News Category: Lumbar Spine

Most spinal fusions are held together with metal plates, screws, and bone graft material. During the healing process, the body fills in and around the fusion site with additional, fresh bone. The initial graft material placed at the fusion site during the procedure is usually an autograft.

Autograft means the bone was taken from the patient. The most common place to harvest bone for the graft is from the patient’s pelvic bone. But there are two major drawbacks to this type of autograft. One is the fact that it requires a second surgery. The second is the fact that sometimes the patient’s bone quality isn’t that good.

Bone graft material can be obtained from a bone bank (donated by someone else). Donor graft material comes with its own set of risks and problems. Scientists are actively seeking alternative ways to provide a strong fusion without bone grafting. One of the methods that has been developed over the last few years is the process of using osteogenic proteins. Osteogenic means bone producing. And that’s exactly what these bone proteins do.

But the process is new enough that it’s still unknown whether bone protein works as well or better than autografts or donor bone. In this study, two groups of spinal fusion patients were compared. One group received the standard autograft harvested from the patient’s pelvic bone. The second group had a graft made up of a bone protein called osteogenic protein-1 (OP-1) mixed with bone from the spine that was removed as part of the procedure.

Everyone was followed for a year. The main measure used to test the results was a CT scan assessing the strength of the fusion. Patients were also given a test called the Oswestry Disability Index (ODI) to measure pain, function, and perceived disability. Complications and problems that developed as a direct result of the fusion technique were also compared.

For those who are interested, the authors provided a detailed description of the preparation of the bone graft substitute as well as the surgical technique used during the fusion. For those who want to cut to the chase and find out what the results were, here’s what they discovered.

First of all, it should be said that the characteristics of the patients in the two groups (male vs. female, age, diagnosis) were basically the same. The length of time in surgery and number of days in the hospital were the same between the two groups. There were no statistically significant differences for outcome measures between the two groups. In other words, rate of fusion, pain levels, and ability to perform daily activities were pretty much the same for all the patients.

Adverse events were about the same between the two groups (very minimal). As expected, the autograft patients reported pain along the pelvic crest where the donor bone was harvested. The OP-1 group had no such problems. And that’s the main advantage of using bone growth proteins. OP-1 combined with bone removed from the fusion site was found to be a safe and effective alternative to autograft from the pelvic crest.

The authors make note of the fact that this was a fairly small (pilot) study of only 36 patients. It was the first time autograft from the pelvis was compared directly to using bone growth proteins in a single-level lumbar spine fusion. This group of patients will be followed for the next 10 years to see if the good results last as long as the autograft group.

Future studies are needed to compare the use of autograft vs. bone protein when applied to various levels within the lumbar spine. Larger numbers of patients need to be evaluated in just the same way this first pilot study was done. Getting the same results with a larger number of people in a repeated study is an important part of proving the process is safe and effective.

A painful condition involving synovial or ganglion cysts can interfere with everyday activities. Synovial cysts are small fluid-filled masses on the synovium, the lining of the joint. Ganglion cysts are cysts found on the tendons. Both types of cysts are most often found in the wrist, knee, ankle, and foot, although they can appear elsewhere, such as the spine. Most often, spinal cysts are associated with degeneration of the spine from diseases such as osteoarthritis (the so-called wear-and-tear arthritis), spinal stenosis (narrowing of the spinal canal), and scoliosis (curvature of the spine).

The spinal cysts were first identified in 1950 and have since been treated with nonsurgical methods, but with very limited success. Most patients end up having surgery, which has many approaches, depending on the location of the cysts and the surgeon’s preferences. The authors of this article reviewed the outcomes of patients who had surgery to remove the cysts, and their outcome, with the benefits and drawbacks, if any.

The authors reviewed 167 patients who had a total of 195 synovial cysts that were causing pain or disability. Symptoms included lower back pain (82.5 percent of the patients), radiculopathy (nerve irritation) of the legs and/or feet (97.5 percent), weakness (39.9 percent), neurogenic claudication (limping from pain in the calf) (20 percent), changes in sensation (33.3 percent), and bowel and bladder incontinence (3.2 percent), to name a few. The researchers noted if the patients were also diagnosed with illnesses such as diabetes (13.5 percent), coronary artery disease (hardening of the arteries) (14.7 percent), osteoporosis (thinning of the bones) (7.6 percent), obesity (7.0 percent), and/or high blood pressure (43.6 percent), and if they smoked (8.3 percent) or had previous back surgery (34 percent).

While reviewing the surgery notes, the researchers noted where the cysts were and classified the surgeries into one of four:

1- unilateral hemilaminectomy, removing one side of bone layer;
2- bilateral laminectomy, removal of both sides of a part of the bone on the vertebrae;
3- facetectomy with in situ fusion removal of part of the bone to keep it from pressing on the nerve root; or
4- <facetectomy with instrumented fusion, fusing of part of the bone to keep it from pressing on the nerve root.

After the classifications were noted, three cases were removed from the study because they could not be identified.

The researchers found that patients who underwent surgery number one alone “were less likely to have motor weakness, sensory deficits, or neurogenic claudication compared to” patients who had one of the other three surgeries. Patients who underwent surgery numbers three and four “had the highest rates of preoperative neurogenic claudication and sensory deficits; all patients with preoperative bladder and/or bowel dysfunction underwent fusion.”

When looking at the location of the cysts, eight were found in the cervical/cervicothoracic levels, the neck down to upper mid-back. Three were in the thoracic/thoracolumbar spine, the mid-back down to just where the lower back begins, and 184 were found in the lumbar/lumbosacral spine, the lower back down to above the “tailbone.”

Surgery for all patients kept them in the hospital for an average of 4.2 days, while those who had surgery four stayed the longest (up to 7.4 days). These patients also lost the most blood and had the highest number of complications during surgery. Among all the patients in the study, this group four were the only ones who experienced cerebral spinal fluid leakage (leaking of the fluid that surrounds the spinal cord), deep vein thrombosis, or DVT (blood clots in the legs), pulmonary embolism (clots to the lung), post-surgery infections, and wound dehiscence (incision opening up after surgery).

Follow-up for the patients was an average of 16.5 months (plus or minus 9.2 months). Although there were patients who needed repeat surgeries for disc herniations (bulging or slipped discs), collapse of some vertebrae, movement of the bone where it didn’t heal properly, or return of symptoms, there was no difference between the number of patients between the surgery groups. Of all patients, 21.6 percent reported recurrent back pain after surgery and 11.8 percent reported recurrent leg pain. Those who were in group two had the highest reports of recurrent back pain. Group four patients had the lowest rate of recurrent back pain. Cysts did reoccur in five patients (3 percent of all patients) at the original spinal level: three among those in group two and two among those in group one.

The authors concluded initial and immediate improvement occurred in patients, regardless of the type of surgery performed, however within two years of undergoing a hemilaminectomy or laminectomy alone, patients did complain of recurrent back pain.

Here’s a surprising finding. In the first study of its kind, researchers from five hospital-based spine clinics discovered that most disc herniations don’t come from lifting (heavy or light) objects. In fact, the majority (62 per cent) have no known cause. The patients say the back and leg pain (sciatica) just came on without warning.

This idea of a spontaneous disc herniation isn’t entirely accurate either. Most experts agree that disc degeneration leading up to disc herniation takes place over a long period of time. Repeated loads on the spine combined with the effects of aging are probably the real culprits. It’s likely that there are some hereditary factors involved as well.

