News Category: Lumbar Spine

Lumbar spinal stenosis (stenosis of the low back) is a common cause of back problems in adults over 55 years old. Spinal stenosis describes a clinical syndrome of back, buttock, and/or leg pain. It is a condition in which the nerves in the spinal canal are closed in or compressed.

The spinal canal is the hollow tube formed by the bones of the spinal column. Anything that causes this bony tube to shrink can squeeze the nerves inside. As a result of many years of wear and tear on the parts of the spine, the tissues nearest the spinal canal sometimes press against the nerves.

In the lumbar spine, the spinal canal usually has more than enough room for the spinal nerves. The canal is normally 17 to 18 millimeters around, slightly smaller than a penny. Spinal stenosis develops when the anteroposterior diameter (front-to-back measurement of the canal) shrinks to 12 millimeters or less. Stenosis can also occur when the transverse diameter (side-to-side opening) is less than 15 millimeters.

Because this can be a painful and limiting condition, health care specialists are actively studying ways to treat it effectively without surgery. Conservative (nonoperative) treatment options include exercise, physical therapy, antiinflammatory drugs, pain relievers, or epidural steroid injections (ESI).

The spinal cord is covered by a material called the dura. The space between the dura and the spinal column is called the epidural space. It is thought that injecting steroid medication into this space fights inflammation around the nerves, the discs, and the facet (spinal) joints. This can reduce swelling and give the nerves more room inside the spinal canal.

In this study, the results of steroid injections were compared against one type of physical therapy intervention. Three groups of patients were compared. All 29 patients had a diagnosis of lumbar spinal stenosis but were in otherwise good health without heart disease, diabetes, past history of spine surgery, or recent episodes of vertebral fracture.

Everyone in all three groups was given a home exercise program and a drug called Voltaren (diclofenac) for pain control. Even though the authors recognized that adding this to the daily program might change their results, they did not think it would be ethical to keep patients from exercising or getting some pain relief from a drug known to help.

By putting everyone on the same base program, they could at least keep the groups consistent and test other variables. The disadvantage of this method is that there is always a potential that the exercise and pain relievers could interact with one of the other treatment methods and change the results. Special mathematical formulas were used to help eliminate this factor in the final analysis.

Of the three groups, the first group participated in a daily physical therapy program for two weeks. A combination of ultrasound, hot packs, and TENS (transcutaneous electrical nerve stimulation) was used in the treatment. Group two got one epidural steroid injection. The drug was administered via fluoroscopy (real-time X-ray) to the most stenotic (narrowed) area of the lumbar spine. The third group served as the control. They did just the baseline exercise and pain control measures.

Results were measured in terms of pain, physical mobility, and function. Specific tools used to measure these parameters included the visual analog scale (VAS), finger-to-floor distance, treadmill walk test, sit-to-stand, and the weight-carrying (WC) test.

Everyone in all three groups had significant pain relief. Patients in groups one and two had more improvement in pain and function than the control group. Their pain relief lasted at least six months (follow-up period). The effectiveness of steroid injections and physical therapy as tested here was equal in reducing pain and improving function. Outcomes suggest that treatment with either steroid injection or physical therapy is better than doing nothing.

But the authors point out several problems with their own study. First, it’s been clearly shown by other researchers that single epidural steroid injections (ESI) work best in the short run. Second, comparing ESI to physical therapy isn’t easy. There are many different kinds of physical therapy treatments available. The methods used in this study are considered passive. Using ultrasound as reported in this study and hot packs (two forms of heat) are not best practice when treating conditions that potentially involve local inflammation.

Third, physical therapy treatment was only given for two weeks. A longer treatment period might have made a greater difference. The authors conclude that further research is needed before declaring one treatment modality more effective than the other.

So far, we know that back, buttock, and/or leg pain truly caused by sacroiliac joint problems gets better when the joint is injected. The treatment is considered successful if using a combination of a steroid (antiinflammatory) drug and a numbing agent like novacaine (e.g., bupivacaine, lidocaine) reduces the pain by at least 50 per cent. Pain that comes back within the first six weeks after injection is a sign of treatment failure.

This type of injection is both diagnostic (confirms the sacroiliac joint as the problem) and a form of treatment. Long-term relief of pain is achieved in patients with sacroiliac joint dysfunction with seronegative spondyloarthropathy. Spondyloarthropathy refers to an inflammatory joint disease affecting the spine, including the sacrum and sacroiliac joints. Seronegative means blood tests came back negative for rheumatoid factor (RhF). RhF is positive when the joint problem is associated with some form of rheumatoid arthritis.

In this study, interested scientists take it a step further. They tried this same treatment on patients with sacroiliac joint dysfunction who did not have spondyloarthropathy. Studies on the effectiveness of sacroiliac joint blocks in patients without an underlying inflammatory cause have been very limited but have not shown any real benefit.

