy may help prevent surgery. In some cases, another surgery to treat the new disc herniation may be needed.

Age and injury can cause the discs between the bones of the spine to wear down. This condition is called degenerative disc disease, or DDD. Most people with DDD get better without needing surgery. They may see a physical therapist, use a brace, or take medications. However, a small number of patients just don’t get better, even after years of trying different treatments.

Surgery is sometimes a final step for these patients. Fusion surgery is commonly used to treat pain from DDD. However, past results have not been all that promising for patients who still had severe pain prior to surgery despite many nonsurgical treatments.

Equally disturbing is the fact that pain sometimes remains high even after fusion surgery. In this study, a group of doctors used an aggressive way to stop movement in the problem part of the low back. They fused the spine in front and back and used screws and plates to hold the spine in place. The results were good. Many of the patients (88 percent) were able to get back to work, and most patients were highly satisfied with the results.

Adults with DDD usually get better without surgery. When surgery is needed, the spine can be fused in one or more places. In some cases of severe and disabling pain, doctors may fuse the spine from the front and back with a good result.

Many studies report how often back pain occurs. If the pain isn’t measured the same way in each study, then it’s a lot like comparing apples to oranges. Researchers in Canada are trying to set the record straight.

A survey about low back pain was sent to adults in the Saskatchewan province. About eight percent of the adults between 20 and 69 years reported low back pain. The measure was taken over a six-month period of time.

Compared to other similar studies, eight percent is high. New information about back pain reports that there are many factors that cause this problem. These include stress, smoking status, quality of life, and the presence of other diseases or conditions.

In Saskatchewan, back pain was more common in people with previous neck pain. Other factors that increased back pain included living in a rural area, being single, and having previous back pain. This information is important for health planners. Knowing how many new cases of back pain will occur in the next six months is helpful. The next step is to find ways to prevent painful back episodes.

Back pain of unknown cause is called nonspecific back pain. It is very common. In fact, seven out of every 10 adults will have nonspecific back pain at some point in their lives. Low back pain in the United States causes lost wages and medical expenses that add up to millions of dollars every year. In cases of nonspecific back pain, there is no infection or fracture. No trauma has occurred and there is no disease present. Many people probably have pain from problems with nerve tissue, but this has not been proven.
A new treatment for nonspecific back pain has been developed in Spain. This is called neuroreflexotherapy. In this treatment, the doctor puts staples in the back and ear at places called trigger points. The staples are left for 90 days or more. They work by blocking the release of substances that cause back pain. These staples also release natural pain relievers.

Twenty-one doctors in seven centers in Spain have been using neuroreflexotherapy. They have compared the results with people who have not received this kind of treatment. The patients receiving neuroreflexotherapy had better results with less pain and better quality of life. The treatment time was shorter with lower costs.

The European approach to nonspecific back pain may offer a new method of treatment. Doctors are trying to use the nervous system to affect the pain. Early results are positive and have been repeated in several studies.

Low back pain caused by disc problems that lasts more than six months is common and hard to treat. There isn’t one best method of treatment. Treatment usually begins with medication and physical therapy. Most people get better with this treatment. For those who don’t, surgery to remove the disc and fuse the vertebrae above and below the problem disc is one option.

However, this type of surgery isn’t always successful, so doctors continue to look for other ways to treat this problem. Intradiscal electrothermal treatment (IDET) is one of those options. IDET is a way to heat the disc to a high temperature (140-150 degrees). This breaks down the tissue, allowing it to grow back together again for better healing.

The success of IDET is measured by increased sitting times, improved physical function, and decreased pain. Quality of life improvement is another way to measure the effect of IDET. A positive change in all these areas is seen with most people having IDET. As evidenced in this study, changes continue to improve for up to two years after the treatment.

IDET is a treatment option for some patients with low back pain caused by a disc problem. When treatment has failed and surgery to fuse the problem area of the spine is the next step, IDET has been shown to decrease pain and improve function. Patients are carefully selected for this treatment. Continued improvement for two years after the treatment makes this a possible choice. Long-term results of IDET (beyond two years) haven’t been studied yet.