This study was done to find out more about the influence of specific inciting events patients associate with disc herniation. Besides looking at possible causes linked with disc herniation, the researchers also compared severity of symptoms with possible causes of symptoms.

The 154 people in the study were all adults (18 years old and older) who had back pain that radiated down the leg. MRIs confirmed the presence of a disc herniation. Pressure from the disc on the spinal nerve root was the source of the back and leg pain.

Only a small number of patients (eight per cent) could identify a specific event that resulted in the symptoms that were caused by disc herniation. Most people started noticing symptoms while doing normal, every day activities. Examples of non-lifting physical activities as inciting events included vacuuming, bending, reaching, leaning, misstepping, and making the bed.

Golf, skiing, and tennis were the most commonly reported sports and recreational activities believed to be associated with disc herniation. Physical trauma from falls or car accidents was listed as the inciting event in only 1.3 per cent of the people.

This finding supports the idea that in many adults, discs don’t rupture. Instead, the outer covering called the annulus slowly weakens. Weakening in the protective layer of the disc allows the center portion (the nucleus) to poke through.

So even though someone develops pain after sneezing or coughing from what later turns out to be a herniated disc, that final event was like the straw that broke the camel’s back. The disc was ready to go and the coughing, sneezing, laughing, or turning one way or the other was just the final physical stress to herniate an already damaged disc structure.

Are the symptoms worse with certain inciting events? Does lifting that leads to disc herniation cause more severe disc-related symptoms than say a sports activity, a fall, or performing some simple household activity? According to the results of this study, no.

Okay, so how about other factors? Does being Caucasian, Black, or Hispanic make a difference in severity of symptoms caused by disc herniation? What about employment status? Does having a job either part-time or full-time make a difference? Are students or retired adults more or less likely to have severe symptoms with disc herniation? No to all these as well.

The authors conclude that most of the time, disc herniation appear to be spontaneous and occur without any known cause. It’s likely that a combination of aging, degenerative, and genetic factors are the real reasons behind disc herniation. The final event is simply that: enough extra force across the disc at the moment of sufficient weakness to result in injury.

The dilemma comes when patients who have disc herniations (that they feel certain were caused by a specific movement or activity) start to avoid those movements. The physician or physical therapist working with them may recommend treatment that involves engaging in activities the patient thinks led to the problem in the first place.

The results of this study may help when teaching patients how and why disc herniations occur. Getting them back on track requires their cooperation and understanding that coughing, sneezing, vacuuming, sitting too long (or whatever they think caused the herniation) isn’t the real problem.

It’s very confusing trying to figure out ahead of time which patients will benefit from back surgery. Surgeons are always looking for predictive factors to help them identify who should have surgery and who would be better off without surgery.

One of those predictors is the use of pain drawings. Patients draw lines, X’s, dots, and use letters like N for numbness or S for muscle cramps on a picture of the human body. The various markings show where pain is located and what kind of pain it is.

The value of the pain drawing as a predictor of success versus failure with lumbar spinal fusion surgery remains unknown. Some studies show it is helpful; others do not. The authors of this study (spine researchers and surgeons from Denmark) took a closer look at the pain drawing as a predictive tool. They add their findings to the mix and offer some ideas about how to interpret the conflicting data.

One of the problems in comparing studies done in this area is the different type of pain problems included in the research. Some studies only include patients who have back but not buttock or leg pain.

Other studies include only patients with both back and leg pain. And like this study, the researchers allow patients with either or both. In fact, about three-fourths of the patients in this study had back and leg pain.

The reason this feature can be so confusing is that patients with both back and leg pain judge their improvement as greater and are more satisfied when there is an improvement in their pain. Patients with only back pain might also improve but it’s not as noticeable as when the pain has two locations. The accumulation of pain in both sites can make it seem much worse than just back or just leg pain.

Another problem area in studying the use of the pain picture as a predictive factor in outcome after lumbar spinal fusion is the fact that patients with chronic low back pain who are potential candidates for fusion have different diagnoses. They could have pain associated with degenerative disc disease, spinal stenosis (narrowing of the spinal canal), or spondylolisthesis (tiny fracture or disruption of the supporting column of the vertebral bone).

They also have different levels of disability and severity of disease. It’s possible that any one of these variables could have a direct link to the pain drawing but it’s difficult to study just one of these differences at a time. They get all lumped together in the same study so no one knows which variable or combinations of differences affect the outcome or can be predicted by the use of a pain drawing.

In this study, only adults between the ages of 21 and 59 with back pain from spondylolisthesis or degenerative changes were included. They all filled out the pain drawing before surgery. They also completed several other standard and well known outcome measures (e.g., Dallas Pain Questionnaire, Low Back Pain Rating Scale).

Pain drawings can be classified as organic or nonorganic. Organic pain is presented as a clearly identifiable pattern. It occurs in the thoracic spine (middle part of the spine). Nonorganic has a strange pattern of pain all over the body with no clear pattern. Results for the two groups were compared to one another.

They found that women were more likely to have nonorganic pain. Likewise, patients who had a previous spine surgery were more likely to draw a picture of nonorganic pain. In this study, patients with nonorganic pain drawings expressed greater dissatisfaction with results of fusion surgery. On the other hand, patients with organic pain were more likely to report better results after surgery — even when they had more levels fused than in the nonorganic group.

Work status (retired or on sick leave) and insurance or litigation claims were two other predictive factors of poor outcome — these were the patients most likely to have nonorganic pain drawings. Patients who reported pain lasting more than two years, patients who smoked, and younger patients were also at risk for poor results after surgery.

What do the results of this study add to the debate about pain drawings as a predictive tool of results after spinal fusion? The key finding here may have to do with patient expectations. Patients with nonorganic pain drawings may have unrealistic expectations of surgery and end up disappointed as a result.

As mentioned, those with back and leg pain seem to get greater pain relief. This is especially true of patients with organic pain drawings. And improvement was greater from before to after surgery in patients with organic pain linked with a diagnosis of spondylolisthesis (tiny fracture defect in the supportive bone).

The authors conclude that the pain drawing is not a good tool to use when deciding who should have surgery. But it can be used along with other risk factors (e.g., work status, age, smoking, legal issues) to predict results. The more risk factors present, the greater the likelihood of poor outcomes. Likewise, the reverse may be true: the fewer risk factors, the better the chances for a good outcome.

When faced with surgery to fuse the spine, patients with low back pain have to weigh the risks against the benefits in deciding to go ahead with the procedure. But what is the patient’s minimum acceptable change in symptoms and/or function before having the operation? Is a drop in pain levels enough to make it worth it? If it were you, would you have the fusion even if it meant you still weren’t going to get back to work?

These are just some of the questions surgeons from Stanford University School of Medicine (Department of Orthopedic Surgery) examined in this study. They surveyed 165 low back pain patients who were planning to have a lumbar fusion.

Everyone was given a variety of questionnaires to fill out along with an expectation survey. For those who are interested in knowing what was used, some of the questionnaires included the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and the Zung Depressive Index. The results were designed to identify minimum acceptable outcomes from surgery. Anything less than the minimum would indicate it’s not worth having the procedure done.

The main measures included were: 1) pain intensity, 2) function, 3) use of narcotic medications, and 4) return to work. There are many other ways to assess success of surgery like spinal fusion. Some surgeons use scales that measure patient satisfaction or patient goals.

Others rely on X-rays to show the biologic success of bone fusion as a means of measuring success. But the authors of this report believe that pain, function, medication usage, and return-to-work status are the most practical when measuring minimum acceptable outcomes after lumbar spinal fusion.