So what did this study offer in the way of additional information on the use of injections with this select group of patients? Well, first of all it should be noted that patients were carefully selected to be in this study. They all showed at least a 75 per cent improvement in sacroiliac joint pain with two or more injections with triamcinolone acetonide. Triamcinolone acetonide is a more potent type of steroid, being about eight times more effective than the more commonly known prednisone. That confirmed they had a true sacroiliac joint problem.

Then they were followed for an average of 45 weeks (some as long as 72 weeks). Measures of treatment effect were taken using a self-report questionnaire of pain and the Oswestry Disability Index (measure of pain and function). Both of these tests were given to the patients before and after injection treatment. Other data collected on each patient also included age, gender, pain duration, body mass index, and history of lumbar or lumbosacral spinal fusion.

Two-thirds of the patients reported more than 50 per cent improvement in pain that lasted for at least six weeks. Those patients were considered a success. The remaining one-third got pain relief but it wasn’t long lasting enough to be labeled a success. This group ended up going to physical therapy instead of having another injection treatment.

They took a closer look at those who had a successful response to the injection treatment. They were able to see that patients who had a spinal fusion were less likely to improve. They were also more likely to experience treatment failure. Pain relief was not linked with gender, age, body size/weight, or pretreatment pain and disability.

No one is quite sure why lumbar or lumbosacral fusion would affect the outcome. It has been suggested that the fused spinal segments reduce movement and increase stiffness of the spinal complex. The result may be added strain and/or load on the nearby sacroiliac joint. There may be a faster process of sacroiliac joint degeneration when there’s been a fusion.

The authors conclude there may be a role for steroid injection in the treatment of sacroiliac joint pain that is not associated with spondyloarthropathy (inflammatory disease). But it may be a select group as not everyone in this group improved. At least one risk factor identified was spinal fusion. But some patients with spinal fusion did respond favorably to the injection treatment, so there may be other risk factors to consider.

What matters to patients with low back pain? Is it the activities they cannot perform? Daily activities? Walking? Sports participation? What does the patient want to achieve with treatment? Maybe treatment should be directed toward the patient’s priorities, not what the health care specialist thinks is important.

In this study, researchers attempt (for the first time) to assess patients’ priorities who have chronic low back pain. A total of 150 patients with chronic low back pain were part of the study. Each one filled out the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR). Although the MACTAR has been used successfully with arthritis patients, this is the first reported use of it with patients who suffer loss of function and disability from chronic low back pain.

There are plenty of other tests out there to assess people with chronic low back pain. Physicians, physical therapists, and other rehab counselors are familiar with the Roland-Morris Disability Questionnaire, the Oswestry Disability Index (ODI), and the Quebec Back Pain Disability Questionnaire (QUEBEC) for looking at disability and participation restriction. They also use tools such as the Visual Analog Scale (VAS) and the Numerical Rating Scale (NRS) to measure pain intensity.

But the MACTAR looks at what the patient would like to do — what the patient cannot do because of pain. These are the issues that really matter to the patient. The MACTAR looks at mobility; community, social, and civic life; domestic life; work; interpersonal interactions and relationships; and self-care.

Each of those main sections has multiple subsections of activities and participation. For example, mobility looks at driving, walking, standing, running, climbing, and changing positions. Community/social/civic life includes sports, recreation, and leisure including crafts, hobbies, the arts, and culture. Domestic life ranges from shopping and doing housework to caring for plants or gardening, and preparing meals.

Besides filling out the MACTAR, the study participants also completed several other tests to measure their coping skills, level of anxiety and depression, and any fear-avoidance behavior. Fear-avoidance refers to the concept that people in pain often stop moving in ways they think might cause their back to hurt or cause another injury. The result of that behavior is more pain from the altered movement patterns or avoidance of movement.

The idea in giving patients other tests besides the MACTAR was to see how well each test correlated with the MACTAR. A test that correlates well means the two tests measure the same things. Sometimes it’s important to confirm research findings about patient population groups. That’s when tests that correlate well are used together. But in other cases, it’s helpful to give patients more than one test that don’t correlate well. That way, more information is added to help direct and guide treatment.

There wasn’t one area that stood above the others as the most commonly placed patient priority among the 150 participants. But analysis of the data did show that there were three general trends: mobility, community and social life, and domestic activities. Patients chose different activities within those groups.

The top 10 activities listed as being affected the most by disability included sports, walking, working, cleaning, recreation, driving, moving around, and taking care of plants. The activities that caused the most trouble were sports, shopping, and walking.

The second arm of the study was to find out which tests correlated well with the MACTAR and which did not. The authors found that there was moderate correlation with the Visual Analog Scale (VAS) handicap score but not with the VAS pain scale. The authors propose that this shows patients can tell the difference between activities limited by pain and activities limited by disability.

There was no correlation between the MACTAR and the Fear-Avoidance Behavior test or tests for coping skills. That means the MACTAR does not measure or assess these two areas of psychologic and behavioral factors. These other tests would be needed if the examiner wants or needs this additional information when planning treatment or managing the rehab program. There was a weak correlation between the MACTAR and the QUEBEC for disability.