The delivery of medicine and health care has taken a turn in the United States. There is a push for evidence that shows specific results for each treatment method. This is called evidence-based medicine or evidence-based practice.

This new direction has resulted in much more research. For example, when it comes to back pain caused by a herniated disc, the results 10 years after surgery show equal results for those who didn’t have surgery. This information shows the need to find ways to treat back pain patients without surgery whenever possible.

Physical therapists are part of the trend toward evidence-based practice. There is a new traction device available called partial body weight support (PBWS). PBWS is a harness device that can help people walk on a treadmill with less weight placed through the spine and legs. Before using this with everyone who has back and leg pain, therapists are finding out who is helped the most and why.

The first studies started with a small number of people to see if it’s worth trying on a larger number of people. A group of therapists looked at the results of using PBWS with six adults. Everyone in the study had low back pain that was increased by sitting, standing, and walking. The PBWS was used to reduce the load on the spine during walking and to allow the patients to walk longer distances (endurance).

Pain was reduced in all the patients. All but one improved in function. There was good carryover of improvement six weeks later. The positive results of this small study signal the go-ahead to study this treatment method with a larger number of back pain patients.

Are you treating yourself for a sudden case of low back pain? Do you know what’s best: heat, ibuprofen, or acetaminophen (Tylenol)?
Muscular low back pain can be treated with heat for the best result. This is true if there is no numbness and no buttock or leg pain.

A special heat wrap can be placed around the low back area. As it heats up, this wrap can be pressed in place to match each person’s shape and size. It keeps the temperature at 104 degrees for eight hours. Muscular pain and stiffness are often reduced with two days use of the heat wrap. Movement increases and overall function improves. These good results continue even after the wrap is removed.

Tylenol and ibuprofen are most often used for self-treatment of low back pain. However, the heat wrap reportedly gives greater improvement in symptoms and function when compared with maximum recommended doses of these medications. Normal activity is advised during the two days of heat treatment. Neither bed rest nor active exercise is recommended during the first 48 hours of painful low back symptoms.

Families have first, second, and third generations with grandparents, parents, and children. Usually, 50 or 60 years passes from the first to the third generations. In the medical world, new treatment methods are the “first generation.” As doctors improve the treatment and better methods are found, a “second generation” is born.

Unlike families, changes in medical treatment can take place quickly. Often, the move from first to second generation or from second to third generation happens over a period of just a few years. This has been true in the treatment of low back pain caused by a herniated disc pressing against a spinal nerve.

Open back surgery involving hemi-laminectomy was first described in 1934. In this operation, the doctor cut open the back muscles to take out a small piece of the backbone. This was done to remove disc pressure off the spinal nerve. There were many complications with this type of surgery when used to treat disc herniations.

Since that time, doctors have looked for ways to avoid opening the back with a large incision to do surgery. The second generation called minimally invasive surgery was “born.” Doctors began using a small incision to pass a slender instrument inside the body to work on the disc. A variety of methods using this idea were quickly developed. However, there were still too many problems, mainly because the doctor could not see inside the body while doing the surgery.

The third generation came along with the birth of fiberoptics. Fiberoptics is the ability to see inside the body using a rigid or flexible tube with a light and eyepiece on the end. Fiberoptics has given doctors a way to see inside the body to guide them during this type of back surgery. This has brought about a wide range of new methods to operate on the spine. Each method has its good and bad points. The surgeon must decide patient by patient which method is best.

Can you remember much about an injury or pain from 10 years ago? Researchers often use “old” information in their studies. They rely on a patient’s memories from years past. They often ask questions about pain, such as where it was located and how severe it was. These studies are usually done by asking questions in a telephone interview or written survey. These are called retrospective studies. But how correct are retrospective studies?

Data collected after the fact does depend on the patient. Using simple, reliable questions is also important. Patient age, hopes, and current level of pain have some affect. The length of time between interviews also affects the ability to remember. This seems to be caused by aging more than by the number of years between interviews.

Many studies used to plan treatment for low back pain are based on a patient’s ability to remember the past. Some information about pain and other symptoms is surprisingly correct. However, there are some problems with collecting data this way. Researchers are trying to find more questions that are reliable and accurate for long-term studies.

