News Category: Lumbar Spine

There’s help for patients who have low back and leg pain from isthmic spondylolisthesis in the form of spinal fusion. But this condition can affect different levels of the lumbar spine. And surgeons want the best results for each patient with the least invasive techniques. That’s why these surgeons took a look back at the results of their patients with this diagnosis after two different types of fusions. The unique thing about the study was not just that they looked at two different types of surgical techniques, but that they compared them at two different lumbar levels (L4-L5 and L5-S1).

Isthmic spondylolisthesis refers to a defect in the vertebral bone. A crack in the pars interarticularis (supportive column) of the vertebra causes a separation of the main body of the bone from the back half where the spinal cord and spinal nerve roots are located. The vertebral body shifts forward over the stable vertebra below. The result is a pulling, traction pressure on the nerve tissue and neurologic symptoms. X-rays taken from a side view show characteristic changes that identify this condition.

Nerve tissue is highly sensitive so a shift of this type usually causes significant low back and/or leg pain. The pain is worse when extending the spine because the shift in the bone is the greatest in this position. Forward flexion moves the vertebra back toward a more neutral position, which takes pressure off the spinal nerves. When rest, improved postural alignment, and exercises don’t help, then surgery to stabilize the segment may be needed.

Fusion is the most successful surgery. But there are different ways to do a spinal fusion. Different techniques can be used along with different approaches. For example, an anterior approach means the surgery is done from the front, posterior approach from the back, and lateral or transforaminal from the side. Often a combination of two different directions gives the surgeon the angle needed to avoid tissue trauma and potential problems or complications.

In this study, the surgeons compared the anterior lumbar interbody fusion (ALIF) to the transforaminal lumbar interbody fusion (TLIF) in patients with a single-level unstable spondylolisthesis. Interbody fusion means they remove the disc and replace it with a metal cage filled with bone chips. Screws were also used to hold everything together and in place until healing and complete fusion occurs.

Essentially there was one diagnosis but four separate groups. Group one had a L4-L5 spondylolisthesis treated with ALIF. Group two had the same level involved but was treated using the TLIF procedure. Group three had a L5-S1 level spondylolisthesis and ALIF. Group four had a L5-S1 level spondylolisthesis treated with the TLIF procedure.

What they wanted to know was whether it’s better to use one approach over another based on the spinal level affected. Results were compared using both X-rays and patient symptoms and function. It’s important to use both types of measures because doctors know that X-ray findings don’t always match patient performance and level of satisfaction. X-rays show the amount of slip or grade before surgery and the rate of reduction after. Patient pain, function, and return-to-work status were measured using well-known tests such as the visual analog scale (VAS) and the Oswestry Disability Index (ODI).

By comparing results using both techniques at two different levels, the surgeons found that results were better for alignment using the ALIF at the L5-S1 level. Functional results were equal using ALIF at either level. But the TLIF approach seemed to have better functional results when used at the L4-L5 level even though there was no difference in alignment based on X-rays. Everyone in all four groups returned to their normal level of daily and work activities.

Surgeons have many things to consider when approaching surgery for these patients. Other studies have shown the importance of restoring the anatomy to as near normal as possible for the best long-term results. The results of this study may actually support those findings. For example, getting better results with the ALIF at the L5-S1 level may be related to the fact that the angle of the disc here is so steep. It’s more difficult for the surgeon to prepare the disc space here for the cage when using the TLIF approach.

The authors consider the results of their research still somewhat preliminary. They want to follow-up with patients and see how the results hold up over time. They also want to consider the psychosocial effects of clinical outcomes for each group. For now they concluded that ALIF was superior to TLIF at the L5-S1 level. TLIF was superior to ALIF at the L4-L5 level. The addition of this new data may help surgeons when making decisions about surgical strategies for patients with unstable lumbar spondylolisthesis. Finding the least invasive, safest, yet most effective treatment for this problem is the goal. Recognizing that one surgical procedure may not be ideal for all levels is important.

The question of whether or not patients on Workers’ Compensation have different results after treatment for back pain has challenged the health care profession for years now. And this study is no different. Here, the researchers compare Workers’ Compensation to non-Workers’ Compensation patients with back pain. Both groups were divided further by type of treatment: conservative (nonoperative) care or surgery. The results of treatment were compared at regular intervals from six weeks to two years.

The goal of a study like this is to see what effect Workers’ Compensation status has on patient outcomes. Is one treatment better than another? Do Workers’ Compensation patients have equal results to non-Workers’ Comp patients when the same treatment is applied? Patients with a lumbar disc herniation treated at 13 U.S. Spine Centers were included in the study. This study was part of a larger on-going research project called Spine Patient Outcomes Research Trial or SPORT.

Low back pain and sciatica (leg pain) were the main symptoms interfering with work and daily life for the nearly 1,000 people in this study. The symptoms persisted for more than six weeks. Most (811) were not on Workers’ Compensation. The minority (113) were Workers’ Compensation patients. Only adults who were not already considered disabled and could return to work (including unemployed patients but not retired folks, homemakers, or students) were included in the study. Conservative or usual care consisted of active physical therapy along with a home exercise program, education and counseling, and medication (anti-inflammatories). Surgery was an open incision discectomy (disc removal).

Everyone was tested before treatment to form a baseline (starting point) of data. They filled out forms that gave a self-report of pain, function, and perceived disability. The same tests were repeated at each follow-up visit with an additional tool to measure satisfaction with treatment. For those familiar with the various questionnaires used to assess patients with back pain, the tools used included: Short Form-36, Oswestry Disability Index (ODI), and the Sciatica bothersome index. One other marker used to measure results included work status such as return to work (yes or no), usual work hours (fewer than before the injury?), loss of pay, and legal status.

Clinical findings such as any neurologic signs (change in sensation, change in reflexes, muscle weakness) and patient characteristics (smoker, other health problems, education level, income, age, sex, racial/ethnic background) were also recorded and analyzed. One final piece of information the researchers used to compare results equally from group to group and treatment to treatment was the duration of symptoms before treatment was started. Some people had suffered with painful symptoms much longer than others before treatment was begun.

By factoring all these variables into the statistical analysis, they could tell which ones were directly linked with results — in other words, which patient factors affected the final outcome. That way if something was a more important factor than Workers’ Compensation status, it would show up. As it turned out, everyone in the study got better with treatment — that was true for both groups and both types of treatment.

A closer look at all the data also revealed that Workers’ Comp patients who had surgery didn’t have as good of results as nonWorkers’ Comp patients who had surgery. And over time, the benefit the Workers’ Comp patients showed early on deteriorated. And at the end of two years’ time, surgery really didn’t improve work or disability status compared with usual (conservative) care. This finding was true for both groups of patients (with and without Workers’ Comp).

It’s not entirely clear why Workers’ Comp patients had worse outcomes after surgery. Despite analysis of the other factors, nothing stood out as a significant factor except Workers’ Comp status — and that was true for patients at all 13 treatment centers. It’s possible that the Workers’ Comp patients go into treatment with different expectations, ideas, and perceptions than nonWorkers’ Comp patients. Some Workers’ Comp patients may feel pushed to have surgery rather than wait for natural healing to occur in order to get back to work sooner. More study will be needed to investigate some of these ideas.

For now, we know that low back pain is a common problem interfering with working status in many adults across the United States. Previous studies have shown differences based on Workers’ Compensation status. This study added data to support those findings. SPORT researchers will continue to look for the underlying reasons why this is so. The authors concluded that their results suggest a more complex relationship between work, Workers’ Compensation, and treatment outcomes — whether that treatment is usual care or surgical intervention. They hope to help patients, physicians, and employers find the best way to get these workers back on the job in the shortest time with the least invasive treatment.

How much do you think it costs to have surgery for a herniated disc? $1000? $10,000? That’s not a trick question but answering it can get tricky. Do you include the cost of conservative care that failed first before the patient had the surgery? That would be around $4700 according to this study from the Johns Hopkins Spinal Column Biomechanics and Surgical Outcomes Lab in Baltimore, Maryland.

If you just calculate the cost of removing one disc surgically, then we’re talking about $5,000. That’s the surgeon’s fee for a minimally invasive procedure called microdiscectomy. With all the other costs of hospitalization, anesthesia, operating room, and post-operative care, the bill comes to about $42,500.00. But sometimes patients end up with severe pain from spine degeneration at the site of the disc removal. Then they need further surgery with a possible spinal fusion. That can be a cool half-million dollars per patient.

Surprised? Substantial health care costs aren’t the norm for single-level discectomy but this Johns Hopkins patient and cost analysis shows it happens in about nine per cent of the cases at their institution. The researchers reveal how often this happens and uncover the hidden costs associated with persistent back pain requiring surgery for spine instability following a discectomy.