The authors conclude that the MACTAR is a valid measure of real-life participation limitations identified by the patient with chronic low back pain. Such information could be very useful when making clinical decisions, establishing treatment goals, and planning treatment. The questionnaire only takes the patient five minutes to fill out.

On the downside, there is a 15-minute face-to-face interview that’s part of the MACTAR. That part is not so easy or inexpensive as the simple five-minute survey. And the MACTAR doesn’t give a global picture of the patient’s needs, wants, or desires. It’s a functional scale that takes a look at patient priorities. As such, it has its own unique place in the assessment process.

Chronic low back pain continues to perplex and confound patients and health care providers alike. The field of health care is now calling for treatment based on scientific evidence of its effectiveness. Groups of experts are getting together to search the literature for enough evidence to support one treatment over another.

Recently, a large multidisciplinary panel of back pain experts was gathered together by the American Pain Society. Their task? Review all published randomized trials looking for evidence to help them draft some guidelines for the treatment of chronic low back pain. Efforts of this type are appreciated by those who work with chronic low back pain patients. Instead of everyone spending hours sorting through all the studies trying to make sense of them, experts in the field get together and perform the task, making summary recommendations for all to use.

This group focused on three areas: interventional diagnostic tests and therapies, surgery, and rehabilitation. Interventional refers to more invasive efforts to find out if specific musculoskeletal structures (e.g., joints, disc, muscles, ligaments) are causing the patient’s pain. The theory is that if areas can be targeted as the main cause of the problem, then more effective treatment can be directed at that area.

Since back pain can be caused by a wide range of anatomic and psychologic problems, this study limited the patient populations studied to those who had nonradicular low back pain, radiculopathy with herniated disc, and spinal stenosis. Nonradicular low back pain refers to back pain caused by something other than pressure on (or irritation of) the spinal nerve roots.

Radiculopathy is the leg pain and/or numbness and tingling that comes from chemical irritation or mechanical compression of the spinal nerve root. In this particular diagnosis, the source of that pain is a herniated disc affecting the nerve root. Spinal stenosis is a narrowing of the spinal canal, the long, narrow tube formed by the vertebrae through which the spinal cord travels from the brain down to the lumbar spine.

The guideline panel got together knowing two things: 1) a small number of people who develop chronic low back pain (probably five per cent) account for 75 per cent of all the money spent on low back pain and 2) management of this chronic problem is complex and requires a shared decision-making process by many people (including the patient, family, and the various members of the multidisciplinary team).

They came out of the review process with eight strong recommendations. The evidence reviewed showed a clear benefit of some treatment approaches that was greater than any potential harm or burden. Types of interventional treatments reviewed included prolotherapy, steroid injection (into the disc or joint), BOTOX injection, radiofrequency denervation, and spinal cord stimulation. Surgery to remove problematic structures such as the disc or lamina (bone over the disc) was also included in the evaluation. The procedures investigated were specific to each of the three diagnostic categories.

The 23 panel members worked together for two full years. When they voted on each recommendation, two-thirds had to agree or the guideline would not be adopted. There was complete agreement on all but recommendations number 1,2, and 3, and there was only one dissenting vote on those. Here is a brief summary of each recommendation.

Recommendation 1. Discography may show signs of degenerative disc disease, but that doesn’t mean the patient’s pain is coming from the disc. Therefore, provocative discography is not recommended. During discography, contrast medium is injected into the disc and the patient’s response to the injection is observed. In theory, pain that is similar to the patient’s current back pain suggests that the disc might be the source of the pain. But there are too many false positives to trust the test. And patients with a positive test who had surgery didn’t have better results than those who didn’t have surgery.

Recommendation 2. Anyone with chronic low back pain who has not gotten better with conservative (nonoperative) care should be managed by a team of clinicians especially including a psychologist or behavioral specialist. This is called interdisciplinary rehabilitation. Best results occur when cognitive/behavioral therapy is combined with a prescriptive and supervised exercise program.

Recommendation 3. The evidence does not support injections with BOTOX, steroids, and prolotherapy. Nerve blocks, intradiscal electrothermal therapy (IDET), and intrathecal therapy with narcotics or other opioid medications can’t be recommended either based on the data available so far. There just isn’t enough evidence to support the use of injections or other interventional therapies. Either the evidence was insufficient or the results were no better than when sham treatments were given.

Recommendation 4. Nonradicular back pain responds as well to conservative (nonoperative) care as it does to surgery, so surgery should be considered a low-priority option. Patients considering surgery should be told about the risks and possibility that the results will be less than satisfactory. Intensive interdisciplinary rehabilitation is always recommended first before surgery.

Recommendation 5. Artificial disc replacements still aren’t proven better than spinal fusion. Yes, they preserve motion at the involved vertebral level. But they can loosen and migrate or sink down into the bone causing problems. Patients may end up getting a fusion when the device fails. And just like with a fusion, patients with disc replacements still develop facet (spinal) joint arthritis and degenerative changes at the adjacent (next) vertebral level.