All 156 patients were operated on by one surgeon performing the same procedure (lumbar spinal fusion). The testing was done after the patients had already decided to have the surgery but before the actual procedure was done. Additional tests were given after surgery including work status, medication usage, and a satisfaction survey.

Here’s what they found. Patients wanted at least a four-point improvement in pain when pain was measured on a 10-point scale (zero for no pain, 10 for maximum pain). They wanted to be free of the need for any narcotic medication. And they considered being disabled, unable to work, or only able to work part-time or with work restrictions as unacceptable.

Overall, the minimum expectation was for a high level of improvement in pain and function. The group did not think it was worth having the surgery if they couldn’t get back to work within two years of the operation. In fact, more than 90 per cent of the group said they wouldn’t have the surgery if they weren’t sure they would be working again.

And it turned out that those patients who did meet their own minimum expectations were, indeed, satisfied with the results. The patients who indicated satisfaction even though their goals weren’t met tended to be those who had other problems with chronic pain, psychologic distress, or who were on Worker’s Comp.

The authors of this study have been investigating the concept of minimally clinically important difference related to spine surgeries for a while now. The results of this study adds information to the overall trends they are seeing.

They are finding that the minimum acceptable outcome varies based on the underlying problem (diagnosis) and type of procedure performed. They also noticed that most patients have a much higher expectation than what surgeons think patients can expect.

Older patients with spinal stenosis (narrowing of the spinal canal) seem to have the lowest expectations for recovery. Patients with degenerative disc disease also have lower expectations than those folks who have spondylolisthesis.

Spondylolisthesis is a defect in the supporting column of the lumbar vertebrae that allows the main body of the bone to shift forward or slip over the vertebra below it. Fusion is done to stabilize the defect and prevent further slippage.

In summary, defining the clinically minimum acceptable outcomes after lumbar spinal fusion shows that most patients have high hopes and high expectations after surgery. Anything less than a major shift in pain, improvement in function, and return-to-work is not acceptable.

Surgeons counseling patients may not want to limit expectations of recovery but should be aware of how high patient expectations really are. The surgeon can use age, diagnosis, and type of surgery as factors in gauging patient expectations when offering information and advice regarding lumbar spinal fusion. When only marginal improvements are expected, patients may not be satisfied with the overall results.

Lumbar spondylolisthesis occurs when one of the vertebrae (bones) in the spine slips forward over the one below it. Doctors believe there are two main causes of spondylolisthesis: spondylolytic (a defect) or degenerative (break down over time), often caused by arthritis. The first kind shows as chronic tiny fractures in the bone, beginning in childhood. The second is a slip that isn’t associated with any obvious defect.

Up to 300,000 lumbar (lower back) spinal fusions are done every year in the United States, many for this condition. But, even though so many surgeries are being done, there is not yet a clear understanding among doctors about the epidemiology, basis, of spondylolisthesis. What doctors and researchers do know is that it affects women three times more often than men and it increases with age. There are very few studies that look at men with spondylolisthesis. The authors of this article conducted a study using x-rays of the spine and data obtained from the Osteoporotic Fractures in Men Study. This study looked at these types of fractures among men in the United States, aged 65 to 100 years old.

There were 5,995 participants in the osteoporotic fracture study. Researchers randomly chose 300 study participants, obtaining their baseline and follow-up visit x-rays of their lumbar spine. Five had x-rays that were unreadable, leaving a total of 295 subjects. By the second visit of the study, 32 men had died, two had withdrawn, leaving 261 subjects. Because of other reasons, such as failure to complete questionnaires, the researchers had 190 final participants, who were an average age of 74 years (ranging from 68 to 80 years).

Upon examining the information and the x-rays, the researchers found that the average time between x-rays (baseline and follow-up) was 4.6 years, give or take three months. One quarter of the study group was obese, 60 percent either smoked or were former smokers. Many had either diabetes or heart disease, or both. Lumbar spondylolithesis was found in 31 percent of the men, seen at the L3/4, L4/5 and L5/S1 levels. These are the third and fourth lumbar vertebrae, the fourth and fifth, and then the fifth lumbar vertebrae and the first sacral vertebrae, the section of the back below the lumbar area.

The spondylolysthesis progressed between visits in 12 percent of the men and the increase in the slip of the vertebrae ranged from 5 percent to 10 percent. One hundred thirty three men did not have the condition at the baseline visit and among them, 12 percent showed signs of it at the second visit, mostly at the L3/L4 and L4/L5 levels.

The authors concluded that the incidence of spondylolisthesis increased with age among the men and may be more prevalent than first thought. However, it did not seem to have any connection between the men’s height, weight, or smoking history, nor did it with any history of diabetes or heart disease. There did seem to be a connection between the condition and the number of men who reported the highest levels of leisure physical activity, however.

Back pain continues to be a major health problem around the world — one that costs the health care system a great deal of money. Studies show that there can be minimal pain but huge disability and vice versa: significant pain but low disability. Finding a uniform way to approach the problem of back pain is difficult with such a wide range of experiences. Some patients need help with pain control while others need to improve their functional level.

The authors of this study from Germany attempted to answer two questions: first, what does back pain look like in the adult German population in terms of severity of pain and level of disability? This type of information could help health care systems provide what patients really need by focusing on the biggest problem area (pain vs. function) instead of treating everyone the same with only moderate success.

Second, is there some way to categorize patients with low back pain that could help direct more specific treatment to each subgroup? Along these same lines, the question arises — should pain and disability be treated as two separate problems or approached as two factors associated with the same problem?

Data was used from a mailed in survey sent to residents of five German urban (city) areas. All participants were between the ages of 18 and 75. Questions were asked about the presence and severity of back pain and loss of function (disability). The first question asked was, Do you have back pain today? From there everyone answered a wide range of questions about pain in the last three months — worst pain, number of disability days, and the number of days pain interfered with daily tasks, social events, or work.

Other studies have shown that 80 per cent of the adult population in developed countries will experience back pain at some time in their lives. This study showed that at any one given time (during the time the survey was conducted), two-thirds (63.7 per cent) had back pain. About half of those adults reported low intensity back pain. Only seven per cent had high pain intensity/low disability. It’s the remaining (almost half) of the group that interests these researchers.

How do we classify that middle gray area? They don’t have one single descriptor to characterize them. By analyzing the data several different ways, the authors were able to see five subgroups. These were labeled:

Chronic low back pain caused by an unstable spinal segment can be treated with spinal fusion. The condition most likely to create this type of instability is called spondylolisthesis. In spondylolisthesis, a defect in the supporting column of bone allows the main body of the vertebra to separate and shift forward or slip over the vertebra below it. This shift narrows the spinal canal where the spinal cord is located. The result is pressure on the spinal cord with pain and sometimes even more serious symptoms.

It makes sense that if a spinal segment is fused and no motion is allowed at that level, there’s a change in the way stresses and forces applied to the spine are transmitted. Loss of motion at one level means greater movement and pressure at the segment above and/or the segment below the fused level. The result can be degeneration of the disc in between called adjacent segment disease (ASD).

Adjacent segment disease (ASD) is a problem potentially created by the treatment for the first problem (fusion for the spondylolisthesis). That’s not good — it means the patient may need another surgery. An important question is: what factor or factors are the most important in this condition? Are there some patients who are more likely to develop ASD? Who might that be and could it be prevented?