There is a huge cost for people who can’t work because of low back pain. The costs include lost productivity at work, medical expenses, and the cost of a long rehabilitation program. Researchers are studying this problem to find out how much and what kind of treatment is really needed.

A study in Norway divided 195 people with low back pain into three groups. The three groups ranged from “treatment as usual” with a doctor visit, medications, and physical therapy, to a more intense daily treatment. The more intense treatment involved daily sessions of individual exercise, counseling, and education.

For men with recent back pain (three months or less), a program of advice and exercise works best. Men were more likely to return to work full time and without sick days with this approach. Women seemed to respond best to treatment as usual. A more intense and longer program doesn’t always have a better result in the long run. This is true for both men and women with low back pain.

Doctors can find it difficult to treat patients whose low back pain lasts more than three months. Finding the right program for each patient isn’t easy. Men and women seem to respond differently to treatment, and men are more likely to return to work. For men who are off work for eight or more weeks, a treatment program of exercise and advice appears to work best. Women in this study responded better to a doctor visit, medication, and physical therapy.

Studies have shown that it’s better for people with low back pain to stay active. In Norway, there’s a program to help workers do this. It’s called “active sick leave.” Active sick leave allows workers to get back on the job sooner. Work activities are reduced or changed to accommodate low back pain. Employers get money to hire full-time help in the meantime, so the work is sure to get done. This sounds like a win-win situation. But for some reason, not many people are using it.

Active sick leave requires the cooperation of doctors, employers, patients, and the insurance administration that pays for it. These authors felt that active sick leave wasn’t being used because of lack of information and poor communication between these parties. The authors came up with two intervention strategies to try to increase the use of active sick leave, thereby decreasing total number of days off work.

The first strategy included extra reminders to doctors about active sick leave and the importance of keeping active during back pain. More information about active sick leave was given to patients, employers, and the local insurance administration. In addition, a standard agreement was set up between employers and employees to make it easier to get the ball rolling for active sick leave.

The second strategy was more aggressive. In addition to the above, doctors were offered continuing education workshops on low back pain and active sick leave. Also, occupational therapists were hired to help doctors and patients use active sick leave.

Did either of these strategies make a difference for over six thousand patients studied? Active sick leave was used a lot more when the aggressive intervention was in place. With the added resources of occupational therapists and continuing education workshops, 18 percent of eligible patients used active sick leave. Otherwise, only 12 percent of patients used active sick leave. Early results suggest that the aggressive intervention led patients to start active sick leave sooner. These patients also took fewer days off work.

What part of the intervention made a difference? Not the continuing education workshops for doctors, which were poorly attended. The personal follow-up of patients by occupational therapists got more patients to use active sick leave. In fact, the personal attention of therapists was so important that active sick leave dropped off once the therapists’ work ended. In general, changes in use of active sick leave came mostly from patients, not from doctors.

This study suggests that health programs are more widely used when patients are personally encouraged to use them. More research is needed to see whether early return to work reduces sick leave, prevents disability, and improves patients’ quality of life.

Low back pain is a major problem around the world. The cost of care and lost wages is increasing every year. For the past five years, doctors from many countries have been getting together to work on this problem. Doctors from North America, Europe, Israel, Australia, New Zealand, and the Far East have all come to these meetings.

Low back pain is no longer seen as a simple medical problem involving only the body. Risk factors also include psychological, emotional, social, and spiritual events.

This shift in thinking has changed the way low back pain is treated. Patients with back pain are told to exercise and stay active instead of resting or staying in bed. Doctors are prescribing medications to treat the anxiety and depression that often come with back pain. In Australia, billboards and television commercials are being used to help teach the public about these changes.

More than half of the world’s population will have back pain at some point. Studying this problem has brought new information about causes and treatment. Doctors no longer view low back pain as purely a physical problem. The current thinking on back pain takes the mind, body, and social and emotional factors into account.

