News Category: Lumbar Spine

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.

When it comes to the treatment of mechanical low back pain, physicians and physical therapists have taken a different approach in the last few years. Research has shown that certain subgroups of patients seem to do better with one form of treatment over another. So, efforts are being made to develop a classification system that will help identify which subgroup a patient should be placed in for the best results.

Mechanical low back pain refers to back pain that is related to the way the spine moves. Some movements or positions make it better while other movements or positions make it worse. These patterns are somewhat predictable. The response (pain is better or worse) is the same each time the movement is used or position is assumed. Mechanical pain usually involves the soft tissue structures, joints, discs, cartilage and/or bone. Another term gaining in popularity for this type of pain is nonspecific low back pain (NSLBP). Mechanical or nonspecific low back pain is not caused by tumors, infections, or fractures.

Traditional therapy for mechanical or nonspecific pain has been through a rehab approach. Patients are given reassurance of recovery, an exercise program, and advice to stay active. Bed rest is no longer recommended. Sometimes various forms of heat or cold are used. But this is a one-size-fits-all kind of approach. And many people are left unhappy with the results. They don’t really know what is causing their pain and they don’t get better.

That’s why health care professionals stopped and took a closer look at patients with low back pain and realized there may be subgroups of patients — patients with certain characteristics, histories, and clinical presentations — who could be treated in a specific way for a better outcome. Some of those subgroups or classifications are based on clusters of symptoms that seem to occur together. Putting those patterns of symptoms together with a history that always seems to go with them is a way to define what are called syndromes. Once the syndromes are identified, the next step is to study types of treatment that work best for each one.

In this study, physicians and physical therapists from the University of Toronto in Canada defined a patient subgroup based on patterns of pain alone. They did not use specific location of pain or other symptoms to identify a syndrome. They didn’t try to identify the soft tissues or anatomic structures involved, or diagnose the underlying pathology as part of the syndrome. Instead, they put patients together who had pain that was constant versus intermittent (comes and goes). They used movement patterns that made the pain better or worse as another way to classify patients.

All together there were four subgroups identified. Patients in group 1 had intermittent or constant back pain that was worse when the spine was flexed or bent forward. Group 2 had intermittent back pain that got worse when the spine was extended. Flexion did not make it worse and sometimes actually improved pain. Group 3 had pain in the buttock and down the leg that fit the diagnostic pattern for sciatica. And group 4 had intermittent leg pain that was predictably worse when walking or in a position of spinal extension and better when resting or in spinal flexion. This pattern is known and recognized as neurogenic claudication.

Almost everyone in the study (over 1,400 patients) easily fit into one of the four classification subgroups. Those who didn’t were excluded from this study but entered another (different) study to find an alternate classification for them. The plan with the four subgroups here was to compare treatment and see if patients in the classification subgroups got better results than patients treated all the same using the traditional approach described.

Patients included in the study were being seen for back pain at 15 clinics in a national network of Canadian rehab centers. They were all ages from 18 to 89 and a fairly equal number of men and women (55 per cent men, 45 per cent women). Patients referred to the clinics came from chiropractors, family doctors, and various medical specialists. The authors took a look at patient characteristics between the comparison group and the classification group before treatment to see what kind of differences there might be. They noticed there were more women than men in the classification group. The women saw themselves as having better function than the men even though their scores on function tests weren’t any different.

People in the subgroups were given education about posture and exercise that was similar to what patients in the traditional group received. The difference in the classification groups was the way they were told to exercise. Treatment strategies were specifically geared toward finding movement patterns that would reduce pain while at the same time avoiding movements that would bring the pain on or make the pain worse.

The results were measured using a couple of different outcomes. First, subjective pain ratings (better, same, or worse) were provided by the patients at the end of the treatment period. Second, the amount of medication used was compared from before to after treatment. Third, any change in how the patient felt his or her function referred to as perceived function was assessed from before to after treatment. And finally, total number of days in treatment was tallied up for each patient. There wasn’t a set number of days in treatment or predetermined period of time for treatment. Each patient received what he or she needed based on the progress made, clinician’s satisfaction that the patient had maximized benefit, or third-party payer required discharge.

In all areas measured, the classification group had significantly better results. Their pain resolved faster, they used less medication, and reported greater improved function. Not only that but it took the comparison group longer to benefit from the traditional treatment approach. The authors concluded that classifying and managing patients produces better results.

The authors readily agree with other experts that the idea of subgrouping to formulate a plan of care for low back pain is a good idea. Whether or not their method of basing classification on the clinical picture (movement patterns that make symptoms better or worse) gets the best results remains to be proved.

For the moment, the major advantage of this approach is that almost all of the patients evaluated could fit into one of the four subgroups. There may be other classification schemes with better outcomes. Time will tell as further studies are conducted using this approach. And whether or not it’s important to know exactly what’s causing the problem in order to treat it remains a point of debate. The authors suggest that’s only the case when conservative care has failed and surgery is planned. One other advantage to this classification scheme knows that anyone in groups 1 or 2 is not likely to be a candidate for surgery (i.e., they get better with certain movements and can avoid aggravating movements). That knowledge alone helps speed up the triage process of deciding who can benefit from conservative care.

In this study, spinal surgeons from The Rothman Institute at Thomas Jefferson University Hospital in Philadelphia take a look at the transforaminal lumbar interbody fusion (TLIF) technique for spinal fusion. They focus on its safety, effectiveness, and compare complications using two different grafting techniques.

The transforaminal lumbar interbody fusion (TLIF) technique is used to avoid the problems that come with entering the spine from the front (anterior approach. Transforaminal means the surgeon gains access to the spine from the back and side. The surgeon makes a posterolateral incision and removes one of the facet (spinal) joints so the disc can be taken out.

Interbody describes how the fusion is circumferential (all the way around and from front-to-back). Once the disc is removed, the two vertebrae are distracted or pulled apart gently and a special device called an interbody spacer is slid into the disc space. The spacer helps restore normal disc height, which in turn, takes pressure off the spinal nerve roots as they leave the spinal cord and pass through the opening formed by the vertebral bones.

Bone graft (human or synthetic) is inserted in and around the disc space to complete the fusion. The patient has a choice of two kinds of human bone graft: allograft (bone from a donor bank) or autograft (bone taken from the patient’s pelvis). A third choice is the use of rhBMP-2 bone substitute. rhBMP-2 stands for recombinant human bone morphogenetic protein type 2, so you can see why they shortened it to rhBMP-2. This protein stimulates the body’s natural production of bone.

All of this is done to treat problems like degenerative disc disease, chronic disc herniation, and spondylolisthesis (misalignment of the vertebral bones). Back and leg pain from these conditions can be severe enough to cause disability. TLIF is one way to eliminate back pain thought to be caused by the disc.

The TLIF has some advantages over other fusion techniques, but it also has some potential problems. The authors of this study are trying to determine how safe the procedure is and whether or not it is effective. The patients in the study were all adults between the ages of 18 and 80. They had a wide range of back problems including degenerative disc disease and/or herniated disc(s), degenerative spondylolisthesis, and previous (failed) lumbar fusion.

Each patient had a single-level TLIF. Some had an autograft, while others were treated with rhBMP-2. Half of the patients who received the bone substitute were also treated with Duraseal, a water tight sealant that keeps the bone substitute from leaking into the spinal canal or around the nerve roots where it could act as an irritant. Without the Duraseal, there is also a risk of bone formation in the spinal canal, which could put pressure on the spinal cord causing pain and dysfunction.

Comparisons were made between the two groups using several measures. Postoperative pain (at the fusion site and at the donor site for those who had an autograft) was the first outcome measured. Patients were interviewed over the phone asking about their pain levels. X-rays and CT scans were taken to show results of the fusion. And the medical records were reviewed looking for reports of any complications.

Previous studies have reported up to a 35 per cent complication rate using the bone substitute. Complications include screws coming loose or placed in the wrong position, interbody cage movement called migration, and infection. Sometimes pockets of blood form called hematomas or too much bone forms, a condition called heterotopic ossification. There can also be enough disturbance in the area of the spinal nerves that results in persistent nerve pain.

After all the information was in and the data was analyzed, here’s what they found. First, regarding pain: one-third of the patients who had bone taken from the pelvis reported continued pain at the donor site. Leg pain from nerve irritation called radiculitis was a common complication affecting 10 per cent all patients. Those who had the rhBMP-2 reported radiculitis more often than the autograft bone fusion. That was not surprising because other studies have reported the same thing. It’s likely that the body responds to the rhBMP-2 as a foreign agent and sets up an inflammatory response.

There were other reasons for the radiculitis. In some patients, there was excess bone formation around the fusion site that extended as far as the opening for the nerve. Bone formation in the spinal canal and around the opening for the exiting spinal nerve root narrows the space for the nerve and compresses (pinches) it. Pressure on the nerve or irritation of the nerve can set up a pain response that may or may not go away when the pressure is removed. One patient had an infection, another a malpositioned screw. But the most significant finding was that patients who did not have the Duraseal were four times more likely to develop radiculitis compared with those who had the Duraseal.