One theory is that people who already have some degenerative changes in the adjacent segment are at increased risk for ASD. Another theory suggests that the type of spondylolisthesis present makes a difference in outcomes. To find out if either of these ideas is correct, a group of surgeons from Korea compared MRIs before and after surgery for patients who had lumbar fusion for spondylolisthesis. They were carefully selected and did not have any sign of segmental degeneration before the fusion operation.

Two groups of patients were included: group one had isthmic spondylolisthesis. Isthmic spondylolisthesis refers to a slip that occurs as a result of a defect of the supporting bone called the pars interarticularis. A tiny fracture develops that fails to heal causing a defect in the bone. This defect could be something that was present at birth or developed over time as a result of a hyperextension injury. Athletes involved in gymnastics, ballet, and football seem to be affected most often.

Group two had degenerative spondylolisthesis. As the name suggests, degenerative spondylolisthesis is age-related and can affect more than one vertebra. Women ages 50 and older seem to develop this problem. Everyone in the study (in both groups) had spondylolisthesis at the L4-L5 lumbar spine level. Fusion was done at that level using pedicle screws in a procedure called interbody fusion.

This type of fusion holds the segment still all the way around — it provides a 360-degree fusion. Interbody fusion can be done from an anterior (front of the spine) approach called an anterior lumbar interbody fusion (ALIF) or from the back called a posterior lumbar interbody fusion (PLIF).

MRIs and X-rays were used to measure before and after results. Types of information collected from these imaging studies included: disc height, motion and translation of the vertebral body, presence of bone spurs called osteophytes, and endplate sclerosis (hardening of the disc where it attaches to the bone). They also measured the angle of the lumbar spine at the fused segment. This measurement is expressed in degrees and is called the L4-L5 segmental lordotic angle.

Remember these patients were all selected because they didn’t have any signs of disc degeneration at the L3-4 or L5-S1 segments. So any changes in the adjacent segments after surgery are especially important. What they found was a fairly equal rate of adjacent segment disease (ASD) between the two groups.

When degenerative changes did occur, it was more likely in the degenerative group. The isthmic groups were able to go longer before adjacent segmental changes were observed. MRIs were the best tool for diagnosing ASD; X-rays were not as accurate. Some patients who had ASD didn’t have any symptoms whereas others had back and leg pain that was worse when walking and better when bent forward or sitting.

There wasn’t a significant difference in who developed ASD based on whether they had an anterior (ALIF) fusion or a posterior (PLIF) approach. What was most significant was the lordotic angle (curve). Patients who had a fusion that placed the lumbar segment at less than 20-degrees of lordosis were more likely to develop ASD.

In summary, this is the first study to report on the occurrence of adjacent segmental disease (ASD) after a rigid (360-degree) lumbar fusion at the L4-L5 level using before and after MRIs and in a group who did not have preexisting adjacent disease before surgery. The authors’ analysis of the data do not support age, gender, or body mass index as risk factors for the development of ASD. Surgeons should pay close attention to the angle of fusion and provide at least a 20-degree lordotic angle (or greater) to assist in preventing ASD.

It is very likely that everyone knows someone who has experienced back pain, if they haven’t experienced it themselves. In the Netherlands, it’s estimated that almost 27 percent of adults have had or do have back pain and one school of thought believes that lumbar disc degeneration is a possible risk factor for lower back pain in adults. Lumbar disc degeneration is the wear and tear of the discs in the lower back, the lumbar region.

X-rays of the lumbar region can show if there is disc degeneration and one research team, led by Lane, developed a grading system that would tell how much degeneration was present, as seen by the x-ray. The authors of this article wanted to see if they could use the rating system, along with patients’ reports of lower back pain, to see if the rating system could tell ahead of time if there would be pain. In other words, could the rating system determine if someone was at risk for back pain.

Researchers obtained 2,819 lumbar x-rays of patients who were over 55 years old; 1,615 of the patients were women. A trained radiologist reviewed the x-rays, looking for disc degeneration. The x-rays were rated as:

– 0 meant no degeneration was seen
– 1 meant there was mild degeneration
– 2 showed moderate degeneration
– 3 showed severe degeneration

Repeat x-rays were done on the patients as they visited the center where they underwent a physical exam, including height and weight, body mass index, bone density, and disability. The disability was assessed using the Stanford Health Assessment Questionnaire, or SHAQ. The patients were also visited at home where the researchers determined their level of back pain. The patients were asked, “Did you have any complaints of the low back during the last month?” They were also asked, “What is the duration of the present low back pain complaints?”

When the results were tabulated, the researchers found that lower back pain was reported more often in women (326) than in men (173), and chronic lower back pain was reported in 84 percent of patients who had lower back pain at that time – again more often in women (95 percent) than men (91 percent). When looking at the x-ray reports, the most common finding among the patients with lower back pain was the presence of osteophytes, or bone spurs. More women than men had narrowing between the discs, although both the osteophytes and narrowing increased with age in both sexes.

The authors concluded that the different findings on the x-rays could be associated with lower back pain, particularly if there were two or more disc levels that were narrowed.

Spinal fusion is a commonly used way to stabilize one or more segments of the spine in older adults. A spinal fusion procedure is also known as a spinal arthrodesis. There are several different ways to perform this operation.

In this article, surgeons from the Norton Leatherman Spine Center in Louisville, Kentucky help us understand how the simplest and most often studied technique (posterolateral spine fusion) is done. It is against this technique that the results of all other methods are compared and judged. Outcomes are measured using patient report of pain and function as well as X-rays of the fusion site.

All patients evaluated had just one spinal level fused. The patients were divided into two groups by age: under age 65 and 65 and older. Everyone was followed at regular intervals for up to two years. The same surgical procedure (posterolateral fusion) was performed on each patient in both age groups.

Patients were placed face down (prone) on a special surgical table called a Wilson frame. This frame can be adjusted to place the spine in the exact amount of curvature (flexion or extension) needed to give the surgeon access to the spine while limiting blood loss as much as possible. A color photo of a sample patient positioned is part of the review.

In layman’s terms, the surgeon makes the necessary incision down to the bone, divides the fascia (connective tissue covering the muscles and spine), and cuts the muscles away enough to get to the spine. The surgeon removes the cartilage around the facet (spinal) joint and then removes enough bone along the sides to form a gutter. This depression is where the bone graft will be placed for the fusion.

Screws are used to hold the segments together (one above and one below) until the fusion takes hold. X-rays are used to make sure the screws are in the right spot for optimal stability. Once the screws are in place, additional bone is shaved or cut away, a procedure called decortication. The screws are locked together with a supporting (vertical) rod between the two segments being fused. The final step involves packing the gutters with bone graft material.

It used to be that surgeons would remove some of the patient’s own pelvic bone to use as an autograft (bone donated to oneself). But more and more, bone from a bone bank is used supplemented by newer materials that work much better. These newer graft substitutes are made up of bone marrow, bone morphogenetic proteins (growth factors), and even ceramic material.

One final X-ray is taken to make sure everything is in place where it should be before closing the incision. Patients are followed routinely to make sure the graft material fills in and stabilizes the segment.

So how do patients fare after posterolateral spinal fusion based on age? This study showed a major benefit for all patients regardless of age. Older adults (65 and older) seemed to get more pain relief but they also went into the surgery with higher levels of baseline back and leg pain compared to the younger patients.

The authors make a final note to say that lumbar spine fusion using the posterolateral technique isn’t for everyone. There are certain indications (reasons to use this method) and contraindications (reasons NOT to use the procedure). For example, this type of fusion works best for patients who have an unstable spinal segment from age-related degenerative disease of the disc, vertebral bones, and/or local scoliosis (curvature of the spine). A local scoliosis affects a small segment of the spine without major deformity.