In medical terms, any word ending with “itis” usually involves inflammation. An “itis” rarely seen in adults is discitis. Discitis is inflammation of the disc, the spongy cushion between each vertebra in the spine. Symptoms include sudden back pain that is sharp or “knifelike.” There is also extreme tenderness when pressure is put on the spine. The painful symptoms are constant but can be relieved a little by rest. Activity makes the pain worse.

Children are most often affected by discitis. This results from infection spreading from the lungs or kidneys to the back. When adults have discitis, it’s usually caused by other medical conditions. Discitis can develop after back surgery to remove a disc. In some rare cases, it occurs without any known cause. This is called idiopathic discitis.

Two cases of idiopathic adult discitis have been reported. Both were in women who had severe pain in the middle of the back. Treatment with rest, medications, physical therapy, and electrical stimulation for pain helped relieve the symptoms. Both women improved over time. By the end of one year, they were both without pain.

There were a few differences between these cases and discitis seen in children and other adults. Only one or two discs were involved in the idiopathic discitis versus many discs in other cases. In these two women, the discs calcified permanently. This means the discs filled with calcium particles and hardened. In other patients with discitis, the calcium gradually goes away.

Discitis affects children but rarely adults. This painful inflammation of the discs in the spine usually has a cause. For the first time, two cases with no known cause have been reported. Both patients recovered with conservative treatment and have not had any further problems.

Muscles seem to have minds of their own. They contract in different ways and at different times depending on body position and activity. Researchers want to learn more about how muscles work during twisting or turning movements. This information may be helpful in preventing back injuries caused by repeated twisting motions.

Researchers studied eight muscles of the back, trunk, stomach, and hip. They found that some muscles only contract when the body twists to one side. Sometimes the activated muscle is the one on the side of the twist. Other moves cause the muscle on the opposite side to work. Some of these muscles contract with movement in both directions. Muscles also respond differently in sitting versus standing positions.

A muscle that runs along the back of the spine called the erector spinae contracts in two separate parts. One part is active when the trunk twists to the right. The other part contracts when the trunk twists to the left.

Muscles are known to work at different times depending on the activity. Muscles on both sides of the body work to balance each other. This gives the body stability. The same muscles may act differently when the body is sitting versus standing. Knowing how and when muscles work may help prevent injuries.

Back injuries are the most common work-related injury. Three groups have a higher than average amount of chronic back pain: nurses and nurses’ aids, heavy manual workers, and drivers. In a survey from New Zealand, these three groups made up three-fourths of all workers’ compensation cases of back pain.

Low back pain that doesn’t last long is not what drains the pocketbook of workers, workers’ compensation, and employers. It’s back pain that lasts longer than three months and keeps the worker from returning to the job. About 10 percent of chronic cases cause more than 80 percent of the cost for low back pain.

The research community has placed a high value on finding out what can predict the occurrence of back pain. Being able to tell ahead of time what risk factors change acute, short-term pain into a chronic, long-term condition would be very helpful.

Risk factors for chronic pain and loss of function are divided into two major groups. These may be related to the individual worker or to the work setting. Knowing risk factors would make it possible to develop prevention programs for both the individual and the employer.

The New Zealand workers’ compensation group was an ideal group to study because it has a “no-fault” system for injuries that are work-related. This removes tension between injured workers and the insurance company. The group used a simple survey to ask questions of workers with back pain. Workers were interviewed right after the initial injury. Their work status was examined three months later. The information gathered helped point out risk factors associated with the transition from acute to chronic back pain.

Individual risk factors included increasing age, obesity, the presence of severe leg pain, sleep disturbance, and depression. Risk factors in the work place included unavailability for light duties, a job that requires lifting objects for one-half of the work day, lifting or moving extremely heavy items often, and driving at least three-fourths of each day.

It is possible to predict early who will develop chronic back pain from a work-related back injury. This means it may be possible to prevent the transition from acute to chronic pain. The result would be to return workers to their workplace earlier and save money otherwise spent on medical care and disability.

The next time something annoys you, don’t think of it as a pain in the butt; think of it as a “pain in the piriformis.” The piriformis is a muscle in the buttock that passes through the same opening in the pelvis bone as the sciatic nerve. When the piriformis is tight or contracted, it can put pressure on the sciatic nerve. This causes a painful condition called sciatica.