Recommendation 6. Steroid injections for radiculopathy due to disc herniation give short-term relief only. There are no long-term benefits of this treatment. There isn’t enough evidence to recommend or reject this treatment for spinal stenosis. If one injection doesn’t do the trick, should another be given? What’s the best timing for injection(s)? These questions still haven’t been answered fully yet (insufficient evidence).

Recommendation 7. Anyone thinking about spinal surgery for herniated disc or spinal stenosis should know that pain relief is possible in the short-term. But the final results (one to two years later) aren’t any different with or without the surgery. So, the cost of the procedure and possible risks should be factored against the possible short-term benefits before going ahead with the operation. There is still much to be studied when comparing one type of surgery over another. Timing of surgery and patient selection are two other factors that might make a difference but for which there isn’t enough data to make recommendations.

Recommendation 8. What can be done for patients who have had unsuccessful back surgery? This is called failed back surgery syndrome. Spinal cord stimulation may be an option. The risks associated with this treatment (e.g., infection, device-related problems, wound breakdown) must be weighed against the benefits for each candidate. Studies are needed to compare spinal cord stimulation with intensive interdisciplinary rehabilitation.

The authors conclude that these guidelines may not apply to each and every patient. There are always reasons why one patient might be different and need additional consideration. Clinicians can use the guidelines to explain the treatment approach they recommend. The American Pain Society plans to review and update the guidelines on a regular basis. Health care providers working with chronic low back patients can look for the next updates by 2012.

In many areas, there is still insufficient evidence to even form guidelines. More study is needed. Having a summary like this of what has been discovered so far and what’s left to explore will be very helpful for researchers planning future studies.

If you’ve ever had low back pain, you know how debilitating it can be. Most people will do whatever it takes to avoid a recurrence. Not only is it painful, but time lost from work and play reduce quality of life. Scientists are studying ways to prevent recurrence of low back pain. They have looked at risk factors and predictive factors trying to help patients find ways to stop back pain from coming back after the first episode.

One of the problems researchers run into is knowing how to tell when an episode of back pain is just a continuation of the last bout or an actual recurrence. Defining recurrence is the topic of this study. When looking at the different ways researchers define recurrence from study to study may seem like splitting hairs. But when trying to assess which treatment works best, the concept of recurrence becomes an important measuring stick.

According to the authors of this paper, a true recurrence really means the patient recovered fully from the first episode. The new symptoms are truly considered a separate incident. But the gray area comes when trying to say just when one episode ended and a new episode began. And there’s some question as to whether features such as pain intensity, duration, or frequency should factor into the definition.

For example, does the pain have to last more than one hour? two hours? half a day? or longer? before it can be considered an episode? Is there a minimum level of intensity that qualifies? Does it have to be at least five on a scale from zero (no pain) to 10 (most pain)? Does the location of the pain matter in the definition? Maybe when back pain is severe enough to limit activities or cause the person to seek treatment, then the incident becomes an episode.

So the first step in answering the question of how to define recurrence was to look at how all other studies defined it and search for common ground. To accomplish this task, all studies on low back pain from 1958 to 2008 were searched. Once the potential studies were gathered together, they looked for the ones that focused on reducing the risk of recurrence.

A total of 53 articles were found. Only 20 of those studies actually gave a definition of recurrence. The rest (33 articles) said they were measuring recurrence but didn’t say how they defined the occurrence. Very few studies even considered recovery or give a definition of it.

The only real consensus or agreement on a definition for recurrence came from one author who happened to publish four studies on the topic. It seems each new study creates a different definition of recurrence (when they even bother to define it at all). This approach just adds chaos to confusion.

Without a consistent definition, it is not possible to combine the data from all the studies in order to look for trends in treatment success. The same is true when trying to compare treatment results from one study to another — if there isn’t agreement on what recovery and recurrence are, then it’s like comparing apples to oranges. When everyone is on the same page with the same definitions, then a true summary of findings can be published. This leads to helpful clinical guidelines for treatment that can be followed by everyone.

The authors of this systematic review suggest that persistence of pain from a first episode that never really recovered is different from recurrence. Persistence of pain occurs in someone who did not recover from the first bout of low back pain. If those patients are included in a study, it’s even more difficult to tell whether or not a particular method of treatment worked. There needs to be clear, separated pain episodes to distinguish recurrence from a continuation of the original pain.

The definition of low back pain recurrence can range anywhere from the patient’s pain returned to the patient had at least a month without back pain before the pain returned and lasted for more than 24 hours. Here’s what the authors of this study have recommended.

First, of course, it should be acknowledged that a standard definition is needed. Then, there must be general consensus among researchers to adopt that standard definition. When all studies use the same outcome measure, then the success of different treatment approaches can be compared. And at the very minimum, the definition should include a minimum duration and intensity.

The authors propose using a level two pain intensity on a scale from zero to 10 lasting at least 24 hours to signal a new episode of low back pain. And the pain must occur after at least 30 days pain free from the last bout of back pain. This last parameter (i.e., pain-free for at least one month) represents the working definition of recovery. Pain-related disability (e.g., pain severe enough to limit activities for more than one day) should be part of the complete definition of an episode of low back pain.