Taking a look at the fusion rates, they found similar rates of nonfusion (around three per cent) between the two groups. The 97 per cent who had successful fusion demonstrates the success of the TLIF procedure. The biggest problem still remains donor site pain for anyone having an autograft. But the authors point out one important finding. The donor site in this study was along the posterior (back) portion of the pelvic bone. The incision for the donor site wasn’t that far from the incision for the lumbar fusion. It’s possible that the combination of pain from both incision sites could have made it seem worse than it really was. They believe this factor bears further study and analysis.

The suspicion that rhBMP-2 would cause a high rate of complications was indeed true. The biggest problem as mentioned was the extra bone growth. What can be done about this? Well, surgeons are trying different things. It’s not clear what is causing the problem. It could be that bleeding when the disc is removed might be a factor. Moving the sponge with the rhBMP on it and the interbody spacer forward (away from the spinal canal, incision site, and area of bleeding) might help. This is another area where further study is needed.

In the end, the authors felt that TLIF has equal complications no matter which way it’s done. But at least with rhBMP-2, there are no additional problems from donor-site pain, infection, and bleeding. On the other hand, the bone substitute seems to set up extra bone growth formation that causes painful radiculitis. Whether or not one is better than the other remains to be seen. Perhaps long-term follow-up will add some helpful information to make that determination. Stay tuned!

Despite the fact that spinal stenosis (narrowing of the spinal canal) affects a large number of people over age 60, there are still many things about this condition we don’t know. For example, when does narrowing of the spinal canal actually become stenosis? Is it when the spinal canal opening is less than 15 mm? 12 mm? 10 mm? Are there certain groups of people more likely to develop stenosis than others? How many people really have this condition anyway? And of those folks who do have stenosis, how many have low back pain caused by the stenosis?

The authors of this study used data from the Framingham study to help answer some of these questions. The Framingham study started out in 1948 as a heart study looking at cardiovascular disease in a group of people living in Framingham, Massachusetts. Over time, as the second (and now third) generation family members have been included in the study, data collected has been used to evaluate other things besides heart disease.

In this study, they used CT scans of participants taken for other reasons to look at the size of the spinal canal indicating spinal stenosis. For their own purposes, the authors defined stenosis as relative when the opening was narrowed down to 12 mm. Absolute spinal stenosis was defined as 10 mm or less. The measurement refers to the anteroposterior (front to back) diameter of the spinal canal. These values were chosen because they have been used in many other studies and that makes it possible to compare results from study to study.

Two types of stenosis are recognized: congenital (something you are born with) and acquired. Acquired develops and progresses over time, usually being age-related or degenerative. Adults over age 60 seem to be most susceptible to acquired lumbar spinal stenosis. Patients in the sample selected for this study ranged from 32 years of age up to 79 years old.

As part of the Framingham study, CT scans were taken of the abdomen and chest looking for hardening of the coronary and aortic blood vessels. The participants also completed a special questionnaire called the Nordic Low Back Questionnaire that identified who had low back pain. Of the 3,590 people who had the CT scans done, 191 were included in this study. Pain was reported most often in the buttocks or thighs, followed by pain in the lower leg, numbness in the leg or foot, and less often, weakness in the leg or foot.

Acquired lumbar spinal stenosis is much more common than congenital. Relative stenosis is much more common than absolute stenosis in all age groups. Not everyone had pain; some people were completely free of symptoms. Clearly, the number of people with lumbar spinal stenosis rises with age. But in order to isolate the specific decade when acquired stenosis becomes more of a problem, the participants were grouped four ways: 1) younger than 40, 2) 40 to 49 years old, 3) 50 to 59, and 4) 60 and older.

What they found was that the prevalence of absolute stenosis (narrowing was 10 mm or less) was most often observed in adults ages 40 to 60 and above. And this was also the group most likely to develop painful low back symptoms. Men and women were affected equally, so there was no difference between the genders. The overall prevalence (how many people have this problem on any given day) for all age groups was 4.7 per cent for relative lumbar spinal stenosis and 2.6 per cent for absolute lumbar spinal stenosis. Just looking at the 60+ age group, these percentages increased dramatically to 47.2 per cent for relative stenosis and 19.4 per cent for absolute stenosis.

The authors concluded there were three major findings in this study: 1) This was the first study calculating the prevalence of lumbar spinal stenosis for a cross-section (wide range) of people, 2) Acquired lumbar spinal stenosis increases with age, and 3) Just because you are over 60 and have visible stenosis on CT scans doesn’t mean your back pain (or other stenosis-like symptoms) are coming from the stenosis. On the other hand, if you are over 60 and you do have stenosis, your chances of developing low back pain increase by a factor of three. In other words, you would be three times more likely to experience back pain compared to someone your same age who doesn’t have stenosis.

Generations of orthopedic surgeons, physical therapists, and sports specialists have used the flip test (also known as the sitting straight leg raise) to confirm sciatic nerve root compression. The technique has been presented in texts books, articles, and other publications for the past 50 years.

The sciatic nerve is a large nerve that starts in the low back and goes down the back of the leg from hip to foot. As it travels through the buttocks area, it passes out of the pelvis through the a hole called the greater sciatic foramen. Nerve compression often comes from disc disease, especially disc protrusion. A disc herniation may also put pressure against a spinal nerve. Pressure on an irritated or damaged sciatic nerve can produce pain that radiates along the nerve. True sciatic nerve pain from disc protrusion or herniation radiates down the leg past the knee, even going as far as the foot sometimes.

The authors of this study suggested it was time to test the validity of the flip test. Does it really measure nerve root tension? Exactly how should the test be administered? Descriptions of the test vary from book to book and article to article.

The basic flip test is done in the sitting position with the patient’s legs dangling off the edge of the table. The examiner holds under the patient’s heel and straightens the knee as far as it will go without putting so much tension on the nerve that it causes shooting pain down the leg. This position and movement place tension on the sciatic nerve. If it is compromised in any way, the test will be painful. The original flip test was considered positive when the patient fell backwards (flipped back) or had to brace him or herself to keep from falling backwards as the leg was straightened.

But here’s where there are some questions. Does it matter how soon the person feels the pain? Is it a positive flip test if the patient can straighten the knee all the way but reports sciatic pain? Is it more positive if the pain begins earlier in the leg straightening process? Is this test the same as doing a straight leg raise from a supine (lying flat on your back) position?

To find out, they tested 67 adults with known sciatica from a disc protrusion that was putting pressure on the spinal nerve root. The diagnosis was confirmed using MRI scans. They all had pain that traveled from the low back/buttock area down the leg to below the knee that was brought on or made worse by doing a straight leg raise in the supine position.

Everyone was tested in two ways. First, they were placed supine and the examiner performed a straight leg raise test. The straight leg raise test was done by the examiner with the patient lying on the table. The examiner lifted the leg off the table by supporting a hand under the heel. The knee remained straight as the leg was lifted as far off the table as possible without pain.

The patient’s range-of-motion, pain response, and report of sciatica being reproduced were all recorded. Then the patient sat up and the test was repeated as a sitting straight-leg-raise test (i.e., the flip test). With the knee in a 90-degree position of flexion to start, the examiner lifted the lower leg by the heel until the knee was as straight as possible before painful symptoms were reproduced.

The results were compared and analyzed and here’s what they found. The flip test didn’t really flip patients backwards when it was positive…at least not with the force or sudden response that was described when this test was first developed. All of the tested patients had a known sciatic nerve compression, so in theory, this test should have been positive 100 per cent of the time. But it was only positive (patient moved backward) in about one-third of the patients. One third of the group showed no reaction at all to this test. That tells us the test isn’t reliable or valid as a dependable sign of nerve compression.

So, the authors suggested using the name sitting straight-leg raise test (instead of flip test) as a more accurate descriptor of the test. Second, the test was only useful as a check of nerve root tension when the patient’s response was pain before the leg was raised 45 degrees. Test validity was much stronger when this modification was made in determining a positive test result.

The authors described various reactions that could be interpreted as a positive flip test. For example, some patients placed their hands beside or behind the buttocks; others leaned the trunk back 10 to 20 degrees. Some merely rolled the pelvis back slightly, but all of these reactions were in response to tension being placed on the sciatic nerve from hip flexion and knee extension.

The authors conclude that the flip test should really be called the sitting leg raise. It can still be used to test for nerve root tension but only to confirm a passive supine straight-raise leg test that is positive between zero and 45 degrees of hip flexion. The definition of a positive test in the sitting position should also be expanded to include back and/or leg pain when the leg is raised or the knee is straightened. Pain (not movement of the trunk backwards) is the defining standard.

Two orthopedic surgeons wrote an article on spinal stenosis that was published in 2004. In this article, these same two physicians revisit that topic and update information on causes of spinal stenosis, anatomy, diagnosis, and treatment. Goals of treatment and the ideal patient for each type of treatment are presented.