They got this information by reviewing institutional billing and accounting records for 111 patients. Each patient was diagnosed with a single-level lumbar disc herniation. Low back and leg pain (sciatica) were the main symptoms but weakness, numbness, and tingling were also reported. Symptoms were severe enough to need surgical intervention because conservative care was unsuccessful. X-rays and other imaging studies showed degeneration and/or instability severe enough to warrant further surgery.

The authors concluded that most patients who have a microdiscectomy procedure for a herniated disc have a very successful outcome and no further treatment is needed. For those who develop back pain later, conservative care seems to clear up any problems. But in a small number of patients, significant health care costs are incurred when additional surgery is needed. Not all of the billed costs are paid or collected. And the cost of pain medications or missed work was not factored in.

Comparing the results of this study at one hospital, the average costs seem in line with other places. The number of patients affected (referred to as the incidence) is about the same as other places as well. Given the high costs of additional surgery, the authors recommend trying conservative care first for any patient who reports postdiscectomy back pain. In fact, they suggest this step for at least three months before even repeating X-rays, MRIs, or other imaging studies. The idea is to reduce the costs associated with this problem while still providing effective treatment.

Lower back pain, usually affecting both men and women between the ages of 30 and 50 years old, is the most common cause of work-related disability and it comes at a high economic cost with time lost to work, workman’s compensation, and medical expenses. Estimates are that lower back pain costs the United States about 25 billion dollars every year and, according to the authors of this article, as much as 100 billion “if overall costs are taken into account.” It is estimated that the vast majority of adults, up to 80 percent, will experience at least one episode of back pain at some point in their life. While many of those will only have a one-time event, others will go on to experience chronic, or long-term pain.

Usual or conventional treatment for lower back pain includes physiotherapy, heat therapy, spinal manipulation, medications, and more. Unfortunately, the conventional treatments don’t always work and people who are living with pain may try other therapies, such as acupuncture. This approach, which involves inserting very thin needles into specific points in the body, has been used for centuries and is gaining popularity in the western world. The points (the Qi where the needles are inserted are along meridians that allow body energy to flow.

The science behind acupuncture isn’t understood but it has been the subject of much study, particularly now that the United States FDA allows for acupuncture needles to be labeled as medical equipment and no longer as experimental devices. So far, however, in studies, acupuncture has only been proven to the medical community as effective in treating nausea and dental pain, although there have been many reports of it being effective in other instances, such as treating addition, headaches, menstrual cramps, lower back pain and others. And, even though acupuncture is gaining in popularity, it is still not a widely accepted practice.

Skeptics of acupuncture cannot understand how a needle placed on one part of the body can affect another part. Because of this, they say that the acupuncture merely has a placebo effect, or causes the person to believe it is working, therefore it does. This theory, however, can be countered with studies of animals. In some studies, animals are given acupuncture and they respond. This would not happen if it was merely a placebo effect.

One hypothesis, belief, is that the needles cause a release of hormones called endorphins, which are responsible for relieving pain. Researchers are coming across several findings that point to this direction. One study, involving rabbits had researchers giving acupuncture to one rabbit, withdrawing cerebral spinal fluid (the fluid that bathes the spine) and transferring the fluid to another rabbit. It turned out that the second rabbit benefitted from the pain relieving properties of the first rabbit’s acupuncture. In humans, study subjects who were addicted to opium were given acupuncture to help deal with their withdrawal symptoms. Those who had acupuncture did not have the same level of withdrawal symptoms than did the addicts who received conventional medication to help them.

Another theory involves the the stimulation of the nerves, neurophysiology. A study by Inoue and colleagues, found a connection with the blood flow from an acupuncture site on the sciatic nerve and lower back pain from a slipped disk. The flow increased around the nerve roots which could be why pain decreased. Neurohormonal reactions are another possibility because women seem to respond better to acupuncture than do men. This could be due to the estrogen receptors in the central nervous system.

The neurogate theory says that fibers that are stimulate by acupuncture could prevent pain input into the spinal cord, while the diffuse noxious inhibitory control theory has another approach. This theory says that by providing a noxious (not “nice) stimulation, the body responds by changing the signals it receives from the painful area being treated.

The effectiveness of acupuncture is becoming more apparent in the studies that are being done but some people expressed concern about accountability and fear of being sued. This is highlighted when some studies show only moderate or sometimes no effectiveness. These studies are continuing and more are showing positive results. An analysis of studies, done in 2007, looked at 35 randomized, controlled trials that studied acupuncture for nonspecific or chronic lower back pain in adults, or dry needling for another painful disorder, myofascial pain syndrome, also in the lower back. The results of the analysis showed that “acupuncture, added to other conventional therapies, relieved pain, and improved function better than the conventional therapies alone. However, the effect was small, and acupuncture was not more effective than other conventional and “alternative” treatments.”

Yet another review that looked at 33 such trials found that acupuncture was more effective than placebo (sham treatment) in providing short-term pain relief for chronic lower back pain.

In 1997, the National Institutes of Health in the United States issued a statement that acupuncture was a reasonable alternative treatment for lower back pain. However, it’s important to understand that acupuncture may not replace other healthcare but work as a complement to specialist visits and physiotherapy. Interestingly though, one study, by Longworth and colleagues, found that patients who had not had any other therapy before trying acupuncture seemed to get better relief. Another study, led by Lundeberg, found that acupuncture for acute symptoms could help reduce these symptoms, avoiding more invasive medical treatments later on.

The authors of this article concluded that there is a lack of good research information on the effectiveness of acupuncture in treating lower back pain. Therefore, for definite answers on if acupuncture is a good approach, more research and more thorough studies need to be done in this area.

Surgeons continue to look for ways to fuse the lumbar spine with the best results and fewest problems. One of the biggest problems with spinal fusion is the need for bone graft material. Bone chips taken from the patient’s hip (iliac crest) work but often leave undesirable pain, infection, and swelling at the donor site. New biologic agents might be able to speed up the fusion process and do it without the use of bone graft material. But there have been some reports of serious side effects. This is a report of four cases of ectopic bone formation following the use of rhBMP-2 or recombinant human bone morphogenetic protein. rhBMP-2 is a growth factor that can be used to stimulate bone growth.

Ectopic bone formation means that the product used worked! It stimulated the growth of bone (bone formation). But unfortunately, not in the right place (ectopic). Instead of creating new bone around the fusion site (between the vertebral bones), bone formed inside the spinal canal and around the spinal nerve roots. In one case, the bone had completely encased the L4-L5 spinal nerve roots. The pressure from the bone on the nerve tissue caused serious neurologic problems.

In the four patient cases presented, the authors make it clear that the use of rhBMP to enhance bone growth was off-label. That means it wasn’t used as it was intended and for what it has been tested. Right now, rhBMP-2 has been approved by the FDA for use in spinal fusions. In its liquid form, it is placed on a sponge (called the carrier). The sponge is put inside a tiny cage that is then implanted between the two vertebrae. The disc that normally sits between the two vertebral bones has been removed first in a procedure called a discectomy to make room for the intervertebral cage.

In its off-label use, the procedure just described with the sponge carrier inside the cage is still used. But in addition, the surgeon has put some rhBMP-2 in the space left by the discectomy before inserting the cage (that’s the off-label use). The rhBMP is pushed up against what’s left of the disc lining (the annulus fibrosis) then the cage is set behind it. This pushes the cage back a bit from where it would normally rest without the additional rhBMP-2. The cage ends up being flush or even with the back wall of the vertebral bone.

Why did ectopic bone form in these four cases? There were a total of 37 patients who had a minimally invasive spinal fusion. The approach to the fusion procedure was from the side at an angle called transforaminal lumbar interbody (TLIF) fusion. Everything went well with the operation and early post-operative response. Patients got pain relief and improved function. X-rays showed that the fusion was successful. But 29 to 51 months later, new symptoms developed that led to the diagnosis of ectopic bone formation.

What went wrong? Well, maybe nothing in terms of the ability to use the rhBMP-2 off-label as presented. It does help stimulate bone growth for bone fusion. But the position of the rhBMP-2 and the cage back so far might be a problem. Without any protective barriers between the rhBMP and the cage or between the cage and the spinal nerve root, the rhBMP could leak out and stimulate bone growth outside the intervertebral space. It’s possible that using so much rhBMP-2 was also a factor — a lower dosage might work better.

The surgeons who tried this method have modified it now. They have built in protective layers using crushed bone and a layer of fibrin glue. A layer of bone is placed between the rhBMP-2 and the annular covering at the front of the empty disc space. Then the rhBMP-2 goes in, followed by another protective layer of bone. The cage filled with the rhBMP-2 carrier is next. And the final layer (fibrin glue) is placed behind the cage. They also pay close attention to where the cage is placed. Putting it as far forward as possible (and as far away from the nerve tissue) may help reduce the problem of neural compression.