When a majority of studies use the same definitions of recovery and recurrence, then efforts can be made to pool study results together. This type of systematic review allows for a more accurate assessment of treatment outcomes.

Since less than 10 per cent of all studies use the same definition, we have a long way to go in turning this trend around. But it is an important step in reducing the cost of treatment and the time lost from work, not to mention providing patients with low back pain respite from suffering and disability.

Artificial disc replacements for degenerative disc disease are new enough that many details about their use, success factors, and variables that predict outcomes are still being studied. One of those variables is the effect of time off from work before surgery. In this study, researchers from the Texas Back Institute Research Foundation tell us what they found about this topic.

Is there a certain time period that a patient could be off work and still have a successful surgery with a disc replacement? Conversely, is there a length of time off work that would suggest the patient shouldn’t have the procedure done because the results would be compromised?

Right now, studies report a success rate for disc replacement anywhere between 63 and 90 per cent. The question is: why do some patients get better results than others? There may be certain predictive factors that could help guide patient selection. Choosing the right patients for the procedure could consistently ensure a success rate closer to the 90 per cent mark.

At least one other study has shown that time off from work before disc replacement is an important factor. And other studies have shown the same thing for spinal fusion. In this study, the length of time off work before surgery was the key focus of interest. They compared a group of patients who had a total disc replacement with another group who had lumbar arthrodesis (fusion).

Everyone treated in both groups had been diagnosed with degenerative disc disease. Their ages ranged from 21 to 60 years old. They had all been treated conservatively (without surgery) for pain but without success. These patients were enrolled in a FDA-regulated trial cdomparing the results of these two treatments for disc degeneration. That’s where the information and data for this study came from.

Only people who were previously employed were included. Students, homemakers, retirees and others who were not working by choice were not included. Anyone with a history of mental illness or serious psychologic problem was also excluded. Anyone involved in a legal battle was not included.

Everyone was followed for a full two years after surgery. Patients in the two groups were compared based on age, gender, insurance type, body mass index, occupation, and number of weeks off work before surgery. Number of vertebral levels (one, two, or three) operated on was analyzed as a possible independent factor.

A well-known test of pain and disability for patients with low back pain was used as the main measure of results. The test is the Oswestry Disability Index (ODI). It is the most commonly used outcome measure for low back pain. This questionnaire was been designed to give us information about how a patient’s back (and/or leg pain) affects the ability to manage in everyday life.

Questions are asked about how pain affects ten areas of daily function (e.g., standing, personal care, sleeping, lifting, social and/or sex life, walking, travel). A numerical score is calculated for the test. Each of the 10 items is scored from zero to five. The maximum score is 50. The obtained score can be multiplied by 2 to produce a percentage score. When using the interval scale of zero to 50, results are interpreted as follows:

What do we know about physical activity and low back pain? Is it a risk factor? Or a preventive aid? The authors of this study from The Netherlands suggest that too little or too much activity might be a risk factor for low back pain.

Some studies have already shown that high physical loads (e.g., twisting, bending, lifting, extreme sports) are linked with episodes of low back pain. Others point out the effect of being too sedentary (inactive) as a possible risk factor. So that leaves us with the question: how much activity is the right amount to promote a healthy back?

One reason we don’t have a quick and easy answer to this question is the wide range of variables to consider. For example, a person’s occupation, participation in leisure activities, lifting and carrying activities, and exposure to physical load are all potential factors in the development of low back pain.

More than 10 years ago, a group of researchers suggested that maybe the relationship between physical activity and low back pain looks like a U-shape. At one end (the upper left side of the U), total inactivity and high risk of low back pain go together. In the middle (the bottom of the U-shape), low to moderate intensity of activity is paired with low risk of back pain. And at the far end (the upper right side of the U-shape) reflects how maximum activity results in a high risk of back pain.

The authors of this study decided to test out this theory. They sent a survey to 8000 adults in Denmark asking about health, levels of physical activity, presence of low back pain, and number of visits to the doctor (or other health care provider) for back pain. The questionnaire also assessed work and health for the year just before the survey. Patient characteristics such as age, gender, occupation, education level, and perception of health were also recorded.

Not all studies use the same criteria to define activity level. The researchers involved with this study took the time to divide up activity into three groups: light, moderate intensity, and vigorous. Each category was based on age and metabolic equivalent (MET). Two age groups were used: 18 to 55 years old and over 55.

Metabolic equivalent values are a standard way to measure intensity of an activity. One MET is defined as the amount of energy used while sitting quietly. For this study, activity intensity was labeled as light, moderate, and vigorous. Light intensity for the younger age group was any activity performed between two and four METs. Moderate intensity was a MET value of four up to 6.5. Anything with a MET value greater than 6.5 was considered a vigorous activity. Metabolic equivalent measures used for the older age group were divided into light (less than three METs), moderate (three to five METs), and vigorous (more than five METs).

Activities ranged from leisure, and sports to occupational, travel, and domestic- or school-related activities. Using these guidelines, it was possible to look at all kinds of physical activities like gardening, bicycling, walking, and doing odd jobs. Specific sports such as golf, weight-lifting, speed skating, tennis, and football were also included.