Spinal stenosis refers to narrowing of the spinal canal or the intervertebral foramina of the lumbar spine. The spinal cord travels down the spinal canal, so anything that narrows that space can compress the cord. The spinal nerve roots exit the spinal cord through an opening in the vertebral bones called the intervertebral foramina.

There are many anatomical changes that can result in pressure or compression on the spinal cord or nerve roots. Most of these have to do with degenerative processes linked to aging. For example, osteophyte (bone spurs) can form around the facet (spinal) joints, thereby covering up the foramina (hole) where the nerve roots exit.

The discs narrow and may even bulge. Loss of disc height compresses the facet joints together. The joints rub together and start to hypertrophy (build up tissue around them to protect them). These changes can also narrow the foraminal openings where the spinal nerve roots leave the spinal cord.

At the same time, the major ligament down the back of the spinal cord (inside the spinal canal) called the ligamentum flavum starts to thicken. There’s just enough room in the normal, healthy spinal canal for the spinal cord and the ligament. A ligament that’s larger than normal adds to the pressure on the spinal cord.

The combination of disc protrusion, thickening of the ligament, and hypertrophy of the facet joint creates a force on the spinal canal that can alter its shape. Instead of a nice, round opening for the spinal cord, the spinal canal gets pinched into a triangular shape. This shape is called a trefoil because it has a characteristic appearance of three overlapping rings. The term trefoil comes from the Latin for a three-leaved plant.

How do you know if you have spinal stenosis? Sometimes you don’t. People with this condition can be completely asymptomatic (without symptoms). But when the problem makes itself known, it’s usually in adults over age 50.

Low back pain develops with numbness, and pins and needles along the backs and sides of the thighs and legs. There is a sensation of weakness or heaviness in the legs. Walking or standing (especially standing up straight) makes the symptoms worse. Leaning forward or sitting makes it feel better.

The diagnosis is suspected by the nature of the symptoms but confirmed with X-rays, MRIs, CT scans or other tests such as myelography. Myelography is a type of radiographic examination that uses a contrast medium (dye) to detect pathology of the spinal cord. It helps show the extent of the stenosis. CT scans are better for seeing the surrounding bone and to look for bone spurs. Myelography and CT scans are also used for patients who can’t have an MRI because of a pacemaker or spinal stimulator.

Sometimes, people in this age group also suffer from a condition called vascular claudication (blocked arteries to the legs with decreased blood supply causing leg pain). The symptoms are similar to claudication (leg pain or discomfort with walking) that is caused by stenosis, so the physician must sort out one from the other. Many times, older adults have both conditions at the same time, making the diagnosis (and treatment) more complex and challenging.

But once it’s clear you have stenosis, then what? The first place to start is with conservative (nonoperative) care. This is the most appropriate approach for patients with mild to moderate symptoms. Since the progression of stenosis is usually slow, there’s time to try conservative care. There’s no need to rush into surgery, especially for older adults who have other health concerns.

Pain relief and improved function in daily activities are the main goals of treatment. These are accomplished by activity modification and rest when necessary to keep symptoms from getting worse. Patients are advised NOT to stay in bed for long periods of time. Staying active without aggravating the symptoms is the way to go. The best way to do this is to avoid heavy lifting or movements that increase the symptoms (e.g., back extension).

Wearing a soft, elastic corset to support the spine may be helpful. Rigid bracing is not advised as this only puts the spine in extension, a position that aggravates the condition. It’s always best to allow the trunk (back and abdominal) muscles to do their job acting as a girdle. Wearing a binder for too much of the day can lead to spinal muscle deconditioning. Short periods of external support followed by activity is the current recommendation.

Medications to control pain and inflammation may be prescribed. A short course of physical therapy or chiropractic care may be beneficial. Spinal manipulation performed by either the physical therapist or the chiropractor can help decrease frequency, intensity, and duration of pain. Manipulative techniques must avoid putting the patient in a position of spinal extension. This type of manual decompression gives irritated nerves a break from the constant compression and loss of blood supply from pressure on the blood vessels.

Physical therapy can also help patients recover faster with less long-term disability through the use of flexion exercises, a program for cardiovascular fitness, and both flexibility and strengthening exercises. A program of this type can increase the area inside the spinal canal and help improve blood supply to the spinal cord. Weight loss is an added benefit to any consistent exercise program. The therapist will also provide instructions regarding posture and conserving energy during daily activities.

The use of epidural injections for spinal stenosis remains a hotly debated topic. The surgeon injects a numbing agent combined with a steroid (antiinflammatory) inside the spinal canal. Some studies show that results using these steroid injections are no better than doing nothing. Others have provided evidence that the injections offer relief from spinal stiffness and pain. The authors suggest there may be a place for this treatment approach to gain control of symptoms for patients who are having an acute flare-up of the condition.

A more specific treatment with the same injection places the medication next to the affected spinal nerve instead of inside the spinal canal. This procedure is called a selective nerve root block (SNRB). It seems to have better results when used with patients who have a herniated disc as the underlying cause of the stenosis.

But if leg pain persists despite a nonoperative approach, then surgery to relieve pressure from the nerve tissue might be needed. The most common operation is a laminectomy. The surgeon removes the lamina, a portion of bone on each side of the vertebra that forms the bony arch around the spinal cord. This is usually done on both sides because just doing a laminectomy on one side often results in problems on the other side later.

A newer (less invasive) treatment has been reported. The use of an interspinous process spacer helps prevent spinal extension without removing bone. The only one out on the market right now is called the X-STOP. By placing this metal device between the interspinous processes, the spine is blocked from moving backwards into extension. The interspinous process is the bony bump you feel along the backbone. It is a bony knob attached to the back of the vertebra.

The XSTOP is best suited for patients who have classic symptoms and MRIs that show stenosis at one or two levels of the lumbar spine. Anyone who has more severe symptoms with muscle weakness and/or sensory loss is not likely to be helped by this procedure. And for those patients who have the X-STOP implanted but still don’t get relief from their symptoms, it’s still possible to have a laminectomy instead.

Making the decision about who should get what treatment isn’t always easy. The surgeon must take into consideration the patient’s age, general health and medical condition, degree of compression, and duration of symptoms. Timing is extremely important.

Early treatment gives patients the best chance of improved symptoms and even recovery. Waiting and holding off on surgery too long can result in permanent nerve damage. Large studies show that if surgery is going to help, it must be done within the first few years before the disease progresses too far.

What’s one exercise that can reduce pain, improve balance and coordination, while supporting your body weight and giving you a warm, fuzzy feeling all over? How does aquatic therapy in a pool of 90-degree water sound?

Water-based exercise has many potential advantages over land-based exercise programs. The warmth and buoyancy combined with elimination of gravity eases joint pain and improves range-of-motion. And because the water gives resistance to movement, you can vary how much or how little resistance by standing in shallow versus deeper water and/or by moving slower or faster through the water.

To use one of today’s more common expressions, What’s not to like? But here’s the real question researchers in physical medicine and rehabilitation are asking: is aquatic exercise more effective than land-based exercise? And in this study, that question is posed with a specific patient population in mind: those who suffer from chronic low back pain.

Two groups of patients with chronic low back pain without leg pain were compared. One group participated in a pool-based exercise program. They met five days a week for a month in a swimming pool heated to about 90-degrees Fahrenheit. Each session lasted one hour and consisted of 15-minutes of warm-up exercises, 40 minutes of aquatic exercises, and a five-minute cool-down period. All exercises were done in the water.

The second group was given instructions by a physical therapist on exercises to do at home. Written instructions were also provided. The program was designed to take approximately one-hour and included a warm-up period followed by stretching and strengthening exercises. There was an aerobic component (jogging and running) and cool-down exercises. Everyone in the home-based land exercise program received an encouraging/supportive phone call once a week.

Before starting the exercise treatment, everyone had a basic spine X-ray taken, routine lab work done, and a physical exam by a physician. Spinal mobility, pain level/intensity, disability, and quality of life were also measured and recorded. Everyone was asked to stop taking antiinflammatory or other pain relieving medications for one week before starting the exercise programs.

In order to compare the groups, evaluations were also performed twice after treatment. The first assessment took place at the end of the four-week exercise program. The second evaluation was done eight weeks later (a total of 12 weeks after treatment ended). They looked at the details of pain (at rest, with movement, at night) and used two well-known research tools (Oswestry Low Back Disability Questionnaire, Short-Form 36 Health Survey) to assess function and disability.

Patients in the groups were very similar in their characteristics (age, sex, duration of symptoms). Everyone had normal results on their blood tests. There was significant improvement after treatment in both groups. This was true at the end of four weeks and again at the end of three months. However, statistical analysis showed that the patients in the aquatic exercise group did much better than the land-based exercise group.

Although aquatic-exercise requires supervision of a physical therapist, the added benefits over an independent home-based program may be well-worth it. More study is needed to determine the optimal level of intensity and type of aquatic program for patients with chronic low back pain. This study involved a fairly intense program. The results support the use of a daily program for a medium-length of time.