Piriformis syndrome is just one of the causes of sciatica. Piriformis syndrome has several symptoms. Besides pain in the buttock and down the leg, there may be difficulty walking. Stooping or squatting tends to bring on the pain. So does lifting the leg while lying flat on the back.

Doctors would like to find a test for sciatic nerve pain that’s caused by piriformis syndrome. This would help direct treatment and suggest when surgery may be beneficial. The problem is that people with unbearable pain sometimes have imaging tests such as MRI (magnetic resonance imaging) that come back normal. Other people have MRI and other tests that suggest a piriformis problem, but no pain or symptoms.

A new test called the FAIR test may be just what the doctor ordered. FAIR stands for Flexion, Adduction, and Internal Rotation. These are all movements of the hip and leg. The test is done with the person lying on the painfree side at the edge of a bed or table. The hip and knee of the painful leg are on top and bent. The foot of the leg on top is hooked behind the knee of the leg on the bottom. The knee on top moves down toward the floor.

In this position, the piriformis muscle presses on the sciatic nerve and may slow the speed at which the nerve can send a signal. To do the test, electrodes are placed on the lower leg, and an electrical signal is sent to the sciatic nerve. How fast the nerve passes the signal to the muscle is measured by how long it takes for the muscle to signal pain or contract. The results are compared to those of people without sciatica.

A group of doctors used this test to check for piriformis syndrome. Patients with very slow reflexes on this test were treated for piriformis syndrome. More than 80 percent of patients with positive FAIR tests improved with physical therapy.

Piriformis syndrome as a cause of sciatic nerve pain has been so hard to test, doctors have wondered if such a problem actually exists. A new test is available to measure how much pressure the piriformis muscle places on the sciatic nerve. The test is a good predictor of whether physical therapy or surgery can change the effect of the piriformis on the sciatic nerve. Information from this test will help doctors decide how to treat patients with sciatica from piriformis symdrome.

Many adults hurt their backs and need surgery to repair a protruding, or herniated, disc. The disc is a jelly-like cushion between each bone of the spine. When a disc is herniated, there is often low back pain and pain that travels down the leg. The pressure of the disc on the spinal nerve can cause muscle weakness and loss of sensation in the leg.

Treatment for disc problems can be with or without surgery. This is usually based on the size of the disc protrusion, the size and shape of the opening for the spinal cord (spinal canal), and the patient’s symptoms. So how do you know when to have surgery for disc herniation?

Fact: The first surgery for low back disc herniation took place more than 60 years ago. Though many years have passed, no single treatment program has been set for all disc problems.

Fact: Surgery is usually advised for large herniations.

Fact: Only 25 percent of people who try treatment without surgery end up having surgery later.

Fact: Patients who have the disc removed (discectomy) have better results at one year than those who don’t.

Fact: There is no difference in the results of those who are operated on and those who aren’t 10 years later.

Fact: In some cases, the body absorbs disc material that has moved into the spinal canal. Doctors aren’t sure how the body does this, or why it happens for some patients.

There are guidelines for the treatment of low back problems in adults. These are put out by the U. S. Department of Health and Human Services. The guidelines urge a shared decision-making process between doctor and patient. This means there is no single recommendation for all patients. Each case must be evaluated on an individual basis. The doctor is the best one to advise when to use a “wait and see approach” and when to have surgery.

Can you rub your belly and pat your head at the same time? If so, try this: contract your transversus abdominis muscle at the same time as your lumbar multifidus. What’s that, you say? It’s a new program of muscle strengthening that’s been shown to work well for back and sacroiliac pain.

The transversus abdominis muscle is one of several stomach muscles. It wraps around the lower abdomen from front to back like a corset. The lumbar multifidus is a deep back muscle that attaches close to the spine in the opposite (up and down) direction.

Contracting these two muscles at the same time is called cocontraction. The force of this cocontraction is like a nutcracker squeezing the spine and pelvis bones together. This makes the joints of the sacroiliac stiffer and more stable. Another way to look at this cocontraction is that it acts like a very deep corset or brace for the low back.