The authors conclude that off-label use of rhBMP-2 to augment spinal fusion is still a good idea and a way to avoid the problems associated with iliac crest autografts. And given the fact that it’s often difficult to get enough bone graft material from the patient, an alternative approach to fusion is a welcome idea. However, patients should be selected carefully for the procedure and given the facts about the potential side effects.

Knowing that it is a delayed response, surgeons may want to follow-up with patients longer than they would otherwise. Watching for any signs of ectopic bone formation and intervening earlier than later might make a difference. If ectopic bone formation does occur, additional treatment (including a possible second surgery) may be needed. This problem is rare, so a standard treatment protocol has not been developed yet. More research is needed in both the use of off-label rhBMP-2 for lumbar spine fusions and treatment response if and when it happens.

For some time now, physical therapists have been trying to find better ways to treat patients with low back pain. By better we mean more effective treatment with successful results. And successful refers to getting relief from pain that doesn’t come back.

A group of well-known therapists started by developing a clinical prediction rule (CPR). The rule is used to predict which patients are most likely to have a good response to treatment. This group of therapists has developed a clinical prediction rule that has been tested and found to be valid and reliable for treating low back pain using one particular thrust manipulation technique.

Once that was settled, they turned their attention to whether the same clinical prediction rule could be used for other types of manual therapy. Manual therapy refers to a hands-on treatment given by physical therapists to reduce back pain and improve function.

Manual therapy techniques vary but include thrust and nonthrust manipulation of the spinal joints. The difference between thrust and nonthrust manipulation is the speed or velocity of the force directed through the joint.

The theory behind the use of joint manipulation is changing. For a long time, it was believed that the manipulation changed the alignment of the spine and spinal joints. Once the joint was balanced with everything lined up nicely, movement is restored and stiffness reduced. Therapists were very careful to apply just the right amount of force in just the right direction to achieve the desired results.

But scientists have shed some new light on how and why manipulation might work. And it may have more to do with the effects on mechanoreceptors and motor neuron excitability than on spinal alignment. Mechanoreceptors are tiny antenna in the joint that detect change in motion. Once the motor nerves have been charged up (excited) by injury or trauma, they don’t calm down on their own. That’s what motor neuron excitability refers to.

If manual therapy can alter mechanoreceptor responses, then maybe any technique used (thrust or nonthrust) will have the same positive effects. Or maybe there are subgroups of patients with low back pain who would respond to one technique better than another. To find out, these therapists treated 112 low back pain patients with one of three manual therapy techniques.

Each patient received two manual therapy treatment sessions with his or her assigned technique followed by three exercise sessions. Exercises prescribed were the same for everyone. All patients met the five criteria for a positive clinical prediction rule. That means they had a high probability of getting relief of back pain with a thrust manipulation manual therapy technique.

In addition to having low back pain with or without leg pain (sciatica) painful symptoms had to be present for less than 16 days to meet the clinical prediction rule (CPR). Other criteria in the CPR included: the pain did not go down past the knee, at least one spinal segment was hypomobile (stuck or lacking full motion), and at least one hip had 35-degrees (or more) of internal (inward) rotation range of motion.

A specific test for fear-avoidance behaviors was also administered. Patients with high scores on this test are fearful of movement and tend to avoid doing anything they think might cause pain. Patients with low scores on the test were more likely to benefit from manual therapy. When a patient met four of these five criteria for the clinical prediction rule, then they could be (randomly) assigned to the 1) the supine thrust manipulation group, 2) sidelying thrust manipulation group, or 3) nonthrust manipulation technique group.

The authors described each technique and provided photos of a therapist performing each one. The supine thrust manipulation was the treatment used when they first developed and tested the clinical prediction rule. The other two treatment techniques were added in this study for comparison. Spinal motion and strengthening the core (trunk) muscles formed the basic exercise program. These exercises were also used during the original studies to develop the prediction rule.

After completing the treatment and exercise program, patients were rechecked at one week, four weeks, and after six months. Patients were asked about any side effects from the treatment such as muscle spasm, fatigue, stiffness, or pain/discomfort. One in four patients experienced at least one side effect but this was not linked with the type of manual therapy treatment they received. Most of the time, when a problem occurred, it was worsening pain with increased stiffness within the first few hours of treatment. These symptoms went away gradually over the next 48 hours.

As far as which treatment(s) were most effective, they found that the two thrust manipulations performed in different positions (on the back, on the side) were equally beneficial. Patients in the non-thrust group had significantly less benefit in the first month of follow-up. By the end of six months, there was no difference in pain or function from one group to the other. The results of all test scores favored early treatment with thrust manipulation and supported the clinical prediction rule using the alternate thrust technique (sidelying) as well.

Patients from different geographical areas were included in this study in an attempt to see if the manual therapy treatments would meet the clinical prediction rule somewhere besides where the main researchers were working. In other words, can the clinical prediction rule be used in other settings besides the one it was developed in? Early results suggest yes, the clinical prediction rule can be generalized to other settings but more research is needed to confirm this finding.

Low back pain with or without leg pain comes in many flavors. There could be just back pain or back pain that radiates (spreads) into the buttock region. Back pain accompanied by shooting pain down the leg can be from two separate problems. The shooting pain down the leg is referred to as sciatica or radicular pain.

Then there’s the patient who experiences allodynia. That’s a medical term for pain caused by a stimulus that normally doesn’t cause pain. For example, gentle pressure or a light touch results in moderate to severe pain. Mild hot or cold temperatures in contact with the skin can cause allodynia. Pain felt with gentle brushing the skin can also be referred to as allodynia.

All of these painful experiences really fall under one of four separate types of pain: nociceptive, somatic referred, radicular, and radiculopathy. And identifying which type or types of pain are present is key to choosing the right treatment. Defining and understanding each of these terms is essential for the physician diagnosing and treating low back pain.

That’s why Nikolai Bogduk, a well-known back pain expert from Australia was asked to write this review defining and describing each of these pain types. Most of the time, a patient with just one of these problems is easy to evaluate and diagnose. But sometimes clinicians confuse one type of problem for another. Then a delay in diagnosis or even a mistake in diagnosis can occur. To help avoid such a situation, physicians must be able to distinguish one type of pain from another. The real challenge comes when patients have more than one type of pain at the same time. Any combination of nociceptive, somatic referred, radicular, and/or radiculopathy can throw a monkey wrench in the diagnostic process.

Dr. Bogduk offers a complete summary of each type of pain based on findings from years of animal and human studies performed and confirmed around the world. For example, nociceptive back pain occurs when an anatomical structure in the spine is stimulated by mechanical or chemical means. Studies of nociceptive pain have used normal subjects and targeted spinal ligaments, spinal joints, discs, sacroiliac joints, and back muscles. By stimulating each of these areas individually, scientists have been able to identify responses used by patients to describe nociceptive pain as dull and/or aching. There are no shooting pains, no numbness, and no allodynia with nociceptive pain.

What about somatic referred pain? What does that look like? Well, let’s understand the term soma (or somatic) first. The soma is actually the physical body as it is made up of structures such as skin, muscle, joint, tendons, ligaments, connective or myofascial tissue, and even bone. Referred means the pain originates in one place but is felt in a separate location. There are no spinal nerve roots involved in somatic referred pain. The patient with just somatic referred pain does not have any neurologic signs or symptoms. On examination, there is no numbness, no muscle weakness, and no change in deep tendon reflexes (all signs of neurologic or nerve involvement).

Instead, nerve endings called neurons are affected. These tiny nerve structures are located within the somatic structures just described. For a better understanding of somatic referred pain, it’s helpful to know that there are three basic types of neurons that send messages from the soma (body) to the brain and from the brain back to the soma. Sensory neurons respond to touch, sound, vibration, light, and other stimuli. The sensory neuron sends signals to the spinal cord and up to the brain so that the individual experiences each of these sensations. Motor neurons receive signals sent down from the brain through the spinal cord and cause muscles to contract. Interneurons connect neurons to other neurons within the same region of the brain or spinal cord.

Patients describe pain of a somatic referred source as dull, aching, and sometimes like an expanding pressure. They often can’t put a single finger on the exact spot that hurts. The pain is more diffuse and spread out over a larger area. A closer look at the map of the pain will point to the underlying cause because the pain distribution will match the nerve innervation of the affected area. For example, a commonly recognized somatic referred pain pattern is pain in the middle of the buttocks on one side. The pain may also go down into the upper portion of the thigh. Mechanical pressure on (or misalignment of) the spinal joints in the lumbar spine (low back) can result in this type of pain report.

Then there is radicular pain. The spinal cord or spinal nerve root is injured or affected in some way. It could be a herniated disc pressing against either or both of these two neural structures. Or sometimes, the damaged or degenerated disc sends out chemicals that irritate the spinal nerve root with the same end result. Technically speaking, there really isn’t pain. The patient is more likely to report a sharp, burning or stabbing sensation that goes down the full pathway of the nerve. The sensation may be alternately described as an electric shock. These patients report the pain goes down past the knee to the foot. You may have heard the term sciatica to describe this type of sensation. But a better understanding of how the nerve pathway is involved has led us away from the use of the word sciatica. Instead, the term radicular pain is the correct description.