Low activity levels (being sedentary) were defined as less than 30 minutes of moderate activity each day for at least five days each week. High levels of physical activity were calculated using number of hours engaged in the activity and intensity. Total physical activity patterns were analyzed by including all daily activities of all kinds. Type and range of different physical activities and their relationship to chronic low back pain were also analyzed.

The results showed that the relationship between physical activity and chronic low back pain is indeed U-shaped. Two-thirds of the people surveyed listed enough activities to meet the Dutch health recommendations for healthy living (30 minutes or more of moderate activity every day for five out of seven days). About 11 per cent of the group was inactive/sedentary. And they did have statistically more back pain than those in the moderate activity range.

Likewise, the remaining 30 per cent in the high physical activity level also experienced greater amounts of chronic low back pain. This U-shaped relationship seemed to hold true more for women than for men. The reason(s) for this remain unknown.

Type of activity also made a difference. Anyone involved in sports activities had a lower risk of developing low back pain. The authors suggest that back loading forces are different for sports activities and this dynamic may account for the reduced risk of chronic low back pain.

Beyond this, it was difficult to say if daily routine activity was more or less likely to be linked with low back pain compared with leisure time activities or other specific physical activities. The reason for this is because most people engage in a wide range of different activities everyday. Data analysis really had to be all or nothing — all activities grouped together rather than measuring level and intensity for each activity type for each person each day.

But even so, the data was enough to show that it’s not a matter of just: are you active or not? Activity level is on a continuum from low to high. Different activity levels have different risks of chronic low back pain. Low or high activity has the highest risk just as the U-shaped model predicted.

Back pain from degenerative disc disease can be very disabling for older adults. In this study, orthopedic surgeons show how a simple spinal fusion can make a big difference. The surgeons fused a single spinal level of 224 patients and then followed them for two years to see the results. The group was divided into two groups by age. Anyone younger than 65 years was in the first group. Patients 65 years old and older were in the second group.

Medicare has asked for more proof that spinal arthrodesis (fusion) in older adults really helps. Until now, most of the studies reported on younger adults. And age could make a difference. We can’t just assume that the results of this procedure in younger adults would be the same in older adults. An advisory committee from the Centers for Medicare and Medicaid Services asked for conclusive evidence to support the use of spinal fusion in patients 65 years of age or older. This age-group includes the Medicare population.

The operation performed was a single-level posterolateral lumbar arthrodesis with iliac crest bone graft. Posterolateral refers to the direction (back and side) that the fusion was done. Iliac crest bone graft comes from the top of the pelvic bone. Instrumentation (rod and screws) were used to hold the segment stable until bone filled in around the bone graft. The spinal level fused was slightly different between the two groups. The older patients’ fusion was in the L345 region. The younger patients were more likely to have a fusion at the L5-S1 level.

In general, the patients in each group were very similar (e.g., education, occupation, alcohol use, general health) except for age. Men and women were included. The main differences were that the younger patients rated their pain higher. They were more likely to still be working and a Worker’s Compensation claim. And the older patients were more likely to have advanced spine degeneration with bone spurs, thickened spinal ligaments, and facet (spine) joint degeneration.

Results were measured using several well-known research tools. These included the Oswestry Disability Index (ODI), the Medical Outcomes Study SF-36, and the numeric rating scale for back and leg pain. X-rays and CT scans were also used to look at the fusion site and see if it was successful or not. These imaging studies showed the presence of bone bridging the vertebral segment (a sign of successful fusion) and any cracks in the bone (a sign of weakness or instability).

Everyone in both groups had significant improvements in their test scores. But the older group demonstrated a larger change in scores indicating greater improvement compared to the younger patients. Complications in the early postoperative period (first 30 days) were higher among the older adults. Half of the older group had an adverse event after surgery. This was compared to one-third of the younger group. Most of the problems were minor but some patients had a heart attack, blood clot, or infection.

The authors concluded that older adults having a single level spinal fusion for degenerative disc disease can have a marked decrease in disability and improved health-related quality of life. The substantial benefit demonstrated in this study supports the use of this procedure for adults 65 years of age and older. The procedure is not without some potential complications, but overall it is safe and effective. Improvement seemed to occur even in those patients who had some type of problem after surgery.

Most adults who experience an episode of low back pain recover and return to work in a short amount of time. But problems develop for those who have chronic pain and have not gotten back to work after three months of sick leave. Rehab and pain specialists are trying to put together a short screening tool to help identify patients early on who are at risk for work disability.

In this study, 346 adults from Belgium who applied for compensation benefits because of chronic low back pain were studied. Since Belgium has a compulsory health insurance system, the number of working days lost and the cost of disabled workers adds up.

In a compulsory insurance system, everyone is required to take out health insurance, just as all drivers have car insurance. There are government tax subsidies to help the poorest pay for their insurance. In Belgium, the program also includes sickness benefits for patients who have stopped all activities because of an inability to work. This adds to the overall costs to society of back pain.