It should not be used in patients who have a normal disc space height or who have had a previous fusion from behind (posterior fusion). Spinal deformities such as kyphosis (forward curve or rounded spine) will need more than a simple one- or two-level fusion to correct the problem.

Surgeons can expect to see spinal fusion remain an important surgical option to stabilize the spine. The procedure itself hasn’t changed much lately. The source of the graft material is probably the biggest change in how the posterolateral technique is performed.

More studies will be needed to see if results are different for patients based on differences in graft material used and number of levels fused — perhaps combined with other factors such as age as was investigated in this study.

Anyone working long hours at a desk job has probably wondered if sitting so much will eventually lead to back pain. A few studies have suggested that might be the case. But a recent review of all studies available makes it clear that working in a sitting position for long periods of time is not a risk factor for low back pain.

Researchers from Canada scoured the literature of published studies from around the world on this topic. There were articles published from the Netherlands, Iran, Nigeria, Sweden, the USA, Finland, Greece, Belgium, England, China, Germany, and Denmark. Of the 2766 studies initially identified as possible sources of good information, only five were high-quality and therefore included in this review.

It makes sense that there might be some risk with long hours of sitting. This position puts pressure on the pubic bones, increases downward compression through the discs, and increases spinal muscle activity. And many workers seem to experience low back pain that reduces work hours and productivity.

But the conclusion of those five studies was consistent: there was no link between occupational sitting and low back pain — not in nurses, not in construction workers, or anyone else for that matter. In fact, if anything, there was some evidence that sitting protects the back. That makes sense when sitting is compared with occupations that involve activities such as lifting, carrying, twisting, and bending.

There may be other more significant risk factors such as previous back injury, body mass index, age, muscle weakness, or lifestyle (smoking, inactivity during off hours, sex: male versus female). Further study is needed to identify any links between these factors and occupational sitting with episodes of back pain.

Anyone engaged in long periods of sitting is routinely advised to stand up and stretch periodically, shift weight in the chair at least once every hour, and engage in physical activity and exercise during the off-hours. But patient education of this type isn’t really based on evidence that doing these things reduces episodes of back pain or offers preventive measures against back pain. However, until more is known about the risks of occupational-related back pain, workers who sit for prolonged periods of time are still advised to follow these steps to assure good spinal and overall health.

Physicians know that X-rays, CT scans, and MRIs don’t really contain the rest of the story. Many patients have all kinds of changes in the lumbar spine but no symptoms — no pain, no change in sensation. There can be narrowing of the disc spaces, spinal stenosis (narrowing of the spinal canal), spinal joint arthritis, and even tiny fractures called spondylolysis but no one knows about it until X-rays or other imaging studies are done for something else.

Most of the folks who have what looks like significant changes of this type in the spine are older adults (65 years old and older). Low back pain can be a common symptom in this age group. So, how much of these changes (and which ones) are linked with back pain? That’s what this group of researchers set out to discover.

They used a group of patients already enrolled in the world famous Framingham heart studies. Those individuals live in Framingham, Massachusetts and participate in a lifelong study of health (especially heart health). In the process of being examined, they each have CT scans done to look for blood vessel calcification (hardening and blockage of the arteries). The imaging studies also showed the structures of the spine, which were analyzed for this study.

The advanced imaging showed a wide range of degenerative changes as described above. Most notable was the high incidence of disc narrowing and spinal joint arthritis observed in two-thirds of the group. The researchers then started analyzing data collected about the patients to see if there were any links between low back pain, age, gender, and body mass index with degenerative structural changes in the spine.

What they found was that only spinal stenosis was significantly associated with low back pain. Disc narrowing, facet (spinal) joint arthritis, changes in the spinal muscle size, and spondylolysis were NOT directly linked with low back pain. There was an association between low-density muscles of the spine (multifidus and erector spinae) and arthritic changes observed in the facet joints. Exactly what that means remains to be determined.

The results of this study don’t answer all the questions around low back pain and imaging studies. Physicians walk a fine line between using imaging to confirm a diagnosis and relying on imaging that could provide misleading information.

The hope is that results of spine imaging tests will help physicians select the most appropriate treatment for each patient. But it doesn’t always work out that way since so many studies have shown that it’s possible to have moderate-to-severe degenerative changes in the spine and still be completely pain free and unaware of those changes.

And this study confirms that even though CT scans provide much more anatomical information than standard (and less expensive) X-rays, the information should not be relied upon except as it concerns the presence of stenosis and low back pain. In other words, the presence of spinal stenosis predicts and confirms low back pain. Treatment directed at the cause of the pain (stenosis) may provide better outcomes for patients. Future studies to assess age-related changes in the soft tissues (such as the muscles) might yield additional valuable information.

When low back pain is caused by a pinched or compressed nerve in the sacral area, a steroid injection into the spinal canal can provide welcome relief. But it’s a tough area to gain access and the chances are high that the surgeon can miss the right spot. That’s been proven over and over in trials conducted by experienced and confident physicians.

What can be done to make this treatment of steroid epidural injection (ESI) more successful? Surgeons in Taiwan suggest using ultrasound images of the sacrum to see exactly where the injection can go in. They are looking for the sacral hiatus, a tiny opening in the middle of the sacrum. The sacrum is a pie-shaped or wedge-shaped bone that sits at the end of the lumbar spine just above your coccyx (tailbone).

The sacral hiatus is further identified by two bony bumps called the sacral cornua that run along each side of the hiatus. Getting the injected fluid through the hiatal hole and into the spinal canal may improve the accuracy of this treatment approach. Missing the mark doesn’t always hurt the patient — it usually just means the injected fluid goes into the soft tissue surrounding the sacrum. When injected into that spot, it’s not very helpful either.

To test out their idea and see if ultrasound could be used as a screening tool before giving the injection, they found 47 volunteers to be in this study. There were both men and women and all had low back pain caused by lumbosacral nerve root compression.

First, each patient was examined using 3-D, real-time ultrasonography. Using the ultrasound photos, the radiologist interpreting the images was able to measure how wide the sacral hiatal opening was and how much distance was between the cornua bracketing the hiatus. The surgeon could use the images to guide the needle into the epidural space.

When the opening was very small, they tried using a smaller gauge needle. But in four patients, the diameter of the sacral opening was about the same as the size of the smallest possible needle. There just wasn’t enough room to insert the needle and inject the medication. One patient had a completely closed sacral hiatus and could not be injected at all.

Seven of the 47 patients had a failed injection. That’s a 15 per cent rate but it’s a lot lower than the 25 to 38 per cent failure rate reported in other studies. Although the surgeon tried to inject everyone, the images and the results confirm that anyone with a closed or absent sacral canal or sacral hiatus smaller than 1.6 millimeters is likely to have a failed injection.

Although the distance between the cornua was measured and compared to the results, it didn’t appear that this particular anatomic feature had anything to do with the success or failure of the injection. Only the size of the sacral hiatal opening was a significant factor. The authors also reported that body fat in the area of the sacrum was not a problem. With the assistance of a surgical tech, the patient’s buttocks could be pulled apart and away from the sacrum, thus providing a flat surface to apply the ultrasound transducer (head or wand).

In summary, when steroid injection of the sacral hiatus is the preferred method of treatment for low back pain, surgeons can use ultrasound to take a look inside first. Ultrasound images give the surgeon precise measurements to use when deciding whether there’s enough space for the needle. This study shows that differences in the anatomy of the sacrum can affect the effectiveness of a lumbosacral epidural injection.