The fourth and final type of low back pain is radiculopathy. Any time a word ends in the suffix -opathy you know there’s something wrong. In this case, there is enough damage to the nerve that it can no longer transmit messages clearly and correctly. The block can occur at the sensory or motor portion of the nerve. In either case, there are neurologic signs and symptoms present. The patient may report numbness and weakness. The examiner may see altered reflexes (e.g., decreased knee jerk response when the patellar tendon is tapped with a reflex hammer). There may not be any pain at all. Only when radicular pain is present along with radiculopathy does the patient experience pain along with the neurologic signs and symptoms.

Putting this all together, here’s what it can look like in the clinic. A patient comes in with shooting pain down the leg. No position is comfortable or reduces the pain. There is weakness of the leg muscles and numbness in the skin. There is a nerve involved here. It’s either being pinched or pressed with an inflammatory response. The patient would be diagnosed with radicular pain and radiculopathy. On the other hand, a patient with back pain that spreads to the buttock but without shooting pain with full leg strength has no nerve involvement. That’s simply a case of nociceptive (back) and somatic referred (leg) pain mixed together.

Dr. Bogduk acknowledges that there’s a lot of confusion about the cause of back and/or leg pain. Unnecessary medical and surgical procedures may be done unless physicians clearly understand the differences between the four types of pain reviewed in this article. Anyone examining and diagnosing patients with low back pain would benefit from a careful reading of this detailed review of the physiology of back pain.

If you’ve ever had neck or back pain, you know that your immediate concern is often how long is this going to last? Or maybe even will I ever get better? Researchers are busy trying to figure out the many pieces to the puzzle presented by spine pain.

In this systematic review, rehabilitation specialists look to see if there’s any evidence that the examiner can predict the final outcome based on symptoms observed during the exam. And secondly, they ask the question: is it possible to tell how well patients will respond to treatment based on how their pain responds to conservative (nonoperative) care?

One particular testing and treatment approach is the focus of this study and that’s Robin McKenzie’s idea that if the pain location or intensity changes, it is possible to predict a favorable or unfavorable response to treatment using McKenzie principles. McKenzie’s movement testing called centralization requires the patient to move in a prescribed direction repeatedly. If the pain retreats from down the arm or down the leg to a central spot in the spine, this is a sign that specific movements can be used to treat the problem.

Many physical therapists subscribe to this theory and are trained in the McKenzie technique. But there hasn’t been enough evidence so far to prove the technique is a reliable predictor of long-term results. And the results of this review of the studies published to date confirmed that evidence is still very limited to support the idea that symptoms changed by repeated spinal movements point to a positive prognosis.

The review was conducted by searching major medical databases for all years available up to March 2007. Of the 4,249 possible articles containing information on spinal pain, symptom responses, and prognosis, only 22 articles had all the data of importance to this study.

All 22 articles were carefully reviewed and analyzed. The authors present the information from all of the studies in table form with columns summarizing variables from each study for comparison. For example, each article was scored to provide an idea of how high the quality of the research was. Other descriptive data included length of time for follow-up (since long-term outcomes were of interest), symptom responses to testing and treatment, and details about how soon/how often patients returned-to-work.

Patient characteristics such as history of neck or back pain, activity level, socioeconomic variables, and type of treatment program used were also recorded in the table. And finally, measurable outcomes using pain, range-of-motion, and function or disability were reported.

Quite literally, the results were all over the map. Patients’ symptoms responded to testing but not with any consistency from one test to another. And there was a wide range of patient responses no matter what type of testing was done (e.g., movement testing, spinal compression or distraction, neurodynamic tests of nerve mobility, tests for spinal instability).

Sometimes the patient’s responses varied from one session to the next using the same test procedures. Studies just didn’t show a consistent symptom response to McKenzie’s principles of centralization and directional preference. Directional preference refers to movements in a particular direction (flexion, extension, rotation, side bending) that reduce symptoms.

There just isn’t enough evidence that using these symptom responses as a prognostic factor of outcomes is a valid or reliable approach. The authors are clear about saying that these results don’t necessarily mean the McKenzie principles are NOT predictive. It’s more the case that better research with high quality methods are needed to investigate this approach.

Finding patient factors that can predict what will happen is a high priority among neck and back pain researchers. Understandably, patients would like to know: How serious is my condition? What do my symptoms mean? How soon can I get back to work? Finding ways to predict the answers to these questions and figuring out what kind of treatment works best for each type of problem remains to be discovered.

It’s time. Time to take a closer look at materials used as a substitute for bone graft in lumbar fusions. How well do they work? Do they all give equally good results? How do they stack up against the patient’s own bone donated for the procedure? This systematic review examines each one of these questions searching for some answers.

There are different reasons to fuse the spine and different ways to do the fusion procedure. Surgeons are studying the results of fusion techniques to get an idea of which one works best for each problem. Fusing two or more vertebral bones together prevents motion at those segments and stabilizes the spine. Instrumentation such as screws or metal plates and screws may be used to perform the fusion. Bone grafting using the patient’s own harvested bone or bone from a bone bank (either without instrumentation) is another approach.

More recently, bone graft substitutes have come onto the scene. These materials made from bone are called recombinant human bone morphogenetic proteins (rhBMP). There are two types of recombinant BMPs available: rhBMP-2 and rhBMP-7. BMP bone graft materials rely on growth factors within the bone to do two things: make more bone cells (osteoinductive) and build a scaffold for the new bone cells to live (osteoconductive).

Bone graft materials are useful because they eliminate the risk of rejection with donor bone and the risk of infection with bone harvested from the patient. There are other potential problems with using patient-harvested bone for the graft.

For example, the donor site can be very painful or sore for a long time. It takes time in the operating room to gain access and then remove the donor bone, which can increase the risk of complications. And then after all that, the bone graft may fail and the patient ends up with a nonunion fusion. In other words, the vertebral bones still move when they shouldn’t so the spine still isn’t stable.

Bone cells from a bone bank are really only osteoconductive — they provide a framework for the body to fill in with its own live bone cells. The donated bone is no longer alive, so it is not osteoinductive (able to make new bone cells). That’s where bone substitutes like bone morphogenetic proteins (BMPs) come in handy. BMPs contain both the bone mineral matrix and growth factors, which makes them osteoconductive (provides a scaffold) AND osteoinductive (helps fill the scaffold in with new bone). Fresh bone graft taken at the time of surgery from the patient does contain live bone cells that are thought to survive and create new bone.

So, all that brings us to the question: how well do BMPs really work? The authors of this review didn’t actually do any studies of their own. They reviewed the literature already published looking for good quality studies on bone substitutes for lumbar fusion. They limited their search to articles in English. They included studies that used either an anterior (from the front of the spine) surgical approach or posterior (from the back of the spine) surgical approach.

Data collected from the studies included operating time, blood loss, length of hospital stay, surgical approach, and type of fusion material. Results were measured and compared using these factors as well as X-rays evaluating the fusion site. Patient pain, function, and disability were measured using a popular and well-known tool called the Oswestry Disability Index (ODI).

A total of 17 studies made the cut based on the standards set for good quality research methods, the use of English, and fusion for lumbar degenerative osteoarthritis. Some of the studies investigated the results of other bone graft substitutes such as demineralized bone matrix DBM), platelet gels, and activated or autologous growth factor (AGF).

Each of these bone graft materials are prepared and used in a slightly different way to achieve the desired results. BMP-2 is mixed in water and placed on a collagen sponge then placed in a fusion cage between two vertebral bodies (where the disc used to be located). BMP-7 is mixed in a saline (salt) solution and combined with collagen then painted around the sides of the bones to be fused together. Collagen is the basic building material of all soft tissues and bone.

When everything was studied and analyzed, they found that the rhBMP-2 had the best results. Patients receiving the rhBMP-2 bone graft substitute had more stable unions/fusions when compared with rhBMP-7, demineralized bone matrix (DBM), platelet gels, and growth factors. There was less blood loss and shorter operating times with the rhBMP-2. rhBMP-2 outperformed rhBMP-7 in all areas except change in function as measured by the Oswestry Index.

The conclusion of this systematic review of bone graft substitutes for lumbar fusion is that rhBMP is a useful alternative to donor bone or bone harvested from the patient. It is safe and cost-effective. The cost savings come from fewer complications during and after surgery with less blood loss, shorter operating times, and fewer infections. More studies are really needed before any final conclusions can be made.

Surgery for degenerative disc disease has traditionally been discectomy (removal of the disc) and spinal fusion. But with the new total disc replacement procedure, more patients are opting for this motion sparing technique. Fusion limits motion at the fused vertebral segments, whereas disc replacement tries to keep as much of the natural motion as possible. With either method, research has shown that total spinal motion is maintained, if not improved. How is that possible in the case of spinal fusion?