The first goal of the study was to find risk factors that might point to future delays in return to work status. A secondary goal was to put together the screening tool mentioned. You might think that the severity of the injury or back pain would be prognostic. But it’s not. In fact, other studies show that factors that delay recovery from back pain tend to be psychosocial rather than medical.

For the majority of back pain patients, staying active and focusing on improving function rather than decreasing pain works well as a rehab model. Workers are advised to stay at work or modify activities and get back to work as soon as possible. But for those who don’t respond to this approach, what would work better? And why doesn’t this method produce good results?

All patients in the study were examined by a physician. The physical exam was an in-depth assessment of the neurologic, muscular, and skeletal systems. Information was collected on the patients’ age, gender, smoking status, and occupation/job (blue collar versus white collar worker). They also looked at pain pattern (frequency, intensity, duration, recurrence), sick leave used, and previous history of surgery.

The patients also filled out a dozen self-report questionnaires on function, pain, depression, stress, fear-avoidance beliefs, catastrophizing, and coping. The authors analyzed the data and found five modifiable risk factors and five screening questions that could be used to predict patients at risk. Finding ways to rehabilitate those individuals and prevent long-term disability is the next step.

Worker characteristics that stood out as potential risk factors included: 1) high score on the Oswestry Disability Index (ODI) test, 2) high score on the fear-avoidance test, 3) blue-collar worker, 4) going on sick leave within 90 days of pain starting, and 5) pain behavior. The ODI is a means of assessing pain and the ability (or inability) to work or play in people with lumbar spine disorders. Fear-avoidance refers to changes in motion or the development of altered movement patterns that occur as a result of fear of reinjury or the belief that certain movements will cause pain.

Having patients fill out 12 questionnaires in order to identify who might be at risk of not returning to work is too time consuming and costly. That’s why the researchers set out to find a quick and easy way to screen for return-to-work status. The five questions (taken from the 12 questionnaires) proposed that statistically showed a link with return-to-work behavior included:

Five years ago (in 2004), the Food and Drug Administration (FDA) approved the CHARITÉ artificial disc. This approval was made based on a two-year trial conducted by orthopedic surgeons at 14 different clinics around the United States. In this study, five-year results for the same patients are reported. This is the largest and longest randomized, multicenter study of artificial discs published in the United States so far.

All patients receiving the artificial disc had severe back pain. They had all tried (and failed to improve with) six months or more of conservative (nonoperative) care. The diagnosis for everyone was degenerative disc disease. Only patients with single-level disease between L4 and S1 were included.

The patients were randomly divided into two groups. One group was treated with a spinal fusion at the affected level. The fusion was done with an anterior approach (from the front of the spine). BAK cages and iliac crest autograft were used to fuse the spine. This means the damaged disc was removed and a titanium cage put in its place. The procedure can be done with a very small incision to limit tissue trauma. The cage has holes in it and the bone grows in and around it, holding it in place. Iliac crest autograft refers to the fact that bone was taken from the patient’s own hip to help get the fusion process started.

The second group had the damaged disc removed and replaced with an artificial disc device. The CHARITÉ artificial disc was designed and tested first in Germany before it was brought to the United States. The CHARITÉ disc has three-pieces. There is a sliding core sandwiched between two metal endplates. The sliding core is plastic and the endplates are metal made from cobalt chromium. The endplates support the core. They have small teeth that hold them to the vertebrae above and below the disc space. The sliding core fits in between.

The main difference between spinal fusion and an artificial disc implant is motion. Fusion stops vertebral motion at the level of the fusion. The disc implant allows continued normal motion in all directions — even including a small amount of segmental translation. Segmental translation refers to the sliding motion of one vertebral body over another. With a fusion, there is no segmental translation at the fused level. Just the right amount of translational movement is needed for normal spinal motion. Too much translation and the segment would be unstable.

Neither treatment (fusion or disc replacement) is perfect. There are concerns that over time, the artificial disc won’t hold up and the patient will need another operation. But fusions limit motion and are known to cause adjacent-level disc degeneration and spinal joint degeneration. There are so many unknowns — that’s why a long-term study like this (comparing fusion to disc replacement) can be very helpful.

Both the authors and the editors reviewing this study raised serious concerns about the way the study was done and the significance of the findings. Let’s look at the results and then discuss why the study design and methods might be under question.

Various measures were used to study the outcomes. Pain, range-of-motion, function, disability, work status, and reoperation rates were all compared between the two groups. For the most part, they found similar results in both groups. The same number of patients improved at the same time and in the same amount in both groups.

Digitized, computerized X-rays were taken to measure differences between flexion, extension, and translation of the vertebral segment operated on as well as the adjacent segments (above and below). The radiologist looked for bone spurs, osteoporosis (loss of bone mass), and heterotopic ossification (formation of bone in the nearby soft tissues).