Can you wait too long to have spinal fusion surgery? Some research has shown that waiting too long may mean a poor result — the patient doesn’t get the pain relief hoped for. But how long is too long? That’s the focus of this study from Great Britain.

Most people recover from back pain with a little time and attention. Those who don’t are often treated with medications such as pain relievers or antiinflammatories. Some seek the help of a chiropractor, physical therapist, acupuncturist, or massage therapist. If the symptoms haven’t gone away after three months, the condition is becoming chronic.

Disc degeneration is a common cause of chronic low back pain. The pain can become so constant and intense that surgery to remove the disc and fuse the spine at that level becomes the next step in treatment. To find out if waiting more than six months would have an effect on the results of spinal fusion, the authors followed a group of 209 patients for a minimum of two years. Most of the patients had painful symptoms much longer than six months — some as long as 28 years!

Data was collected before and after surgery using a variety of tests and measures. X-rays were used to look for evidence that the fusion was solid and successful. Patients filled out several different surveys with questions about pain, function, disability, attitude, anxiety, depression, and so on. All tests were repeated at regular intervals (first at six weeks, three months, and six months after surgery; then every year thereafter).

The authors found that everyone got better — even the patients who had chronic pain for years and years. And the improved pain and function continued. Despite the common belief that waiting too long means surgery won’t help, there aren’t many studies to support or disprove this idea. This study may be the first one to really address the issue.

The idea that chronic pain can’t be changed with surgery comes from the belief that over time pain messages get so engrained in the central nervous system (spinal cord and brain) they can’t be turned off. Scientists refer to this as a central pacemaker. The pacemaker gets turned on when persistent and continuous pain messages are sent from the nerves to the spinal cord and then up to the brain. The result is called centralization of pain.

But this belief that a long period of pain leads to a poor prognosis wasn’t supported by the results of this study at least. Even taking into consideration factors like mental health (depression, anxiety) and general health (presence of other diseases or conditions) didn’t change the fact that the majority of these patients got better after surgery.

Did they just beat the odds or was this an outcome that can be repeated? Since patients were still reporting positive results (pain relief, improved function) up to five years later, it looks like the results are real and long lasting. The authors of the study do point out that in their patient selection they were careful to select patients with just one pain diagnosis. No one in the study had other causes of chronic pain like fibromyalgia or arthritis.

The particular approach used in the spinal fusions for all of these patients was one called posterior lumbar interbody fusion or PLIF. The procedure was done from the back of the spine. An open incision was made, the disc removed, and the bone on either side of the disc (lamina and facet joint) was cut away. The bone taken out was ground up and used to pack the middle of the disc space before inserting a device called a cage. One cage went on either side of the bone chips. Then a plate and screws were used to hold everything together until bone filled in to complete the fusion.

The authors conclude that at least for patients with disc degeneration, a posterior lumbar interbody fusion (PLIF) works well even when the patient’s symptoms have been present for a very long time. Chronic and severe pain is not a reason to avoid spinal fusion using the PLIF method. This study also brings the theory of centralization of pain into question. Future studies are needed to further investigate these new findings.

Despite our many advances in medicine and especially all the improved technology, we still don’t know what causes back pain for many people. And without an understanding of the cause, it is difficult to find an effective way to treat it. We do know now that some patients have back pain coming from the facet (spinal) joint(s). Using an injected anesthetic to the facet joint’s nerve has confirmed that this area can be a pain generator. Once the nerve can no longer send signals to the spinal cord, then the pain stops. Destroying that nerve with heat using radiofrequency denervation relieves the pain permanently.

In this study, X-rays and MRIs were reviewed after patients who had both a nerve block and radiofrequency ablation (destruction) of the nerve. The authors were looking for any clue from the anatomy that might help point to those patients who will have a good response from nerve blocks and ablation. Radiologists who didn’t know what treatment was done or what the results were (who got better, who didn’t) looked at each of these areas: disc height, disc condition, vertebral alignment, facet joint space, and joint condition.

In particular, they were interested in knowing if the presence of decreased disc height might be a predictor of treatment success or failure. Secondly, they looked at stenosis (narrowing) of the spinal canal or of the intraforaminal spaces as a possible spinal pathology linked with joint pain. The intraforaminal space is a hole where spinal nerve roots pass through going from the spinal cord down to the leg. Sometimes disc degeneration leads to increased load on the joints, which, in turn, cause joint pathology. Arthritis, bone spurs, and thickening of the joint could also be the origin of nerve irritation leading to back pain.

What they found was that people with spinal stenosis did benefit from radiofrequency ablation (RFA) of the nerve to the affected facet joints. Identifying patients with stenosis might help guide treatment to include RFA when it might not have been considered otherwise. It was observed that patients with spinal stenosis did tend to have facet joint hypertrophy.

Joint hypertrophy refers to an enlargement of the joint due to arthritic changes. There are some experts who think that it’s these changes in the joint that put more strain on the joint making them more likely to develop pain. It wasn’t clear if the joint hypertrophy led to the stenosis or the other way around. So for now, they can’t use joint hypertrophy as a way to predict treatment results.

As for whether or not a decrease in disc height made a difference — they found that patients with decreased disc height were more likely to get pain relief from the nerve block but not from the nerve ablation. Just what the relationship between disc height and disc condition is with facet joint pain remains unclear. It makes sense that a thinner disc would bring the facet joint surfaces closer together creating increased load and subsequent arthritic changes. But this particular study wasn’t able to offer any additional information to further understand that relationship.

The statistical analysis did not support spinal stenosis as a strong predictor of treatment success. There just weren’t enough patients who had a positive response to the nerve block and then to the radiofrequency treatment. The authors suggest a follow-up study should be done with more subjects. This study included 127 patients and may not have been large enough to make firm conclusions.

In general, more studies are needed to help sort out which patients can best benefit from radiofrequency nerve denervation. Whereas patients with stenosis were previously told facet joint treatment wouldn’t help them, this study calls that recommendation into question. Older adults are more likely to suffer from stenosis and that was consistent with the fact that older adults got better results from nerve blocks and nerve ablation compared with younger adults with persistent back pain.

There are a wide variety of treatment options available for the patient with low back pain that don’t rely on medications. There’s spinal manipulation, acupuncture, massage, nerve stimulation, biofeedback, yoga, behavioral counseling, lumbar supports, and much, much more. This article is designed to assist physicians and patients in understanding what’s out there and how and when to use it.

It’s clear that most low back pain is not life-threatening. It might hurt but it won’t harm you. It is called self-limiting because it goes away after a few days to weeks. The diagnosis is often nonspecific mechanical low back pain. That’s a fancy way of saying, we don’t really know exactly what’s causing the problem. We just know it isn’t a fracture, infection, tumor, or other serious pathologic process.

Specific treatment beyond staying active and modifying activities (don’t do things that make it hurt!) isn’t really needed. More and more research is pointing to depression as a major factor. But whether back pain is a symptom of depression or depression develops after back pain becomes chronic is still undecided.

When back pain persists beyond a couple of weeks up to a month further testing can be done to make sure there isn’t something else going on. When testing has ruled out any serious underlying pathology, then what? Should the patient try chiropractic care? Physical therapy? A massage? Maybe acupuncture?