Evidently, the segments above and/or below the fusion increase their contribution to the total overall spinal motion. But exactly where is this motion coming from? That’s the subject of this study that looks not just at overall improvement of lumbar spine motion, but changes that occur at each spinal segment. Both quantity and quality of motion are measured.

Two groups of patients participated in the study. They came from three different centers in the northeast (Albert Einstein College of Medicine, Bronx-Lebanon Hospital Center, and University of Pennsylvania Department of Orthopedics). Everyone had one-level degenerative disc disease in the lumbar spine (either at L4/5 or L5/S1).

One group (155 patients) received a ProDisc-L replacement. The other group of 45 patients had a circumferential spinal fusion. Circumferential means the segment was fused from the front, sides, and back. X-rays and motion analysis were used to measure intervertebral motion segment by segment, including the operative level as well as two and three adjacent levels (above and below the fusion or disc replacement site).

The authors expected to find smoother motion in disc replacement patients that was evenly distributed at the operative site, and at the adjacent levels above and below the operative segment. And because the disc replacement is designed to maintain motion (whereas fusion is meant to stop motion), they expected to see more overall, total lumbar spine motion in the disc replacement group. They call these predictions their hypotheses (what they expected to find).

What they actually found was that the disc replacement patients lost a little motion at the replacement site that was made up by the level above (L34 for patients who had an L45 disc replacement). No change was seen at the L5S1 level. In the fusion group, the loss of motion at the fused site was made up a little bit by each of the levels above the fusion site. The immediately adjacent vertebral segment contributed the most.

A closer look at all of the measurements taken showed that patients in both groups started out (before surgery) with about the same amount of total lumbar motion. Two years after surgery, the disc replacement group had gained a significant amount of motion from before to after surgery. As expected, this was not the case for the fusion group — they had the same total lumbar motion before and after surgery.

Comparing the two disc replacement groups (L45 versus L5S1), they did find that the extra motion was made up at L4/5 by the first segment above (L34). The L5/S1 group gained back more of the total lumbar motion from the second level above the surgical site (i.e., L34). Overall, patients who received a disc replacement at the L45 level had better total motion after surgery than the group who received a disc replacement at the L5/S1 level. Changes were measured at the third and fourth levels above the L45 total disc replacement but these were not enough to be statistically significant. Likewise, in the fusion group, most of the motion was made up at the first two levels above the fusion with some contribution at the third and fourth levels — again, not enough at these further away segments to be counted as significant.

Studies like this are important because with new technology such as disc replacement, we don’t know what the long-term results will be. Can total disc replacement prevent or slow down disc degeneration at the other spinal levels? How long does the protective role of the total disc replacement last? Will patients with disc replacement eventually end up needing the disc replacement taken out and a fusion after all? These are just a few of the many questions left unanswered regarding disc replacement versus spinal fusion.

Each procedure affects total lumbar spine motion and therefore biomechanical movement of the spine. Identifying how each operation changes spinal motion and movement patterns may be helpful in measuring final, long-term outcomes. Clearly, the lost motion caused by spinal fusion, is made up by multiple adjacent levels above the fusion. The role of altered biomechanical stresses and shifts of loads to the adjacent levels is part of the ongoing investigation into the effects of these two procedures. This first-time look at first, second, and third adjacent levels is one important piece of the total picture.

The authors conclude by saying that a total disc replacement helps maintain lumbar mobility better than spinal fusion. If the implant is placed with good alignment, then normal biomechanical motion is preserved. This reduces the risk of uneven stresses and evens out the load transmitted to adjacent vertebral segments above. If the goal of total disc replacement is to preserve spine motion in normal patterns of movement and thereby prevent biomechanical strain on the rest of the spine, then the results of study support continued use of this technique to manage degenerative disc disease in the lumbar spine.

Bone grafts, attaching bone to bone, are a frequently performed surgery in the United States. Many of them are autologous, where a piece of bone is taken from the person who is getting the bone graft (auto = self). When doctors take bone for an autologous graft, it is most often taken from the iliac crest, part of the pelvis. The problem is, however, that when an autologous graft is done, the patient ends up with two surgical sites – where the bone came from and where the bone was grafted. Each and every time someone has surgery, there is always a risk, so two surgical sites doubles the risk of complications after surgery.

The authors of this study have found that there are a wide range of complications that could occur from having bone removed from the iliac crest. These include pain, infection and injury to surrounding body tissue. As well, it’s now being reported that some people are experiencing chronic pain from the site where the bone was removed, most often in patients who had spinal surgery. To investigate this further, this study looked at iliac crest graft harvest pain in patients who had an elective lower spine surgery. The surgery was for either spinal stenosis, spondylolisthesis, spondylosis, degenerative disc disease, scoliosis, or flatback syndrome.

The study began with 110 patients, six were unavailable a year later, so results are based on 104 patients (56 female). After the surgeries, the patients were evaluated at 6 weeks, 6, months and one year later. Pain was measured using the Visual Analog Scale, with zero meaning no pain and 100 being the absolute worst pain ever. Pain was evaluated at both the iliac crest harvest site and at the spine surgery site.

In general, at six weeks after surgery, the pain rating of the harvest site (the iliac crest) was about 22.7, decreasing to 15.9 at 6 months. At one year, it was a bit higher, at 16.1. For patients who had lumbar spinal stenosis (narrowing of the spinal canal), the pain ratings were 19.7, 17.5, and then 11.2.

Looking at the patients’ lifestyles, it was found that patients who were work and receiving workman’s compensation had higher levels of reported pain than those who were not receiving workman’s compensation – almost 75 percent higher at six weeks and 400 percent higher at one year.

There were a lot of persistent symptoms at the harvest site at one year, with persistent pain being common (16.5 percent). Numbness at the site was also common (29.1 percent). When asked about daily activities, 15.1 percent said that the pain at the harvest site made it difficult to walk, 5.2 percent said they had difficulty working, 14.1 percent had a hard time doing household chores, 12.9 percent weren’t able to participate fully in their recreational activities, 14.1 percent experienced sexual activity problems, and 5.9 percent said that they had problems with irritation from clothing.

The authors concluded that there remains a high rate of pain among people who undergo an iliac crest bone harvest, up to one year after the surgery. This pain can affect how a person is able to return to their previous levels of activity.

Is low back pain (LBP) during pregnancy normal? If studies are right and half of all women have low back pain sometime during pregnancy, does that support the idea that this symptom is to be expected during pregnancy? Available studies provide only a snapshot of what’s going on with women, pregnancy, and low back pain. The answers to these and other questions are not to be found in the many small studies already published.

That’s why the results of this very large study conducted in Iran involving more than 1,000 pregnant women have gained international attention. Iranian women ages 15 to 41 and who were pregnant were included in this project. For some of the women, this was their first pregnancy, while others had as many as eight pregnancies. All women were in their first, second, or third trimester ranging from five to 41 weeks gestation (age of developing fetus).

The women came from 18 health centers across rural and urban areas in northern Iran. Anyone with spinal deformities or previous spine surgery was not included in the study. Other health concerns such as spine tumors, osteoporosis, bone fractures, inflammatory disorders, or other chronic conditions were also reasons women were excluded from the study.

The goal was to find out how common low back pain is during pregnancy. The researchers also wanted to know what risk factors for low back pain might be present and what makes the pain better or worse (relieving versus aggravating factors). Information was collected using a survey of personal questions and several standard research tools.

The Visual Analog Scale (VAS) was used to assess pain intensity. The Oswestry Low Back Pain and Disability Questionnaire (ODQ) measured function such as ability to walk, sit, carry out daily activities, and participate in social life. The women also completed a pain drawing to help show the location of their pain and other symptoms. For this study, low back pain was defined as pain between L1 and L5, including the sacroiliac joints.

Conducting a study of this size helps improve the validity of the findings. Results are more statistically significant and reliable when the data is collected on more than just a few women. Analyzing the data showed some interesting patterns. For example, pain was progressively worse over time, so that the most severe pain was reported at the end of the pregnancy (third trimester). Younger women and women who had been pregnant multiple times (called multiparity) had higher rates of pain. Consistent with findings of other studies, they also found that pain was more likely to occur in women who had previous episodes of back pain (whether during pregnancy or not).

There were other important findings from this study. Women in rural areas were less likely to develop back pain during pregnancy. The authors suggest this may be due to the fact that women in rural settings are more active. It may mean that physical activity and exercise could turn out to be a preventive step in eliminating back pain during pregnancy. In all women, those who were more active and who exercised were less likely to develop back pain. This outcome supports, but does not prove, the role of physical activity and exercise as a deterrent to low back pain during pregnancy.