When aquatic therapy is not available, a land-based home program can work well. Results may be better than usual because of the follow-up phone calls. But phone calls don’t assure patient compliance or good technique in doing the exercises. And it’s not clear yet if one type of exercise is better than another when treating chronic low back pain.

The optimal approach may be to start patients out in a water-based exercise program and then progress them to a home-based land program. This might get the best of both approaches and make it possible for people who couldn’t exercise otherwise to get started. Aquatic therapy makes it possible to reduce joint loading while still getting an aerobic workout. What’s not to like?

Surgeons attending the International Society for the Study of the Lumbar Spine (ISSLS) got the surprise of the decade. A group of researchers from Stanford University led by Eugene Carragee presented the results of 10 years of study on discography. Discography is a diagnostic test used to determine which disc in the spine is causing problems. A dye is injected into the suspected disc(s). If the injection reproduces the patient’s pain, the test is considered positive.

This test is used in a number of ways. First, it helps identify when and where a disc is the underlying cause of a patient’s pain. That is very helpful when planning treatment that will specifically address the cause of the painful symptoms. On the flip side, it can rule out a disc problem. No one wants surgery to remove a disc only to find out there was nothing wrong with it. Anytime treatment is focused on the disc, the disc provocation test offers very useful information.

But the results of Dr. Carragee’s work suggests that the puncture wounds left by discography eventually lead to disc degeneration. That puts the patient at an increased risk of disc herniation. In the study cited, two groups of adults without back pain were compared after 10 years’ time. They all had baseline MRIs of the lumbar spine taken. One group had discography done at three lumbar levels (L345). The second (control) group did not have discography done. Follow-up MRIs were conducted whenever possible.

Three findings stand out from this study. 1) Patients with discs that had been punctured were at greater risk of disc degeneration compared with the control group. 2) The discography group had more than twice the number of new disc herniations compared to the control group. And those herniations were usually on the side of the puncture wound. 3) There were more reactive changes seen in the vertebral endplates in the discography group. The endplates are round discs of cartilage between the disc and the vertebral bone.

Based on the results of numerous studies (including this one) from Dr. Carragee’s group, it’s easy to jump to the conclusion that discography simply shouldn’t be used anymore. If not from an evidence-based standpoint, then from a medical legal one. It would be one thing to show that the discography isn’t a good (reliable, valid) diagnostic tool. It’s something else to say it leaves people at risk of harmful side effects.

But Dr. Carragee pointed out that there are some other findings to consider. First, not all of the discs that were injected actually developed degenerative changes. Most of the degeneration was not accompanied by any symptoms. Without the MRIs, the patients wouldn’t even know they had a herniated disc. Looking at other areas of the lumbar spine, there was no evidence of accelerated disc degeneration. That helps prove that the changes observed weren’t just part of the aging process and would have happened anyway even without discography.

What’s the take-home message from all this? Well, first-of-all, the value of discography must be considered. Certainly, the results of the Stanford group must be carefully reviewed and repeated in other studies. Some members of the audience who sat in on the presentation of these findings asked if smaller needles or lower injection pressures would make a difference. Dr. Carragee noted that those two measures were already used in this study with the results as reported. In fact, they even used a nontoxic dye and avoided injecting the discs with antibiotics (using intravenous antibiotics instead).

It was also pointed out that if injection of the discs with discography causes disc degeneration, then other procedures that involve injecting the disc must be re-evaluated. That would include procedures such as intradiscal thermal therapies and disc replacement. It also complicates diagnostic testing before spinal fusion to identify the involved levels. Right now, there are no other tests that could do what discography does. An alternative way to test the disc must be found.

It’s possible discography could be used effectively and safely with certain subgroups of patients but that hasn’t been investigated or discovered as yet. For now, it’s clear that the role of discography is being questioned and some further answers are needed. The Stanford Discography Project hopes to answer some of those questions in the not-too-distant future.

Stem cell research continues to make the front-page news from time to time. Many scientists are convinced that the results of aging-related degeneration of the spine can be altered. For example, the breakdown of disc material between the vertebral bones could be repaired by regenerating discs with stem cells.

But until that’s really available, other researchers continue to study alternative methods to replace the intervertebral discs. In this report, efforts to just replace the center portion of the disc called the nucleus pulposus are the focus.

Intervertebral discs separate the vertebrae (bones of the spine). The discs are made of connective tissue. Connective tissue is the material that holds the living cells of the body together. Most connective tissue is made of fibers of a material called collagen. These fibers help the disc withstand tension and pressure.

A disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are connective tissues that attach bones to other bones.

Healthy discs work like shock absorbers to cushion the spine. They protect the spine against the daily pull of gravity. They also protect it during strenuous activities that put strong force on the spine, such as jumping, running, and lifting.

Artificial disc replacements are already on the market and have been in use in the United States since 2004. These replace the entire disc unit (both the nucleus and the annulus). But there’s a need for less invasive treatment. That’s where just replacing the center portion (the nucleus pulposus) comes in. Advanced technology now allows the surgeon to remove the damaged or degenerated nucleus pulposus and insert an implant in its place.

The implant (prosthesis) is designed to bear the load through the spine at that level and prevent further collapse of the affected vertebral segments. The hope is that the remaining disc will be protected and remain strong over time.

Nucleus pulposus biotechnology has already gone through several generations of pulposus replacements. Replacement materials for the nucleus come in two basic types. There are mechanical metal or carbon devices that are inserted into the space left by removal of the pulposus. And there are injectable elastomers that fill up the nucleus pulposus cavity and harden after they have been squirted into place.

It’s these biodegradable elastomer type nucleus pulposus replacements that are the subject of this article. Surgeons from the University of Pittsburgh present an update on what’s happening in the world of nucleus pulposus replacement technology. The elastomer type provide a more natural substance that mimics the body’s own disc material. It provides a scaffold or frame for the body to build (rebuild) its own nucleus.

It sounds like a simple procedure but there are many, many factors to take into consideration. That’s when we get a much better appreciation for all that the native disc actually accomplishes on a day-to-day basis. For example, the disc must be able to handle compression, bending, rotation, and vibrations — thousands, if not millions, of these forces over time.

And like natural discs, the replacement materials must perform all these functions while still preventing degeneration of the rest of the disc. The materials must not transfer load to the annulus (outer covering). When injected, the materials must not shoot past or ooze out of the inner space for the nucleus.

This complication is called extrusion. The tiny hole made in order to inject the material into the disc center leaves an opening for a quick exit of the same material. The hole must be closed to keep this from happening. Finding the right material to make the patch, seal the hole, or develop an effective suture to close the open edges is part of today’s research efforts.

Another potential problem is subsidence — the new nucleus sinks down into the annulus (outer covering). Researchers are tinkering with the shape and size of the implant to help stop this problem. By measuring the stress or load placed on the endplates, they have been able to see higher stress at the center of the endplate. This information has guided them in reshaping the implant.

Right now scientists are still working with various liquids that flow smoothly and then self-cure (harden after injection) into one piece. This process is called polymerization. The process requires careful temperature control to move the liquid at body temperature and shift from a liquid to a gel without clumping or swelling while still conforming to the shape and size of each patient’s disc space.

Different materials are being tested. For example, silk and elastin proteins are being tested as an implantable liquid that cross-links with collagen within 90 seconds of injection. The advantage of that feature is that it restores the disc strength and biomechanics right away. The next test will be to see if it can hold up under the many, many fatigue cycles placed on it by the average adult.

In other laboratories, a different approach is being investigated. Preshrunk forms are inserted into the disc center and rehydrated as the implant sucks up nearby fluid, swelling to fill the cavity. The fully hydrated implant transfers load from the disc to the vertebral endplates. The endplates are fibrous cartilage structures between the disc and the vertebral bone.

Studies so far have been encouraging. A large proportion of the small number of patients studied experienced pain reduction, decreased use of narcotic drugs for pain, and improved function. Complication rates (expulsion and subsidence) have been low. And the discs have been shown to withstand 10 million cycles of fatigue when tested biomechanically using cadavers (vertebral segments preserved for study after death).

Most of the studies done so far have been completed by the companies that designed and developed the implants. Before these can be adopted for regular use, tests must advance from cadavers to animals to clinical trials with humans — first by the disc replacement industry and then by outside, independent agents. The race is on to find a way to slow or reverse disc degeneration eliminating the need for nucleus (partial) or disc (complete) replacement.

When a new treatment like disc replacement comes along, it takes a while before it’s clear who should have this surgery. So patient selection is extremely important. At first, it’s just a limited group of patients who qualify for the procedure. That’s okay because surgeons want the best results for their patients.

In this article, a neurosurgeon familiar with cervical disc arthroplasty (neck disc replacement) summarizes the use of this device. Pros and cons for its use, patient selection, details of surgery, and postoperative complications are discussed.

Artificial disc replacement (ADR) is relatively new. In June 2004, the first ADR for the lumbar spine (low back) was approved by the FDA for use in the US. Replacing a damaged disc in the cervical spine (neck) is a bit trickier. The disc is part of a complex joint in the spine. Making a replacement disc that works and that will last is not an easy task.