These new exercises have already been shown to reduce low back pain, pelvic pain, and sacroiliac joint pain. The cocontraction of these muscles also prevents the return of painful symptoms in most patients. We know these exercises work, but why do they work?

To delve into this question, researchers in the Netherlands measured vibration across the sacroiliac joint. Vibration is transferred best when the joints are stiff. Loose or lax joints do not send the vibrations across as well. A second method of measurement involved the use of imaging called real-time ultrasound.

This technology allows scientists to combine three-dimensional sound waves with the fourth dimension of time. This imaging shows the relaxed and contracted states of the muscles. Changes in the shape of the stomach muscles can be viewed as a picture. The abdominal bracing pattern is clearly shown. In all patients, sacroiliac joint laxity is decreased by the contraction of one abdominal muscle along with one low back muscle. In other words, the sacroiliac joint just got stiffer and more stable from cocontraction.

Using these muscles to form a self-brace will be included in new exercise treatments for low back pain. This replaces the previous whole-body approach. New technology may also improve testing before surgery to see which patients will benefit from surgery.

If you’ve ever had a bout of low back pain, you know it affects all kinds of movements. Suddenly, you can’t get out of bed so easily. You walk more slowly. And turning takes actual thought and planning.

Finding ways to measure and treat loss of motion is the focus of recent research. In the past, trunk movement in people with low back pain was studied by measuring range of motion and the amount of muscle force used. However, new technology developed in the last 10 years has made it possible to go beyond these simple measures. Looking at other areas of body movement during walking will help physical therapists design more specific treatment for back pain patients.

As might be expected, people with low back pain show decreases in walking speed, step length, and how long they can walk. Moving forward requires the pelvis and trunk to rotate in balance with each other. Back pain can change the timing and coordination of these movements. This slows a person down considerably.

A recent study using a treadmill and advanced recording technology has given some new information about walking. At slower walking speeds, the pelvis and trunk coordinate together in a pattern that is called in-phase coordination. This is true for people with or without back pain. But as the speed of walking increases, people without back pain switch to an out-of-phase pattern called anti-phase coordination.

Interestingly, patients with back pain try to keep the in-phase pattern as they increase walking speed. This is probably because they are using muscles to lock the trunk and pelvis in place. When a person is in pain, the muscles tend to contract and hold. This is called protective guarding. Physical therapists can use this information to plan exercises that will return movement patterns to normal at all speeds.

If you have back pain, you probably don’t lift objects the same way as someone without back pain. There are strength differences between people with and without back pain. But how much load does the spine take when someone with back problems lifts compared to someone without back pain?

This was the question a group of researchers in a movement laboratory set out to answer. Using a new method of measuring muscle activity, the researchers evaluated how low back pain affects spine loading during lifting activities. “Load” refers to vertical (up and down) pressure through each bone of the spine. The researchers also measured the force of one bone moving against another in a sideways motion, called lateral shear.

People with low back pain showed much higher readings for both types of spine forces than people without pain. To be exact, they had 26 percent more spine compression and 75 percent more lateral shear. The greater loads were caused by the other muscles that contracted to help protect the low back.

This information is important because studies have shown that increased loads on the back can lead to degeneration of the discs. The disc is a jelly-like substance between each vertebra in the spine. It offers a cushion of protection for the spine during movement. For people with back pain, loading the spine can lead to further spine damage and long-term back problems. This is especially true when people lift heavy weights over a long period of time.

The study also compared the loads that come from lifting different weights at different heights. As expected, lifting heavier weights from down low increased the load on the spine the most. Excessive body weight also put extra strain on the back by adding to the compressive forces through the spine.

From these results, researchers can make recommendations for people with low back pain. First, anyone with back pain who is returning to work should arrange the workplace so that lifting is done from waist height. All objects should be lifted close to the body, with the arms close to the body. Second, lifting activities should be broken up and alternated with other tasks. This can help prevent a cumulative load over a long period of time. Finally, reducing body weight during the recovery process is very helpful in unloading the back.