Well, this is where the evidence is lacking to help us direct and guide patients. Studies show that manipulation performed by a chiropractor or physical therapist can be helpful for acute low back pain. Massage and acupuncture also seem to have some benefit in terms of enhancing healing. Long-term effects are not as likely (i.e., these techniques don’t prevent future episodes of back pain).

Physical therapists can often identify problems with posture, movement, and alignment that may contribute to the development and recurrence of low back pain. An individually designed rehab program can help restore spinal alignment, normal muscle function, and motor coordination. Many therapists combine traditional approaches with other physical modalities such as yoga, Pilates, and/or relaxation techniques to aid in recovery and then maintain spinal health.

What about those folks who just don’t seem to get better no matter what they try? When that happens, it’s time to go back to the drawing board. Physicians are encouraged to review the case for anything that might be missing. Taking a closer look at the patient’s personal goals, activity limitations, work issues, attitudes, and beliefs might help pinpoint the next step.

Sometimes behavioral or psychologic help is needed. Catastrophizing or dramatizing life events (including pain) can lead to more intense pain that doesn’t go away. Behavioral specialists are trained to help people literally change their minds — change the way they think because these maladaptive thoughts are contributing to the persistence in painful symptoms.

People who start avoiding certain movements or stop moving to avoid any chance the pain will start up again are experiencing something called fear avoidance behaviors. That’s another dimension to chronic back pain that must be addressed. Behavioral specialists working with physical therapists can help patients overcome this trigger for back pain.

When low back pain becomes chronic and many of these nonpharmacologic (without medication) techniques are tried but fail, then a team of specialists combine various approaches to create a multidisciplinary rehabilitation program. Medications for pain control and antidepressants may be used. A program of intense, graded activity and exercise supervised by a physical therapist is supported by behavioral counseling to help patients prepare mentally to cope with their pain and the intensity of the program.

There isn’t a one-size-fits-all approach to low back pain. But evidence from studies so far support clinical practice guidelines such as were outlined in this overview article focusing on nonpharmacologic treatment approaches. Patients must work with their physicians to find the program that works best for them and stick with it. When one approach doesn’t seem to fit the bill, then it may be time to try another or to combine several methods together.

Patients need to be advised that acute low back pain is often self-limiting. Give it time and stay active. Rest may help in the first couple of days, but don’t stay in bed. When acute pain doesn’t go away with this approach and chronic pain develops instead, expect to work hard to overcome this problem.

A cure doesn’t always take place. At that point, it becomes a matter of pain management. But patients can function and even regain a measure of quality of life when pain persists. Don’t give in and don’t give up. There are many alternative approaches that can help you stay active at home and at work — despite the pain.

Neurosurgeons from Italy are the first to report a new complication with X-stop devices used in the lumbar spine. What are X-stops? And what’s the new problem?

X-stops are spacers placed between two vertebrae to hold them apart. They are used to manage various degenerative conditions of the lumbar spine such as spinal stenosis (narrowing of the spinal canal) and disc degeneration. The surgeon implants the X-stop between the spinous processes — not between the main bodies of the vertebrae. The device is called an X-stop because it stops the movement of spinal extension at that level. The spinous process is the bony projection off the vertebra that you feel as you run your hand down along your spine.

The new problem is a fracture of the spinous process with dislocation of the X-stop distractor. Three cases have been reported in patients who had two X-stops placed between L3-L4 and L4-L5. The surgeons named this new type of fracture the sandwich phenomenon because the broken spinous process (L4) was sandwiched between two X-stop distractors.

The spinous process at L4 between the two implanted X-stops fractured without warning and without apparent cause. Fractures without injury or outside force are called atraumatic (without trauma).

Although X-stop is a fairly new treatment technique, two-level implants of this type have been used in many patients around the world without problems. The atraumatic fractures described in this report affected three men of different ages. It is considered a rare postoperative complication. In all three cases, the initial response after surgery was complete pain relief. But after a few months, the patients’ back and leg pain came back.

That’s when the diagnosis of spinous process fracture was made. X-rays and CT scans showed that with a fracture of this type at the base of the spinous process (where it attaches to the main body of the vertebra), the X-stop was pushed away from the spine (dislocated). Surgery was done in all three cases to remove the X-stops and fuse the spine.

What causes a spontaneous fracture like this? That presents an unsolved puzzle. There could be some anatomic difference in these three men contributing to the fractures. But what exactly that difference is remains a mystery. There was no sign of osteoporosis (decreased bone density leading to brittle bones) that could account for the fracture. The double-level procedure was the most likely key feature.

The authors of this report suggest a possible piston effect on the spinous process. Having an X-stop above and another one below the process applied pressure to the bone with every spinal movement until the spinous process finally snapped. They concluded that despite this rare sandwich phenomenon, X-stop implants are still safe and effective.

Future cases of fatigue fracture in double-level X-stop devices from the sandwich phenomenon will be investigated carefully to find out why this happens. Anatomy, biomechanics, device size, and spinal mobility will be studied as possible contributing factors.

Placement of the devices too far forward or too far back in relation to the spinous process may be another possible cause. And there’s some speculation that each patient has one or more risk factors unique to him or her. No recommendations are being made to avoid double-level surgeries until further information has been gathered and data analyzed.

In summary, by distracting the spinous processes of two vertebrae, the X-stop takes pressure off the spinal nerve roots and reduces back and leg pain. But in rare cases, there can be complications with spinous process fractures when double-level X-stops are used. Patients should be warned about this. Any recurrence of pain and neurologic symptoms should be reported to the surgeon right away for evaluation.

Physicians at trauma centers must be prepared for the weird, the unusual, and the rare cases of everything because they see everything in all three of these categories. This case presentation of an extremely rare sacral fracture in a 13-year-old demonstrates this point very well.

The girl fell from a second-story building and came to the trauma center with the main symptom of low back pain. She didn’t have paralysis but without knowing it, she did have an injury to the lower part of her spinal cord called the cauda equina. The result was a loss of sensation in the groin area called the perineum and a loss of bowel and bladder function. She had no sensation that her bladder was full or that she had to empty her bladder (urinate) or have a bowel movement.

The physician who examined her was careful to conduct some special tests that revealed the cauda equina lesion. X-rays confirmed a transverse fracture (transverse means through the sacral bone), which had then shifted so that the two pieces of the sacrum were overlapping one another.

She was sent to surgery right away in order to take the pressure off the cauda equina before the bowel and bladder problems became permanent. The surgeon removed a portion of the sacrum that was pressing on the nerve tissue. This procedure is called a decompression surgery. The fracture couldn’t be reduced (bone fragments put back together) without a metal plate to hold it together. She was put in a lumbosacral orthosis (LSO) (type of rigid back brace) to stabilize the low back and sacrum.

Her sensation and bowel and bladder function came back very gradually over a six-month period of time. The doctors credit the fast action between arrival at the trauma center, diagnosis, and surgery (a total of four and a half hours) for that good result. That’s why they wrote this case up for publication — to help other physicians know how to recognize these rare (only nine ever reported) and very serious cases.

Although the fracture in this case was obvious on plain X-rays, these fractures can be very subtle and easily missed on X-rays and CT scans. MRIs are really the best way to diagnose sacral fractures. Likewise, the fact that the patient had not gone to the bathroom and was unaware of the need to do so (an important neurologic sign) can be overlooked.

Surgery isn’t always required with transverse sacral fractures. If the fracture isn’t displaced (separated) and the patient doesn’t have any neurologic damage, then conservative (nonoperative) care may be all that’s needed. But severe fractures with displacement, bony malalignment, and/or any sign of neurologic compromise warrants an immediate surgical procedure.