The artificial disc is inserted in the space between two vertebrae. The goal is to replace the diseased or damaged disc while keeping your normal neck motion. Disc replacement can be done instead of fusing the neck and losing neck motion.

With cervical fusion, there is concern that the spine will develop similar problems over time above and below the affected spinal level. This is called adjacent segment disease. The hope is that disc replacement will help avoid such problems. A few studies comparing fusion to disc replacement have been published. The short-term results seem to show that adjacent segment disease occurs less often in patients with disc replacements compared with cervical fusion. Time will tell as long-term results are observed and reported.

Who’s the best candidate for a cervical disc replacement? Well, for starters, anyone who is also a candidate for cervical fusion. These patients have obvious cervical disc disease with herniated disc, bone spurs, and/or neck/arm pain from myelopathy or radiculopathy. Myelopathy is any damage to the spinal cord as it travels down the spine. Pressure on the spinal cord can cause significant symptoms and disability. Radiculopathy is pressure or irritation of the spinal nerve roots as they exit the spinal cord and travel down the arms (or legs).

In Europe where disc replacements have been done much longer than in the U.S., there is a broader patient selection. For example, patients with a failed cervical fusion, patients with multilevel degenerative disease, and patients with segmental disease after fusion are also candidates for cervical disc replacement.

Surgeons now have more choice in selecting the right device for each patient. Newer, improved implants are available compared to when the first disc replacement came out. There are different basic designs in how the implant is held between the vertebrae and how movement is produced. Different materials are used such as titanium, cobalt, chrome, or combinations of these alloys.

In fact, there are many things to consider when designing a perfect disc replacement. The pore size and surface coating of the implant can influence how fast and how well the bone grows in and around the device. That’s important in holding the implant in place and avoiding complications such as implant migration (moving) or subsidence (sinking). Implants that are held in place with teeth or spikes seem to take a while to settle into the endplates. The endplates are fibrous cartilage between the discs and the bone.

Certain patients may not be good candidates for this type of surgery. Brittle bones from osteoporosis or other significant diseases may keep a patient from having this type of surgery. Local problems in the spine such as infection or severe degeneration of the facet (spinal) joints are also possible contraindications (reasons NOT to have the operation).

If the spine has already started to fuse itself (autofusion) with bone spurs crossing the disc space, then disc replacement is not advised. And if the patient has an unnaturally straight cervical spine called kyphosis, cervical disc replacement may not be a good choice. The kyphosis can get much worse after surgery. The result can be worse neck pain than before surgery. In time, with the right design and placement, this problem may be resolved. But for right now, preoperative kyphosis is considered a contraindication for cervical disc replacement.

Not much is known about how to prevent subsidence or other complications with cervical disc replacements. The few studies that have been done offer surgeons some ideas. First, save the endplate and use them to help anchor the implant. A wider, thinner implant might be helpful when the disc space is small to begin with. Patients with a collapsed disc fall into this category. Anything that changes bone structure is considered a problem. This could be osteopenia (a pre-osteoporotic state), any other bone disease, and/or medications that reduce bone quality.

Migration hasn’t been reported as a major problem with artificial cervical replacements. Spontaneous fusion seems to be more common. So much bone forms around the implant that motion is lost. Once again, surgeons are encouraged to avoid drilling into the endplate as a way to prevent this complication. Selecting the right size implant also seems to be helpful. Too small of an implant may result in the body filling in with bone and eventual fusion.

Despite the fact that it sounds like complications are common with this procedure, many patients do have a successful result. The outcomes are equal to (if not better than) cervical spine fusion. Surgeons in the United States are slowly expanding use of the implants for multisegmental (more than one level) spinal disease.

With long-term studies, it will eventually be possible to answer the question of whether adjacent segmental disease can be prevented with disc replacements. That would definitely give implants the advantage over cervical fusion.

It’s still not entirely clear whether disc replacement is a better treatment approach than just doing a fusion. And with improved materials, fixation methods, and surgical techniques, the overall results with disc replacement may improve enough to put all these questions aside in the end.

There are many different ways to treat low back pain. When surgery is needed, there are different options as well. Spinal fusion may be necessary in the case of degenerative disc disease, tumor, infection, deformity, or spinal instability. Just like everything else, fusions can be done in different ways with different approaches.

In this article, two spine surgeons from the San Diego Center for Spinal Disorders in California provide an extensive and detailed overview of extreme lateral interbody fusion (XLIF). Interbody fusion refers to the fact that after removing the disc, the surgeon inserts a metal cage, spacer, or bone graft material in the empty space. Bone is packed in and around the area to help the fusion process along.

Even with interbody fusion, there are different ways to approach the spine. The surgeon may come in from the front of the body. This is called the anterior approach. Surgery from the back of the spine is a posterior approach. Sometimes a posterolateral approach is used — angled between the back and the side. No matter which method is used, the goal is always the same: to restore the disc height and vertebral segment spacing and restore spine stability as close to normal as possible.

Each approach has its advantages and disadvantages. The development of an extreme lateral interbody fusion (XLIF) was in response to some of the problems that occur with other types of fusion procedures. The XLIF is less invasive with a smaller incision, less disruption and damage to the soft tissues, decreased blood loss, and provides a faster recovery.

With the ability to gain access to the disc space without stripping away the muscles, there is a hope that future problems with adjacent segment degeneration can be prevented. Adjacent segment degeneration refers to the breakdown of the next vertebral segment as a result of a transfer of load from the fused site to the next mobile segment.

The XLIF is a new technique of reaching the disc space. The surgeon goes through the side with only disruption of the psoas (hip) muscle. There are no major organs to avoid (as with the anterior approach). There’s no need to strip away large groups of muscles or cut through nerves (as with the posterior or posterolateral approach). The benefits of a minimally invasive approach of this type include decreased blood loss, shorter operative time and hospital stay, and less postoperative pain. Patients recover faster and return to work with fewer sick leave days used up compared with other fusion techniques.

Another advantage of the XLIF is that a larger implant device can be slipped into the disc space. A larger implant means the load is spread out more, the spinal segment can be aligned more accurately, and there’s less chance it will sink down into the endplate. The endplate is a fibrous piece of cartilage between the disc and the bone to support and cushion the disc/spinal segment junction.

XLIF can only be used for fusion of the lumbar spine above the L5 level. For L5S1 fusions, the pelvic bones get in the way of the surgeon trying to reach the lumbar spine. The authors provide pages and pages of descriptions, photographs, drawings, X-rays, and intraoperative views of the XLIF procedure. They take the reader through the five major steps of this procedure: patient positioning, access to the body, passing through the psoas to the disc, removing the disc, and inserting the implant.

Special X-ray techniques such as fluoroscopy and real-time electromyography (EMG) are used to guide the surgeon and monitor the patient. Using these tools, the surgeon can move safely through the body to the spine avoiding the abdominal contents and without damaging vital nerves, blood vessels, and soft tissues.

The most difficult part of the operation is to move through the psoas muscle without disrupting the lumbar nerve plexus. That’s where EMG comes in handy. The tool used for the XLIF has a tiny EMG electrode on the tip giving the surgeon continuous feedback on the location of the psoas muscle. The fluoroscope is used once again after the disc material has been removed to put the spacer in place and to pack it with bone graft material.

Patients often go home within one to three days after the XLIF surgery. Sometimes a special brace is needed to support the spine during the healing and recovery process. But more often, patients go home and return to their daily activities and work quickly and easily. That’s not to say problems don’t ever occur. There are some potential complications from XLIF.

If the lumbar plexus or genitofemoral nerve is damaged during the procedure, thigh and/or groin pain and numbness are possible. Trauma to the psoas muscle can also produce hip pain and weakness. Most of these symptoms are temporary and will go away in time (six weeks to six months).

The authors say that in all the small studies done so far, the results have been good. There’s been no question about the safety and effectiveness of XLIF for interbody fusion. They have even used it with multilevel fusions in patients with other problems like scoliosis. But the studies are limited and with only a few patients. Larger, randomized controlled trials comparing XLIF to other fusion operations will provide the rest of the story in time.

Piriformis syndrome: what is it? How do you get it? How do you know you have it? How do you get rid of it? What else do you need to know? That’s the substance of this review article written by two well-known and well-respected physical therapists on the subject of piriformis syndrome.

Let’s start with: what is the piriformis syndrome? Piriformis syndrome is an irriation of the sciatic nerve as it passes next to or through the piriformis muscle. The piriformis muscle is a flat, pyramid-shape structure. It starts along the anterior (front) part of the sacrum and inserts or attaches on the greater trochanter of the femur. That’s a bony bump at the top of the upper thigh bone.

The muscle is close enough to the sciatic nerve that the muscle can put pressure on the nerve when it contracts or if it gets bulky enough from repetitive overuse. In about 10 per cent of all cases, the sciatic nerve actually runs through the piriformis muscle. Anytime the muscle contracts, the nerve gets squeezed.