All together, risk factors for low back pain in pregnant women included:

While only one out of 2000 patients are diagnosed with cauda equina syndrome, it is diagnosed in one percent to 16 percent of patients who have lower back (lumbar) disk herniations (bulging or slipped disks) and in two percent to three percent of patients who end up needed surgery for the herniated disks.

Cauda equina syndrome, if left undiagnosed, may cause a lot of damage. It can cause loss of bladder or bowel control, and it can affect sexual function. Unfortunately, because the syndrome isn’t seen very often in every day practice, it may slip past a doctor undiagnosed. For this reason, the authors of this article wanted to review the signs and symptoms of caudal equina syndrome and how to identify it.

Researchers searched through the medical literature looking for articles about cauda equina syndrome. They identified 111 articles but had to discard six, leaving them with 105.

Interestingly, the researchers found 17 different definitions of cauda equina syndrome within the articles. Nine defined it by how it was caused while the other nine by the way it showed up. They also found 14 different pathologies or beliefs of what caused the syndrome.

There were also many different descriptions of how the syndrome presented:

– 10 involved the bowels
– 6 involved pain
– 5 involved sexual dysfunction

The study authors also described the physical aspects differently:

– 7 involved sensory issues
– 10 involved power
– 7 involved reflexes

There is also a difference between complete and incomplete cauda equina syndrome, as described by one of the studies by Gleave and Macfarlane. They felt that it was extremely important to point this out. The defined incomplete cauda equina syndrome as “a patient with urinary difficulties, altered urinary sensation, loss of desire to void, poor urinary stream, and the need to strain to [urinate].” On the other hand, complete cauda equina syndrome was “painless urinary retention and overflow incontinence.”

In conclusion, the authors of this article suggest that it is necessary for more to be done in defining cauda equina syndrome. They write that doctors should ask patients about any problems with bladder or sexual activity and monitor any bowel issues. As well, they should pay special attention to the saddle area and the genital area for changes in sensation. Finally, if there is any suspicion of cauda equina syndrome, they must take quick action to prevent further injury.

In the late 1990s, the United States government made it easier for doctors to order opioids (narcotics) to help relieve pain not caused by cancer, called chronic non-cancer pain. As a result, the prescriptions of opioids has grown so doctors could help treat patients living with chronic pain. Some studies showed that these medications could help treat chronic pain, however some of it wasn’t very strong.

Now, over 10 years later, it still isn’t really known who well opioids relieve non-cancer pain. One large study, done in Denmark, was unable to find a significant difference between patients who took opioids and those who used other methods of pain relief. In addition, there are dangers associated with increased use of opioids, including overdoses and poisoning. For this reason, it’s important to identify how much good these medications are doing for patients with chronic non-cancer pain.

The authors of this article undertook a study to determine the patterns of opioid prescription and morphine equivalent doses over a one-year period for patients with back injuries, the factors related to long-term opioid use, association of opioid use and pain and function, and the quality of doctor-related documentation of opioid use.

The study group consisted of 1,843 workers with back injuries. They were interviewed about 18 days after their first claim submission and again after a year. To participate in the study, workers had to be at least 18 years old, have lost four or more days from work due to the injury, and have had at least one day of pay compensation within the year. The researchers determined the injury severity by going through the workers’ records and a computerized medical billing database was used to determine opioid use.

The first interview was done by phone. The workers were asked about their socioeconomic status, pain and function, healthcare, lifestyle (such as smoking), and psychosocial issues. The workers were asked to rate their pain on a 0 to 10 scale, with 0 being no pain and 10 being the worst ever. They also had to rate how much the pain interfered with their daily activities, also on a scale from 0 to 10. The workers’ ability to function was measured using the Roland-Morris Disability Questionnaire. The workers were also assessed about how they reacted to their pain with the Pain Catastrophizing Scale and their expectations were measured with the Vermont Disability Prediction Questionnaire. Finally, the workers also completed the Fear-Avoidance Beliefs Questionnaire and the SF-36 v2 Mental Health Scale. One year after the study began, a follow-up interview was done, rating pain intensity and functional status.

The results of the study showed that of the 1,843 workers, 781 (42 percent) were prescribed at least one opioid prescription over the year, most of which were filled (694 workers). The prescriptions were filled by 59 percent in one quarter of the year (three month period), 15 percent in two quarters, 10 percent in three quarters and 16 percent for all four quarters.

Among the workers who took opioids for all four quarters, 39 percent saw their prescriptions increased in strength by 62 percent. Previous studies of opioid use also found similar results. The majority of long-time users (61 percent) did see stable prescription strengths or even lower ones. Of the nine patients that were found to have dramatically increased doses, only three reported meaningful improvement in pain and none of them had any meaningful improvement in function.

The researchers found that the greater the pain, the worse the physical function and the greater the severity of the injury. Interestingly, being Hispanic and seeing a chiropractor when the injury occurred resulted in lower opioid use. Nine workers were prescribed very high doses, enough to cause concern regarding other health issues that could result.

The authors of this study concluded that patients with acute back injuries don’t usually end up taking opioids for pain control. Those who do, however, didn’t – for the most part – experience any great relief in pain or function. Therefore, the authors suggest that it is necessary to do more studies on use of opioids for chronic non-cancer pain. As well, doctors who are prescribing opioids for this type of pain should be monitoring their patients for improvements and if none is seen, rather than increasing the dose, reevaluate if opioids are the appropriate treatment.

Health care, like most other things in life, has a cost attached to it. For people with low back pain, this cost can be significant. According to a recent study in the United States, costs from low back pain had increased from 52 billion dollars to 102 billion dollars – doubling in only seven years. If there were more people with back pain, this could be understandable, but the number of people experiencing low back pain has not doubled as the cost has. The costs are the result not only of direct treatment, but lost work and early retirement. This can add up to 85 percent of overall costs.

One issue that adds to the cost of caring for low back pain is the large number of choices a patient has. Someone with back pain may choose to be treated with traditional medicine, while others may try chiropractors, physical therapy or various types of complementary and alternative medicines (CAM). Interestingly, given the many choices for care, there are some who suggest that cost-effectiveness may be a better way of choosing treatment than clinical effectiveness (how effectively the pain is relieved).

The authors of this study wanted to look at methods and results of cost utility analyses by looking at clinical trials and studies of low back pain treatments. To do this, researchers searched through medical literature to find these studies, looking for studies that involved adults, two or more types of treatment for lower back pain, reports of the costs, and reports of utility. In all, they found 15 studies, most of which had been published in the previous three years, that met all of their criteria.

The results showed that most studies were done in the United Kingdom, involved lower back pain and lasted for at least one year. The most common intervention was education, follwed by exercise therapy, spinal manipulation, surgery and then “usual care” from a general physician. Patients who underwent naturopathic care had fewer spinal manipulations and physical therapy, as well as fewer pain medications. The patients who were followed for usual care did receive more spinal manipulations.

The cost of the treatments varied tremendously, from only 304 dollars per year to 579,527 dollars per year, with 13,015 dollars being the median amount.

The authors were disappointed at the lack of studies done to understand the cost related to low back pain, as well as the quality of the studies done. They feel that this is an important issue that needs addressing in order to help patients return to work and to keep health care costs under control. The studies that were included in this research compared everything from one type of surgery to another, to education and exercise to care from a general physician. Because the goals were so varied, it really wasn’t possible to come with a firm conclusion regarding costs related to low back pain. The authors suggest that researchers be educated regarding the importance of studying the same sorts of things so that findings can be compared fairly and properly.

There are different reasons to fuse the spine and different ways to do the fusion procedure. Surgeons are studying the results of fusion techniques to get an idea of which one works best for each problem. In this study, patients who had a spinal fusion for degenerative spondylolisthesis with one of three fusion methods are compared. Two of the fusion techniques used instrumentation such as screws or metal plates and screws. The third method used bone grafting without instrumentation. Outcomes were measured in terms of pain and physical function for up to four years.

Spondylolisthesis is a condition in which one of the vertebral bones slips forward over the one below it. Spondylolisthesis alters the alignment of the spine. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. In older adults, degeneration of the disc and facet (spinal) joints can lead to spondylolisthesis. Spondylolisthesis from degeneration usually affects people over 50 years old. This condition occurs in African Americans more often than in whites. Women are affected more often than men.

In this study, almost 400 patients with degenerative spondylolisthesis who had a fusion procedure to correct the problem were included. Data from patients’ charts was gathered from 13 spine centers in 11 different states. The three fusion techniques included 1) posterolateral in situ fusion (PLF), 2) posterolateral instrumented fusion with pedicle screws (PPS), and 3) posterolateral instrumented fusion with pedicle screws AND a 360-degree interbody fusion (fusion all the way around the spinal column at the affected level). The 360-degree approach was also referred to as PPS Plus.

Let’s take a little closer look at the anatomy to understand this condition and why a fusion procedure is needed. Each vertebra has a main body of bone with a circle or arch of bone that attaches to the back of the vertebral body. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This tube, called the spinal canal, surrounds and protects the spinal cord as it passes through the spine.