Some experts suggest that surgery can be preventive in a way. If the fracture looks stable but develops a large bone callus during the healing phase that presses on nerve tissue, then it would have been better to operate early on. The same thing applies if the bone fragments move after the imaging study showed they were lined up and stable.

These cases are so rare, no one knows how to predict when those complications might occur and prevent them in any other way than by doing early surgery. This is especially true when you consider that these fractures are difficult to treat and displacement of the bones only makes it that much harder to realign and stabilize them.

This case also helps physicians know that they can reassure patients with neurologic problems from a transverse sacral fracture that it takes quite a long time to recover after surgery. Reviewing the results of the other nine cases, it looks like complete neurologic recovery is more likely with surgery — another reason to support early surgical decompression and stabilization for this condition.

The causes of low back pain and best ways to treat this problem continue to elude scientists, orthopedic surgeons, and other concerned health care professionals who treat these patients. In an effort to study every aspect of back pain, researchers have established the Spine Patient Outcomes Research Trial or SPORT as it is referred to most often.

Data is gathered from multiple spine centers where the focus is on spinal problems and especially back pain. By collecting the same information on every patient and putting it in a single database, researchers from around the United States can analyze the data looking for answers to specific questions. The authors of this study took a closer look at lumbar spinal stenosis (narrowing of the spinal canal) in an effort to see if stenosis at more than one level affects outcomes of treatment.

To break this down even further, it’s helpful to know that spinal stenosis can occur in people who have good spinal alignment. There is normal vertebral alignment but other factors are impinging on the opening for the spinal cord. There could be osteophytes (bone spurs), thickening of the spinal ligaments, disc degeneration, joint hypertrophy (arthritic changes), or any combination of these age-related changes.

It’s also possible that spinal stenosis can develop as a result of a condition called degenerative spondylolisthesis. This is another age-related condition affecting adults (most often women) over the age of 50. A fracture in the supporting column of the vertebra allows the body of the vertebra to slip forward over the vertebra below it. The forward shift narrows the spinal canal and puts a pulling or traction force on the spinal cord or spinal nerve roots (depending on the level affected).

Treatment for spinal stenosis is becoming more effective as we gain a better understanding of the underlying pathology. Studies show that age-related spinal stenosis responds well to conservative care, whereas patients with stenosis from degenerative spondylolisthesis do better with surgery to stabilize the spine.

Now with this study, we add an additional layer of understanding by looking at the results of treatment linked with number of spinal levels affected (one level, two levels, three or more levels). It boils down to one question: How do patients with spinal stenosis fare with and without degenerative spondylolisthesis at one versus multiple lumbar levels? Bear in mind we will be looking at the answer to this question for two types of treatment: surgical versus nonoperative (conservative care).

One of the nice things about using data from the SPORT study is that researchers can pull together a group of patients who are very similar in order to compare them equally. So in this study, they made sure everyone in the spinal stenosis group had been accurately diagnosed with X-rays and reported painful symptoms for at least three months. Everyone in the degenerative spondylolisthesis group had spinal stenosis associated with at least one level of spondylolisthesis. They were also symptomatic for at least three months.

Everyone in the SPORT studies completes a wide range of test measures. They fill out surveys and answer questions about symptoms, function, disability, general health, and overall satisfaction with their health status. By comparing these measures before and after treatment, it is possible to get an idea of how patients respond to surgery versus conservative care for both conditions (spinal stenosis with and without spondylolisthesis).

After examining the data collected, here are a few discoveries they made about patients in both groups:

Lower back pain – everyone knows someone who has experienced lower back pain at one time or another. Chronic low back pain is a major health issue in our society today and it is the most common musculoskeletal reason doctors are visited. Chronic low back pain doesn’t just affect a person physically, it has an big impact on society as it costs money for the person living with it, as well as their employers. Geography doesn’t protect against back pain as it happens around the world. In Denmark, for example, chronic low back pain is said to affect 10 percent of the adult population.

Despite the commonality of chronic low back pain, there isn’t a lot of agreement on the best methods of treatment and management. Exercise has been shown to be quite effective in helping patients regain strength, reduce pain and disability. The type and duration of exercise isn’t always agreed upon though. The authors of this article investigated the difference in outcomes of patients with chronic low back pain who underwent multidisciplinary biopsychosocial rehabilitation and those who underwent an intensive therapist-assisted individual back muscle exercise program.

Researchers recruited 286 patients who had been experiencing low back pain for at least 12 weeks, with or without pain radiating down one or both legs. The patients ranged in age from 18 years to 60 year. They were assessed through the usual testing procedures, x-rays and computed tomography (CT) scan or magnetic resonance imaging (MRI), as well as physical examination. The patients informed the researchers whether they were working and they completed the visual analog scale (VAS), a scale from zero to 100, indicating what level they rated their pain. The patients were evaluated at the start of the study (baseline), at three months after the start, and again at six, 12, and 24 months after the start.

The groups were assigned randomly to group A (multidisciplinary, or team approach) and they worked in groups of six patients. They were given a program of combined exercise, eduction and pain management for a 12-week period, divided into three periods of four weeks. The patients worked on warm-up and stretching exercises, aerobic training, as well as strengthening of the back, upper buttocks, and abdominal muscles. There were 22 exercises in all to be completed, plus there were ball games, hot water training, and ball stick training. In addition to these exercises, the patients also were taught anatomy, postural techniques and pain management, by a physiotherapist, and back care and lifting techniques, by an occupational therapist. Ultimately, the patients benefitted from about 12 hours of therapist assistance.

Group B were the patients who received individual treatment, with a program of specific and intensive muscle training exercises to strengthen and shorten the muscles in the back and upper buttocks region, but did not include strengthening the abdominal muscles or stretching exercises. The patients were attended to on a one-on-one basis with the therapist and they were seen about one hour, two times per week, over a period of 12 weeks. They benefitted from about 24 hours of therapist assistance.

The researchers assessed change and improvement in back pain using the visual analog scale and the Roland-Morris Disability Questionnaire (RMDQ), as well as two other more generic questionnaires and the medical outcomes study 36-item short form general healthy survey. At the end of treatment, the researchers found a 20 percent to 30 percent improvement in visual analog scored pain in both groups. This continued through the follow-up as well. There was no real difference in the number of analgesics, pain medications, taken between the two groups. There was, however, a noticeable difference in the improvement in disability. While both groups improved, those in group A improved more and continued this improvement over the follow-up period. Both groups also improved in the general health and emotional aspects after treatment, but again, group A patient showed more improvement than those in group B.

When the study first began, only 29 percent of the patients in group A were able to work and 36 percent of those in group B. At the end of treatment, both percentages rose: group A to 40 percent and group B to 38 percent. This continued to improve throughout the follow-up period to 48 percent for group A and 54 percent in group B.

Not all patients completed the study. Eleven in each group dropped out. In group A, one patient required back surgery and one had sustained a concussion after a fall. Seven patients in group A and five in group B withdrew because they experienced either delayed onset of muscle soreness or a worsening of leg pain. The other patients who withdrew had other reasons not related to the study, were lost to follow-up, or became ill.

Despite the drop outs and a few limitations to the study, such as the large number of dropouts from the group-based management, the authors wrote that the study did show a slight superiority to the multidisciplinary approach, but not enough to come out with a recommendation that it is a better treatment program. Some factors to consider include how many people are needed for the team approach and availability, and the amount of time that the patients must invest versus the number of hours one therapist needs to invest for the one-on-one treatment.