Some experts think it’s this pressure that causes the symptoms that make up piriformis syndrome. Those symptoms include aching, burning, or sharp pain in the area controlled by the sciatic nerve. The pain starts in the mid-buttocks on one side and can shoot down the upper leg. Symptoms may go down as far as the knee but only occasionally go past the knee. How far down the leg the pain goes can help distinguish it from a herniated disc. Pain that does go past the knee down to the foot is more likely to be from a protruding disc putting pressure on the spinal nerve root.

Before going much further, it’s important to say there are some medical specialists who don’t believe the piriformis syndrome even exists. So, some effort has been put into identifying just what constitutes the idea of a piriformis syndrome. Here are six indicators of this condition:

Some new and important discoveries are being made about low back pain. For example, it used to be said over and over that eight out of 10 people would suffer a bout of back pain at least once in their lifetime. That’s still true. But the next part of the story may not be so true.

Based on the best evidence available at the time, doctors told their patients that with a short period of rest followed by as much activity as tolerated, the pain would go away in one to two weeks. That’s still true, too — but not for everyone. In fact, some recent studies have reported that three out of every four back pain patients still have back pain three to 12 months later.

A closer look helps explain some of these statistics. Advanced imaging and neurophysiologic and precision diagnostic techniques have shown scientists that spine pain can come from more than one place. Pain could be from the muscles, ligaments, discs, joints, or a combination of two or more of those places.

Since each one of these areas requires a slightly different approach, one treatment method may not be effective. In fact, that probably explains why there are so many different ways to treat chronic low back pain. Some are nonoperative while others involve complex and challenging surgeries. Somewhere in between is a technique called interventional procedures.

Interventional procedures involve a minimally invasive operation. The surgeon inserts a long needle through a tiny incision in the skin and advances it to the spine in order to carry out the procedure. This method is called percutaneous. A special real-time X-ray called fluoroscopy is used to guide the surgeon.

Or the surgeon can make a slightly larger incision and insert a tube through which an endoscope is placed. The scope has a tiny TV camera on the end that also shows the surgeon the spine and surrounding anatomy. With the guidance offered by fluoroscopy or endoscope, the surgeon can be much more precise and accurate without making a large incision and opening the patient up.

The evidence for interventional procedures is the topic of this report from the American Society of Interventional Pain Physicians (ASIPP). The past president of this organization (Dr. A. Trescot) has put together an evidence-based summary on interventional approaches to chronic low back pain. Epidural steroids, epidural adhesiolysis, nerve blocks, radiofrequency ablation, and sacroiliac joint injections are just a few of the treatments discussed. Treatment for disc problems called intradiscal therapies is also presented.

So what does the literature have to say so far about interventional pain techniques? First, it might be best NOT to measure results based on pain relief. Pain is just too subjective from person to person. It’s best to evaluate the patients’ function as a better measure of treatment effectiveness.

Specific ASIPP treatment guidelines for epidural injections remind researchers that image-guided injections can be delivered to several different anatomical locations. When studying epidural injections, it’s best not to lump all injection sites together in one study. Right now, results from studies that have separated treatment based on site of medication delivery are limited in number. Most studies combined all-site epidural injections into one group of patients.

Epidural injections provide short-term pain relief. If at least 50 per cent of the pain is gone and stays gone for six to eight weeks, then it’s okay to repeat the injection at the end of eight weeks — but only if it’s really needed. If more than one area is being targeted, then the injections should be given at the same time. The total number of epidural injections at each site should not be more than four to six times per year.

A second interventional procedure under investigation is adhesiolysis. This particular method uses radiofrequency or extremely cold temperatures (cryoneuroablation) to destroy tiny adhesions. These scars form around the nerve root and inside the epidural space (space around the spinal cord inside the spinal canal formed by the vertebrae). Breaking up the adhesions once again allows normal motion of the nerves as they leave the spinal cord and travel down the limbs.

Adhesiolysis is used most often for patients with disc-related back pain or for those who develop scarring and pain after back surgery. ASIPP treatment guidelines recommend limits to these procedures based on whether they are done percutaneously (needle through the skin) or endoscopically (larger scope down to the surgical site).

Spinal joints called facet or zygapophysial (z-joint) can also generate back pain. When the discs degenerate and lose height, ligaments around the joints become lax. The end result is increased movement at the joint and joint degeneration. Pain from the joints can be relieved with nerve blocks. These nerve blocks can be done first to diagnose and then treat to the problem.

ASIPP guidelines suggest facet joint injections can obtain short- and long-term pain relief. Diagnostic injections should be separated by at least a week (two weeks is better). Therapeutic injections should be separated by two to three months (or longer). Second or third injections are only given when the patient has had at least 50 per cent reduction in pain that lasted at least six weeks.

Nerve blocks don’t always last forever. The pain often comes back. But at least the surgeon knows it’s coming from the joint. Other methods of dealing with facet joint pain involve not just blocking the nerve pathway but actually destroying it. This is called facet neurotomy. Radiofrequency and cryoneuroablation therapy can be used for this treatment. This is similar to performing a root canal on a tooth. Neurotomy may have to be repeated more than once but should not be done more than three times per year at the same site.

There are several more interventional procedures discussed in this very comprehensive article: sacroiliac joint injections, intradiscal therapies, and spinal cord stimulation. Sacroiliac injections may help with low back pain that is really coming from the sacroiliac joint (SI). At first, diagnostic injections of the SI joint seemed like proof positive that the sacroiliac joint was the source of the problem.

It turns out that these injections don’t always give patients pain relief even when the SI joint is the problem. So there are a fair number of false negative responses. False negative means when the joint was injected, the pain didn’t go away. The conclusion was that the SI joint wasn’t the cause of the problem after all. But in fact, later tests confirmed the sacroiliac joint as the true source of pain. It has been suggested that missing the target with the injection might account for these false negative responses. With the use of fluoroscopy, false negative responses should decrease.

ASIPP guidelines for managing sacroiliac joint pain with steroid injections or radiofrequency neurotomy (destroying nerve tissue) are based on limited evidence. SI injections for diagnostic purposes can be done twice. The same recommendations apply as for other types of injections: repeated only if at least 50 per cent pain relief is reported and no sooner than a week apart. Both sacroiliac joints should be injected at the same time. A maximum of four to six injections per year are suggested for treatment. Radiofrequency neurotomy has a longer separation time (at least three months) and a maximum of three total treatments per year.

What about intradiscal therapies? Surgeons are looking for ways to avoid surgery. Instead of removing the damaged disc, there are ways use heat to destroy (vaporize) the disc. Two examples of interventional procedures of this type for discs include intradiscal electrothermal therapy and radiofrequency posterior annuloplasty. The evidence around both of these procedures is too limited to even make specific guidelines or suggestions at this time.

And finally, implantable therapies such as spinal cord stimulators (SCSs) and intrathecal pumps (ITPs) are discussed. These devices are placed first with electrodes on the outside of the spine. If they provide good relief from pain during a one- to two-week trial, they can be implanted (placed) inside the body.

Like other pain relief mechanisms, the spinal cord implants deliver an alternate stimulus to the spinal cord to override the pain messages. The intrathecal pumps provide a constant stream of pain relieving medications into the spinal fluid.

There has been some good short- and long-term success with implantable therapies. Patients with back pain associated with failed back syndrome and nerve pain from complex regional pain syndrome seem to have the best results with implantable therapy.

The author concludes by saying that current best evidence is always welcomed when making decisions about the most effective way to treat someone’s back pain. But studies are limited and sometimes it’s not possible to compare one treatment to others or to a placebo (pretend or fake treatment). That makes gathering real evidence a challenge.

A final quote seems to sum up the state of affairs around evidence for or against interventional procedures. Lack of evidence in the literature is not evidence of lack of effectiveness. In other words, just because a treatment hasn’t been studied enough or can’t be adequately compared to other treatments doesn’t mean it doesn’t work or isn’t effective.

Evaluating these procedures will continue as an ongoing research theme. In the meantime, don’t throw the baby out with the bath water while looking for objective measures of success. Any modality that helps control or eliminate pain should be used until conclusively proven ineffective.

People in pain don’t want a trial-and-error approach to treatment. They need an evidence-based treatment plan that is going to work right from the start. One way to achieve this is by identifying subtypes of pain — in other words, what’s nerve-related (neuropathic) and what’s not? No sense treating pain with an approach that doesn’t even get at the underlying pain mechanisms. We know that can be a waste of time and money.

Dr. J. Scholz, a neurologist at Harvard Medical School (Boston, Massachusetts) is leading the way in this approach. He has developed and tested a bedside tool called the Standardized Evaluation of Pain or StEP. It is a highly sensitive and specific test for telling the difference between neuropathic and non-neuropathic pain.

Who might benefit from this type of test? Anyone with chronic pain from diabetes, herpes, or spinal nerve root compression. A study was done with a special focus on patients with chronic low back pain from radiculopathy. Radiculopathy refers to compression of the spinal nerve root (usually from a herniated disc) causing back pain that travels into the buttock and sometimes down the leg.