Two sets of bones form the spinal canal’s bony ring. Two pedicle bones attach to the back of each vertebral body. Two lamina bones complete the ring. The place where the lamina and pedicle bones meet is called the pars interarticularis, or pars for short. There are two such meeting points on the back of each vertebra, one on the left and one on the right. The pars is thought to be the weakest part of the bony ring. This is where a tiny fracture in the bone called spondylolysis can develop. When the two sides of the fracture separate, the condition becomes a spondylolisthesis.

Without a fusion to hold the structures together, the vertebral body shifts farther and farther forward, putting pressure on the spinal cord and spinal nerve roots. The affected individual suffers from significant low back pain, leg pain, muscle weakness and atrophy, and sometimes even paralysis. So, back to the purpose of this study: which one of these surgical methods works best?

Well, to find out, the authors measured pain and physical function using two main tools. The first was the SF-36 bodily pain and physical function test. The second was the Oswestry Disability Index (ODI). Both are well-known and reliable measures of outcomes after treatment. They specifically wanted to know if patients had better health after surgery (compared to before treatment) and how did the patterns of symptoms, function, and health change after surgery (comparing the results of one procedure to another)? Patient satisfaction with final symptoms and care was also evaluated.

By following patients at six weeks, three months, two years, and finally, four years, they were able to see a pattern of results. At first, the posterolateral (noninstrumented) method had the best results. About one-fifth of the patients (21 per cent) had this procedure done. Of the two instrumented procedures, the posterolateral instrumented fusion (56 per cent of the patients) had better results at first (six weeks, three months). But by the end of the second year, patients in the 360-degree group (17 per cent of the patients) had better pain relief and less disability. Fusion rates were equal between the two instrumented techniques. The posterolateral fusion group had the lowest fusion rate. They did not find any differences in patient satisfaction from one group to another with care received or symptoms. This was true at all measuring points in time.

The most striking finding was what they found at the end of the four-year period: no difference in results between the three fusion groups. Any of the differences observed early after surgery were not maintained over time. These findings are important because statistics show that more and more older adults on Medicare are having back surgery and specifically spinal fusion. With the rising costs of health care, it’s necessary to find safe, effective, and cost-reducing ways of treating common age-related conditions like degenerative spondylolisthesis.

The authors concluded that there wasn’t an obvious winner among these three fusion techniques. They all produced about the same results when looking at pain, physical function, and patient satisfaction. With only a few minor postoperative complications, there was no harm done to the patients having each type of fusion. Fusion rates were slightly higher for patients who had instrumentation. These results are consistent with what other researchers have reported about fusion rates in previous studies of spinal fusion.But as far as naming one method the best in terms of outcomes, they couldn’t do it.

Artificial disc replacements are gaining in popularity as studies show how well they are working. They are still used primarily for patients with degenerative disc disease, but the number and types of patients with this diagnosis who have benefited continues to expand. For example, younger patients (less than 65 years old) and younger adults with early disc degeneration from trauma or work-related repetitive motions are now getting artificial implants of this type.

Artificial disc replacements do have their own problems. Sometimes they break or migrate (move). In some cases, malposition of the implant results in uneven wear and eventual hardware failure. Bone growth around the implant is expected and helps hold the implant in place. But in some patients, ossification occurs — so much bone growth that the implant is buried and nonfunctional.

But these complications are fairly rare and short-to-medium term studies report good-to-excellent results with patient satisfaction described by a majority of patients. What we don’t know is how well would an artificial disc replacement hold up under significant trauma? This idea can be tested in the laboratory using cadavers (spinal segments preserved from humans after death). But without the dynamic effects of muscles, ligaments, and other connective or soft tissues, it’s impossible to know how a traumatic force might affect the implant.

That’s why this case report is so important. It details what happened when a 31-year-old manual laborer with an L4-5 Charité artificial disc fell off a roof and fractured his spine at the L3 level (third vertebral bone in the lumbar spine). The compressive load through the spine was powerful enough to cause the L3 vertebra to burst into tiny pieces. This injury is called a burst fracture. The fracture was unstable meaning that pieces of the fractured bone shifted, pushing into the spinal canal and pressing on the nerves. The accident occurred 10 months after the implant was put in the spine and while the patient was back to work full-time.

Fortunately, there was no evidence of damage to the artificial disc between the fourth and fifth lumbar vertebrae. The L4 and L5 vertebrae were also undamaged. In fact, the authors think that maybe the artificial disc actually protected the vertebrae above and below it. The young age of the patient (31 years old) might have contributed in a positive way as well, but there’s no way to know that from a single case study — just something to consider.

Of course, there are very few cases like this, so no clinical practice guidelines have been published to guide the surgeon in knowing the best way to treat it. In this case, surgery was done to fuse the spine from L2 to L4. Motion at the L4-L5 level was saved. The last lumbar vertebra (L5) was already fused to the sacrum in a previous L5-S1 fusion procedure. Now the patient only has motion at the first lumbar segment and at L4-5 where the artificial disc is located.

This is a unique case because now the spine is fused above and below the level of the still functional disc replacement. That potentially puts a lot of stress and strain on the artificial disc, which in turn affects the facet (spinal) joints on either side. Anytime the disc is compressed, the facet joints are also compressed. The opposing joint surfaces get squeezed together and rub instead of sliding and gliding against each other. The result over time can be degeneration of the spinal joints. The authors hope to follow this patient long-term to see how well the implant holds up and what effects the fusion on either side might have on motion, biomechanics, and spinal stability.

For now, cases like this (and other already reported in the literature) show that artificial disc replacements can be used in patients who have had other levels fused in previous surgeries. This case confirms the successful use of an artificial disc with fusion above and below the implant. It also proves that artificial disc replacements can sustain major trauma without breaking loose or being fractured along with the bone fracture.

Typically, artificial disc replacements don’t have good shock absorption. The authors point out that one of the main reasons this implant held up so well was because of its optimal placement. Other studies have shown that when placed with good alignment, these implants do indeed hold up better and last longer with fewer problems over time. The makers of artificial disc replacements are considering ways to improve the design to help absorb compressive loading and vibration. The hope is that the implant could actually help protect the segments above and below it, rather than transfer the load to the vertebrae above and below.

What happened to this particular patient? Well, after surgery, his symptoms of back and leg pain, numbness, and motor weakness gradually improved until he was able to return to work full-time at his same job. Two years later, he reported minimal low back pain but continued decreased sensation in his right leg and a little bit of weakness in his right foot. X-rays confirmed a good solid lumbar fusion with preserved motion at the L4-L5 level where the artificial disc continued to work properly.

In an ongoing quest to advance evidence-based spine surgery, the authors of this study evaluated a nationally-representative sample of patients undergoing posterior lumbar fusion (PLF). They analyzed the data on over 66,000 patients who had spinal fusion for acquired spondylolisthesis. Complication rates while in the hospital were reported and described. The goal of this research is to help surgeons select the most appropriate patients for this procedure in order to have the best outcomes possible.

Acquired spondylolisthesis is usually a condition seen in older adults (though it can be seen in younger individuals). Acquired means it’s something that happens to the person, rather than being a condition he or she was born with. When spondylolisthesis occurs in childhood, it is usually as a result of an injury. In older adults, degeneration of the disc and facet (spinal) joints can lead to spondylolisthesis. This type of acquired spondylolisthesis is sometimes referred to as degenerative spondylolisthesis.

Spondylolisthesis describes a condition of the spine in which one of the vertebral bones in the lumbar spine (low back) slips forward over the one below it. As the bones shift, the spinal canal opening (where the spinal cord is located) narrows. The result can be pressure on the spinal cord or peripheral nerves leaving the spinal cord in the lumbar region. Back, buttock, and leg pain are the main symptoms of this condition. Over time, leg weakness may also develop.

Studies show that surgery to fuse the spine is very effective. But when surgery and hospitalization are involved, there is always the risk of complications that can negatively impact the final outcomes. Studying these problems and the patients who develop them may help surgeons identify a subgroup of individuals who are the most (and least) likely to experience complications.

Surgeons from the Department of Neurosurgery at Stanford University in California conducted this study. They used data from the Nationwide Inpatient Sample (NIS) — data collected from patient records while in the hospital. And in particular, information about patients having a posterior lumbar fusion procedure for acquired spondylolisthesis. Because it’s a nationwide database, the results will reflect national (not regional or local) trends.

As it turns out, they found that the death rate following posterior lumbar fusion for acquired spondylolisthesis was fairly low (0.15 per cent). That’s much less than one per cent. But the overall complication rate was 11 per cent and that’s fairly high. Hematomas (pocket of blood at the surgical site) were the main problem. These are usually fairly minor.