By testing patients for signs and symptoms and asking a set of specific questions, it was possible to see distinct patterns to separate neuropathic pain patients from those suffering from non-neuropathic pain. After analyzing the data and coming up with six subgroups of neuropathic pain patterns and two of non-neuropathic pain, the author was able to refine the StEP test.

It all boiled down to six questions to ask patients and 10 simple physical tests to give each patient. By administering the StEP test, they could at least tell which patients were suffering from nerve-derived pain and who was not. The next step is to find which treatment approach works best for each of the subgroups identified in this study.

Researchers believe that a better understanding of the exact mechanism producing pain will improve the chance of success in treating chronic pain patients. The target of therapy should not just be masking pain but should go right to the active mechanism causing the pain and put a stop to it.

While others continue to use the hunt and peck method of pain control (try this, try that, see what works), Dr. Scholz has come up with a way to assess patients’ pain accurately early on. That will ultimately help pain experts predict what patient responses will be to specific treatments. Choosing a treatment right from the start that has a high chance of success is the ultimate goal in pain management.

For the past 10 years, research in the area of low back pain has taken a different direction. Instead of studying large groups of heterogenous (all different) people, the approach now is to find subgroups of low back pain patients who are most likely to respond to treatment. Sometimes the focus is on treatment in general. In other studies, the response of a subgroup to a specific treatment idea is investigated.

In this study, researchers from Canada and The Netherlands teamed up to detect possible patient factors that might affect response to treatment. The workers studied were all employed in physically demanding jobs. They had been off work on sick leave for eight weeks. Previous studies have already shown that age, gender, and poor function are predictive of longer use of sick leave.

The question in this study was whether or not these same factors would change how workers responded to a workplace intervention. The intervention was an unspecified graded activity. The authors just stated that modified and ergonomic work was provided. The goal was to successfully return the worker to his or her job after an episode of low back pain. The workers were divided into two groups. One group received usual care. The second group participated in the workplace intervention.

Data collected on each participant included number of weeks on sick leave, pain level, function, and time to return-to-work. Function was measured using specific tests such as the Roland Morris Disability Scale and the Dutch Musculoskeletal Questionnaire.

Analysis of the data showed that older adults (44 years old or older) were more likely to benefit from the intervention and return-to-work sooner than younger adults. Anyone who had a previous history of taking sick leave for their low back pain was also more likely to get better and return-to-work sooner.

Another way to look at the results of this study is to say that there are certain subgroups of low back pain patients who seem to respond to this particular intervention. The workplace intervention is a good idea for older workers and for those who have already used sick leave before. Selecting workers for this type of program to get them back on-the-job shouldn’t be based on their gender (male versus female), how much pain they are in, their level of function, or even whether or not their job involves heavy labor.

The bottom-line of this study was to find ways to return workers to their jobs faster after being off work for low back pain. Providing the right treatment to the right group of patients is the current goal of studies like this one.

Understanding why certain patient characteristics affect how well a particular treatment works may be helpful. In the case of these two modifiers (age and previous sick leave), no clear explanation was obvious. The authors suggest it’s possible that older adults who have been off work before for low back pain realize the need to make changes in order to prevent future episodes. And maybe those workers who took sick leave just needed a more practical way to deal with their back pain.

The future of back pain research will continue to focus on finding the best way to get patients back on their feet and back to work as quickly as possible. Looking for subgroups and modifiers of treatment within those subgroups could be a very good way to choose the right treatment for each person.

No matter what causes low back pain, homeopathy may be able to help reduce symptoms, eliminate the need for pain relievers, and improve quality of life. These are the results of a study from Germany where the use of homeopathy is more widely accepted than in the United States.

Homeopathy refers to a form of alternative medicine that treats an illness with heavily diluted preparations that are thought to cause effects similar to the disease’s symptoms. It was first reported on by a German physician Samuel Hahnemann back in 1796. The homeopathic substances are referred to as remedies rather than drugs.

Homeopathic treatment takes into consideration the whole patient — mind and body, not just the symptoms. The homeopathic treatment of the whole patient (with all signs and symptoms) is referred to as classic homeopathy. Paying attention to all aspects of the person (not just the fact that they are having back pain) means that the remedies vary from patient to patient. Anyone with any type of low back pain from trauma, arthritis, disc degeneration, or other physical (and even psychologic) causes can benefit from a homeopathic approach.

In this study, 129 adults with low back pain from any cause were treated by 48 homeopathic-trained physicians in many different centers across Germany. Before treatment, the patients wrote down all of their symptoms and rated their pain intensity from zero (no pain) to 10 (worst pain). They also filled out two other surveys of questions related to physical and mental function as well as quality of life.

Most patients received an average of six homeopathic remedies over a period of three to 12 months. Everyone had chronic (longstanding) low back pain. Some patients also had other symptoms such as headache, hay fever, trouble sleeping, fatigue, or skin problems. A wide range of different remedies was used but most of them boiled down to one of 10 basic categories.

Everyone was followed by phone consultation and/or personal follow-up visits for up to two years. At the end of the two years, one fourth of the group was fully cured (no back pain). About 20 per cent said they were at least 50 per cent better. The rest experienced some, but not as much, improvement. No one said they got worse.

As mentioned, there were four main benefits observed: decreased pain, improved quality of life, reduced use of prescription or over-the-counter drugs, and reduced use of health care visits. But the authors were quick to point out that there are some important things to consider when reviewing these results.

First of all, the patients in this study were seeking homeopathic care. It was not a randomized controlled trial where some patients are randomly placed in two or more groups. Some are treated one way (e.g., conventional means) and other patients are treated another (e.g., homeopathic treatment). The methods used in this current study don’t control for the placebo effect. Placebo means the patient expects to get treatment that will be helpful, so even when they are getting a sugar pill, they get good results.

The fact that the patients in this study were self-selecting homeopathic care was examined more closely. It turns out that these patients were better educated and with higher incomes than traditionally treated patients. One other observation: the patients in this study had been treated conventionally and turned to homeopathy when the results were unsatisfactory. This set of patient characteristics called demographics may be important and bear further study.

It was also the case that only physicians with certification and experience in classic homeopathy were included in this study. And only about one per cent of the certified practitioners were included. So there’s lots of room for different results in the general population who are seeking the care of other than classic homeopathic practices.

The results of this one study don’t answer all the questions. But they got the discussion started about the role of homeopathics in the treatment of chronic low back pain. Just knowing that many people seek this type of alternative care after traditional medicine failed to help them will alert those people responsible for making decisions about health care policies.

Can putting a simple pair of insoles inside your shoes prevent low back pain? What about using them to treat back pain once it starts? After conducting a systematic review of all the evidence, the conclusion was No to prevention and Not enough evidence to say for treatment.

But can we trust the evidence? How do researchers come up with answers like these? In this case, a group of physicians from Israel searched four major electronic databases (Central, Medline, Embase, CINAHL) for any studies, reviews, or guidelines on this topic. The authors reviewing materials worked independently of one another in order to be blinded to the opinions of others. This research technique helps keep the results unbiased.

Some of the databases had information from as far back as 1966. Others started collecting data in the early 1980s. All four data banks were searched up to the present (October 2008). Part of the job of the independent reviewers was to look at how the studies were done and make sure only those with the highest quality were selected for inclusion in this review.

Considering the high cost of care for patients with low back pain (more than $100 billion each year in North America alone), finding something as simple and easy as shoe insoles as a prevention or treatment technique would be very helpful. But of the six randomized controlled trials involving more than 2,000 patients, there just wasn’t the evidence needed to support the use of shoe insoles.

The next question was whether or not using custom-made versus off-the-shelf (prefab) insoles made a difference. There were some studies that compared the use of insoles with a placebo (sham inserts with no real effect) and with no treatment.

Any studies with insoles used to correct a leg-length difference were not included. The decision to exclude studies with special insoles to treat limb-length inequality was based on previous research showing a lack of evidence to support limb-length linked to back pain.

Part of a systematic review of evidence involves evaluation of the methods used in research on the topic. The reviewers looked at quality of research design, type of data collected in each study (e.g., patient age, gender, type of insoles used, how long patients were treated, occupation), and outcomes/results measured. Studies combined and analyzed have to be similar in all of these areas to be able to be of any value.

The authors used a well-known method of study review: the Cochrane Handbook. The Cochrane Collaboration is a group of over 15,000 volunteers in more than 90 countries. The group reviews the effects of health care interventions (treatment) tested in biomedical randomized controlled trials. The results of these systematic reviews are published as Cochrane Reviews in the Cochrane Library. Health care professionals rely on Cochrane Reviews as valid and accurate summaries on many topic of interest.

The results of this systematic review may have found a lack of evidence to support the use of insoles as a treatment for low back pain but that’s not the end of the discussion. That lack of evidence was related to poor research design in some of the studies already done. Without clear criteria for the selection of patients included in studies, proper analysis of data, and the collection of complete data, the evidence can be presented as favorable when, in fact, the evidence is really limited. That was the case in studies reviewed using insoles for the treatment (vs. prevention) of low back pain.

Where does that leave us on the issue of shoe insoles for the prevention or treatment of low back pain? That’s a good question. Right now, there are so many different kinds of insoles on the market, it’s difficult to know if perhaps a specific insole might be the answer. Some are customized, others are not.

Most of the large studies were done on military (male) soldiers. We don’t really have much information on women or older adults regarding this issue. And some of the studies reported a shift of pain from the back to the legs. So, in today’s modern lingo, it might be appropriate to ask, What’s up with that?

The authors concluded that there is strong evidence that insoles don’t prevent back pain. More trials are needed to come to any conclusions about the use of insoles to treat back pain. And, the book is wide open on whether or not there’s one single insole that’s the best or if certain insoles work better for some problems than others.

Back pain once is a painful nuisance. But it usually goes away quickly. Then it’s back to business as usual. Back pain that recurs is much more than a minor inconvenience. It can be chronic, disabling, and costly. In fact, it’s estimated that recurrent back pain is one of the most expensive health conditions being treated in health care today.

Studying back pain recurrence has been a bit difficult. For one thing, when is back pain a recurrence of the old problem and when is it a new and different problem? Is a second (or third) bout of back pain a recurrent episode if less than six weeks has gone by? Six months? Does the patient have to be pain free for any particular length of time (or at all) before the episode is considered a recurrence?

How do we draw the line? Maybe it should be based on the patient’s pain duration, location, and intensity. Maybe recurrence of back pain should only be counted as an episode if the person loses time off work or goes to see a healthcare or other back care specialist.

The authors of this study acknowledge all of these difficulties in defining back pain recurrence or back pain disorder (BPD). Their task (given the challenges of defining back pain recurrence) was to find individual indicators that back pain is likely to recur. There is probably more than one indicator but the first step was to identify any factor(s) already existing.

They relied on three ways to study this problem. The first was an overview of the available studies already published. The second was the opinion and consensus of an expert panel. The third involved discussions at workshops held at the International Classification Forum on Primary Care Research and Low Back Pain.

In the overview step, they looked at research on back-related recurrence to find any indicators that might point to recurrence. They used the same research publications to look for a model of health and disability that might work to classify patients. They chose the newly adopted World Health Organization’s ICF model.

ICF stands for International Classification of Impairments, Disabilities, and Handicaps. The ICF works well to describe patients in terms of abilities rather than just disabilities. It provides a more accurate way to see patients’ function and restrictions in the everyday world.

Both the expert panel and the workshop discussion groups discussed the current definitions of back pain as a health condition. They said that when using the ICF model, back pain disorder couldn’t just be defined by pain. Back pain is a health condition if any one of three conditions is met:

The value of Minimally Invasive Spine Surgery (MISS) is more than surgeon assumption or a marketing whim. That sounds very poetic, but what does it mean exactly? The author answers that question in this review article on the topic of minimally invasive spine surgery.

What is MISS? In the simplest terms, it means the surgeon makes a very small incision and there is as little disruption of the underlying soft tissues as possible. Special surgical instruments developed just for MISS are used such as intraoperative microscopes and fluoroscopes (real-time X-rays).

But experts in the field say that defining what is and is not a minimally invasive surgical procedure is more difficult than just saying it’s a small incision. For one thing, how small is small? Is it a certain number of inches — or just smaller than an open incision for the same operation? If a small incision is made but the surgeon still cuts through muscles, is it still minimally invasive?

Some researchers have used blood markers of inflammation to gauge how much soft-tissue damage has occurred. In this way they can determine whether a procedure has been minimally invasive or not. Those studies have provided some interesting information to consider. Open procedures do tend to have higher levels of inflammatory substances. When the final patient outcomes are the same, perhaps this one difference could be enough to support the benefit of minimally invasive over open procedures.

Can any type of procedure fall under the category of MISS? Sometimes the surgeon is injecting a substance into an area. In other cases, there is resection (removal of tissue) or instrumentation. Instrumentation refers to the use of metal parts to help hold an area together until healing takes place. This could include cages, plates, screws, nails, or rods.

All this sounds good but no one wants to be the first patient a surgeon treats with some new-fangled idea. But patients can be rest assured; minimally invasive spine surgery is well-researched with over 850 articles already published since the year 2000.

Of course, each surgeon will have his or her own transition time learning how to do these techniques. It does take time to learn any new skill or surgical technique. But the basic skills required don’t change from procedure to procedure. Patient safety and good results are always on the surgeon’s mind. Studies so far don’t show a high complication rate for surgeons developing this new set of surgical skills.

One of the latest developments in MISS is the tube-based procedure. The original MISS operations started with needle-like instruments such as the endoscope used for vertebroplasty, kyphoplasty, discectomy, or destroying tumors with radiofrequency. Larger portals openings into the body with the same small incision are possible with tube-shaped surgical tools.

The tube allows the surgeon to access a larger area underneath the incision, take photos inside the body at the operative site, and even allow for more extensive surgeries that would have needed an open incision before tubular retractors were developed. Retractors help hold the skin and underlying soft tissues open to give the surgeon access to the intended surgical area.

Minimally invasive spine surgery is not the norm yet. Surgeons would say it’s not the community standard. But as more and more studies are published supporting its use, surgeons are being trained in using this technique. The methods used are compared to constructing a ship in a bottle. More highly technical skills are needed but they can be done with the newer microsurgical tools now available.

To repeat with greater understanding now, recall what the authors first said: The value of Minimally Invasive Spine Surgery (MISS) is more than surgeon assumption or a marketing whim. Here are some practical examples of just what that means. 1) Patients experience less tissue trauma. 2) There is faster recovery of muscle strength when muscles don’t have to be cut away and reattached at the end of the operation. 3) Some studies show less blood loss with MISS, shorter hospital stays, and lower costs as a result. 4) With fluoroscopy for viewing the spine, accuracy is improved when placing tiny screws in the vertebrae through these small incisions.

In the future, it is likely that more types of spinal surgeries will move from an open approach to a minimally invasive method. This expansion has already been observed in some places. Surgeons will specialize in MISS. Surgical instruments will continue to improve as technology moves forward. And the reported records of patient (good) results will bear out this treatment method as safe and more effective with fewer complications.

In this article, two neurosurgeons bring us up-to-date on the use of four different interspinous spacers for the treatment of back pain from spinal stenosis. Interspinous means the spacers are placed between two spinous processes. Those are the bumps you feel along your back. They are knobs of bone that extend out from the vertebral bodies.

Spinal stenosis is a narrowing of the spinal canal, the opening formed by the vertebral arches. This is where the spinal cord travels from the brain to the base of the spine. Lumbar spinal stenosis is a common problem in older adults (age over 65). Low back pain and/or leg pain/discomfort are the first signs of this problem. Flexion bending forward relieves the pain, so patients adopt a bent posture called the shopping cart sign.

Because symptomatic spinal stenosis can be very disabling, surgeons are looking for ways to help support and stabilize the spine. Keeping the vertebrae from bending backwards (a direction that makes the symptoms worse) is the goal. These interspinous spacers may be helpful when more conservative (nonoperative) care doesn’t improve symptoms. They can be used in frail, elderly adults who aren’t well enough to have surgery.

Only one spacer on the market has been approved by the Food and Drug Administration. That’s the X-Stop. Three others are being studied with the intent to seek FDA approval. They are the Interspinous U (also called Coflex, the DIAM, and the Wallis system. They all work to limit spinal extension.

Color photos or schematic drawings of each system are included. These pictures help show where and how these spacers are used. Again, each one does the same thing: holds the spine in a position of slight flexion to decompress (take pressure off) the spinal cord or spinal nerve roots. The spine can still rotate or bend to the side when the spacer is in place.

The placement varies slightly based on the shape and design of the device. The manufacturer of some of these spacers says they can be used for more than just spinal stenosis. Scoliosis, compression fractures, herniated discs, spinal instability for any reason, and degenerative disc disease are some of the conditions listed.

Each one of these has its own pros and cons. Some are static (they have no give; they keep a constant state of the same amount of distraction no matter what) while others are dynamic (they compress and distract a bit, especially with spinal movement). The X-stop is the only one that can be inserted under local anesthesia. The ligaments around the spine are saved from being cut. The device slips right through a slit made in the ligament.

So, everyone agrees the X-stop is easy to use. But does it work? That’s the question! Right now, there isn’t enough evidence from high-quality designs to answer that question. Early, short-term results show a positive benefit (pain reduction, improved function) in more than three-fourths of the patients. Safety is a concern but complications such as infection, fracture, increased pain, or implant movement or breakage have been very low so far.

There’s no data on larger groups of patients or on the long-term results. The authors of this review commented on the poor quality of some of the research that has been done. They say that the study design was questionable for some of the studies. Research must be done to look at the adjacent levels for possible adjacent vertebra degenerative disease. The authors strongly urge random controlled trials to find out when these devices should be used and with whom.