More serious complications included blood clots, heart attacks, kidney infections or kidney failure, and less often, neurologic problems. Patients 65 years old and older were much more likely to develop complications. Anyone with more than one medical problem was also at increased risk of post-operative complications.

The authors examined the data collected with several other thoughts in mind. For example, did the complication rates differ based on hospital size (small or large), location (rural or urban), or patient characteristics such as gender or race? No, there was no difference in complication rates based on these factors.

But they did find that the risk of death went up when complications developed. And, of course, the number of days in the hospital increased with most minor and all major complications. Any complication increased the cost of hospitalization by thousands of dollars.

The results of this study will help surgeons develop treatment recommendations and national policy decisions to improve safety for patients having a posterior lumbar fusion for acquired (degenerative) spondylolisthesis. Knowing that patient age and the presence of other illness, diseases, or conditions will complicate the results of surgery are important findings.

Spinal fusion is still a safe and effective procedure for this condition. But now, surgeons can screen their patients more carefully before suggesting spinal fusion. And patients can be given more accurate information about what to expect, what could happen, and how likely it is that they might develop complications while in the hospital. This information will help both surgeons and patients weigh the pros and cons, risks and benefits of spinal fusion for this condition.

The authors make suggestions for additional studies to follow up on what they were able to report. For instance, they did not figure out how many people left the hospital but were later readmitted for one or more complications. They did not evaluate how or why the complications occurred — did the type of fusion that was done make a difference? How about number of levels fused or type of instrumentation used in the surgery (e.g., plates, screws, pins, wires)? There is plenty of room for additional study on this topic and in finding specific ways to reduce in-hospital complication rates.

You have to learn to live with the pain. Have you ever heard these words? If you are a chronic pain sufferer and you’ve been told this, you know how frustrating it is. Twenty-eight years ago, Penney Cowan, the founder of the American Chronic Pain Association heard these words and chose to do something about her pain. She had become physically deconditioned after back pain from a car accident left her in pain, fearful, and unable to work. Six years after her accident, she was still expecting some medical doctor somewhere to figure out what was wrong with her back and fix it.

But, as with many cases of nonspecific low back pain, even when there’s a known cause (car accident), tests are negative and no known anatomical reason exists for the pain that continues past the time of healing. If that’s your situation, then it’s time to take action. What Penney Cowan found out was that she could learn to manage her pain, reduce the sense of suffering, and understand her pain, rather than fear it. She did this through a multidisciplinary program of pain management, physical therapy, cognitive behavioral therapy, counseling, and activity.

Entering a comprehensive pain-management program gave her the tools she needed to get back control of her life and improve her quality of life. Does she still have pain? Yes, but it no longer dictates what she can and can’t do. She has learned how to live with her pain and remain active. She credits herself with changing from a passive patient waiting for a cure that was never going to come to a person with improved quality of life and a desire to continue learning in spite of her pain.

You may wonder why some people come out of car accidents with back pain that never quits and others walk away unaffected. Scientists don’t know all the answers to that dilemma. But research has shown that there are certain risk factors that contribute to this type of response. Trauma of any kind can play a role. A past (or current) history of physical or sexual abuse or trauma is a key factor. It’s estimated that as many as half of all patients with chronic back pain have some type of abuse history.

Although the pain itself might not be the result of posttraumatic stress disorder (PTSD; also known as posttraumatic stress syndrome or PTSS), the level of pain intensity and chronic duration seem to be linked with PTSD/PTSS. PTSD/PTSS seems to affect severity of symptoms, level of disability, and depth of depression. One other psychologic factor that seems to be part of the picture with chronic pain is pain catastrophizing.

Pain catastrophizing refers to a negative view of the pain experience. It is exaggerated or blown out of proportion. Sometimes it refers to a patient who actually has pain already. In other cases the person isn’t even in pain yet — he or she is still just anticipating it might happen. A person who tends to catastrophize sees things as worse than they really are. Studies show that without intervention these behaviors can lead to chronic pain and disability over time. Catastrophizing or expecting the worst to happen increases pain. Catastrophizing boosts anxiety and worry. These negative emotions stimulate neural systems that produce increased sensitivity to pain. It can become a vicious cycle.

No one doubts that patients with chronic low back pain have pain and even an underlying cause for that pain. The three most common causes for chronic low back pain are disc disorders (degenerative discs, disc herniation), back disorders (arthritis, spinal stenosis), and back injuries. Scientists and doctors just don’t know the exact neural mechanism that sets up the pain signals. There’s some evidence that pain signals disrupt normal brain structure, processing, and function related to thinking and feeling. Until we know more and can find a way to turn those signals off without drugs, the best medicine is a focus on pain management through exercise, activity, and counseling.

People like Penney Cowan can get back to work, walk three miles a day without being limited by pain, raise a family, stay active, and remain a contributing member of society. But just like it takes a village to raise a child, it can take a coordinated plan through a community of health care providers to provide all the tools needed to manage chronic pain. If you suffer from chronic low back pain, don’t let it have a negative impact on your quality of life and level of function. See the American Chronic Pain Association (www.theacpa.org/) for more information concerning services, conditions and pain management issues.

Imagine lying on a soft mat completely relaxed and pain free. This is how most yoga classes end. Sometimes the class begins and ends this way. The pose is called Savasana or corpse pose. Chronic back pain sufferers often think, “Oh, yoga, I can’t do that — I have too much back pain. But in this study, back pain sufferers not only did yoga twice a week for 90 minutes over a period of six months, they also reported decreased pain intensity, improved function, and even relief from depression.

Surprised? More and more studies are taking a look at alternative ways to treat chronic pain. Yoga has taken a front and center place in the quest for a low cost, accessible treatment approach for many health problems. And since back pain is so common, finding ways to reduce pain and disability without drugs or surgery could save patients and the health care industry a lot of money.

Not all of yoga is a resting pose. And there are different styles of yoga (e.g., Iyengar, Hatha, Bikram) with varying levels of intensity. The Iyengar style is especially adaptable for people with health problems, including chronic low back pain. Participants in Iyengar style of yoga can use props such as bolsters, blankets, and supports to help them assume and maintain any pose that is too difficult to reach or hold without help. With careful movement and focused breathing, the postures can be achieved with practice.

The patients in this study who participated in the yoga therapy were between the ages of 23 and 66 and had low back pain lasting more than three months. They could get up and down off the floor and agreed to attend 40 to 48 yoga sessions over a period of 20 to 24 weeks. They also practiced yoga at home for 30 minutes on nonclass days. And they agreed not to attend other classes (e.g., other forms of yoga, Pilates) or receive other forms of alternative care (e.g., chiropractic, acupuncture, massage).

A fair number of restrictions were placed on who could participate in this study. Anyone with spinal stenosis, abdominal or spine tumors, spinal infection, osteoporosis with vertebral fractures, or scoliosis (curvature of the spine) were excluded (not allowed) from the study. Women who were pregnant, anyone who had major depression or substance abuse issues, and patients with neurologic disorders were also excluded. Of course, anyone who was unwilling to try yoga or those who had already been doing yoga on a regular basis weren’t signed up either.

For those readers who enjoy yoga themselves, the authors provide a table listing all of the yoga postures used in this study. No photos or drawings were provided. The names of the poses might not mean much to anyone who is not familiar with Iyengar (or other forms of yoga). Patients in the yoga group weren’t necessarily familiar with the terms or poses either. A certified Iyengar yoga instructor conducted the classes. Each participant received an instruction manual with photographs and instructions to follow in class and for use at home.

There was a second (control) group of patients with chronic low back pain who followed standard medical care without the addition of yoga. Results for both groups were measured in a variety of ways. First, each person completed a well-known survey assessing disability called the Oswestry Disability Index (ODI). They also filled out the Visual analog scale (VAS) used to measure pain intensity. Depression was measured by the Beck Depression Inventory (BDI). And finally, everyone recorded what and how much pain medication was used. All measures were taken before and after treatment.

A few people in the yoga group ended up dropping out for reasons unrelated to the yoga. For the most part, everyone stayed committed and attended classes as well as practiced yoga at home. Six months after the study, two-thirds of the patients in the yoga group were still doing yoga! Most of the benefit from yoga was seen in the first 24 weeks. Although there was some continued improvements between 24 and 48 weeks, the results were not considered statistically significant.

Some people might think they are too old or too stiff to do yoga. But the participants in this study found that neither factor kept them from improving just as much as younger, more flexible folks. The yoga group was also able to reduce the number and frequency of medications for their back pain — significantly more than the patients in the control group.

The authors compared the results of the yoga group with other studies of yoga, Pilates, and lumbar stabilization exercises. They found that this yoga group achieved equal if not better results when compared with all other studies available. The authors conclude that Iyengar yoga is safe and effective when applied over time by patients with chronic low back pain. The benefits of this style of yoga (e.g., resting poses at beginning and end of class, use of props to support the body) contributed to reduction in pain, depression, medication use, and disability and improvement in function.