The X-rays showed some loss of disc height over time with both the BAK fusion and the CHARITÉ implant. The BAK group also had a small amount of measurable translation (0.1 mm compared with 0.4 mm to 0.8 mm in the CHARITÉ group). Ossification in the disc area that could affect motion affected about one out of every five patients with the disc replacement.

The groups were very similar in terms of race, age, weight, activity level, and work status before surgery. The only significant difference was the larger number of patients in the disc replacement group who had prior (minor) back surgery. The CHARITÉ group was also more likely to be working full-time before surgery compared with the fusion group. After surgery, long-term disability was much more likely in the BAK group (20 per cent compared with eight per cent in the disc group).

And the most important finding was that the results for both groups after five years were the same as was observed after the first two years. The consistency of results from two to five years supports the idea that mid-term to long-term results are good for the disc replacements.

Now, what about the concerns raised concerning the study design? The authors reported a loss of two-thirds of the patients from the two-year study. In other words, only one-third of the patients in the original study participated in the full five-year review. And only eight of the original 14 clinical sites were involved.

The authors report that there were many legitimate reasons for these changes. But the editors question the fact that not all patients were contacted at five years. Those who were contacted had similar results between the BAK and the CHARITÉ. Whereas the authors say the disc replacement is just as good as a fusion, the editors point out that the outcomes were disappointing. In theory, the artificial disc replacement should produce better results than a fusion. In reality, only slightly more than half the group had improved function and that was very minimal.

The editors suggest that the results of both treatment methods weren’t really acceptable. And the fact that the patients chosen for either surgery were highly selected raises some questions, too. If patients were so carefully selected but didn’t really get the hoped for results, what does that suggest?

Although the authors say the disc replacement is safe and effective for this patient population, the editors advise caution. Future studies are needed to look at some of these problems and answer the difficult questions raised before giving artificial disc replacements the green light as safe and effective for long-term use.

Pain coming from the sacroiliac (SI) joint can be difficult to diagnose. That’s because the problem can be inside the joint (intraarticular) or it can be extraarticular (outside of the joint). Extraarticular structures include ligaments and muscles. And the diagnosis is made more difficult by the fact that pain coming from the SI joint can be felt in the buttock, groin, and/or leg — not just in the area of the sacroiliac joint.

There isn’t one single test that can be used as the gold standard in diagnosis. Instead, doctors use a variety of pain provocation tests and/or joint injection with a numbing agent combined with an antiinflammatory medication. Pain provocation tests stretch, compress, or contract tissue structures around the SI joint. Injection numbs or silences the pain-generating structures.

But there are questions about how valid, reliable, and sensitive or specific these tests are. In order to help those who examine the sacroiliac joint, the authors of this report conducted a systematic review of diagnostic tests for sacroiliac pain. The researchers (from The Netherlands) looked at all published studies on tests to diagnose SI joint pain.

They used the diagnostic criteria set out by the International Association for the Study of Pain (IASP). The IASP proposes that 1) SI joint pain can be identified by the location of the painful symptoms, 2) SI joint pain will be reproduced by carrying out the provocation tests, 3) And the pain will go away after injection with the numbing agent. But is this really so? There are some experts who say both sets of tests are needed. And even then, the results are not 100 per cent full-proof.

In the studies included in this review, both sets of tests were performed with a day apart but no more than seven days separating them. The goal was to avoid influencing the results of one test by the use of the other test. The hope is to find a test that is 100 per cent sensitive and specific. That means the results of the test would always be positive in patients with an SI problem and negative when the pain wasn’t coming from the SI joint.

A reference standard was used in all studies included in the analysis that were using intraarticular injections as a diagnostic test. In this case, it means that before patients received an intraarticular injection with a local anesthetic, the placement of the injected material was checked first. This was done by injecting a small amount of dye into the joint. In this way, it was possible to make sure the injection really got where it was intended (inside the SI joint).

A second important feature of the studies included was how they defined success of the injection. All studies agreed that at least 50 per cent pain reduction was required. And it had to last at least one hour. Most studies defined success as 75 to 80 (up to 90) per cent pain reduction.
Studies comparing the use of an intra-articular injection confirmed that patients definitely got pain relief. No one getting a placebo (pretend) injection got 70 per cent or more of pain relief.

Attempts to analyze provocation tests were met with less success. Of the five tests included (compression, distraction, thigh thrust, Gaenslen’s test, and Patrick’s test), only results for the thigh thrust test and the compression test could be included.

Studies of the other tests were just too different in how they were carried out to include them. That doesn’t mean these tests didn’t have good diagnostic validity. It just means there’s a need for better, more consistent (across different studies) designs for future studies.

The authors conclude from their analysis of the many studies in this systematic review that just using the location of pain as a diagnostic tool is not a valid approach. Too many patients with pain around the SI area end up with a problem originating someplace else. And too many patients with true SI joint problems have buttock, leg, or back pain (not SI joint pain).

With that out as a gold standard, two of the pain provocation tests might be helpful but they don’t really isolate exactly where the problem is coming from. For example, is it ligamentous? If so, which one(s) is involved? The same goes for muscles — is there a muscular problem and if so, which one is generating the pain signals and why? The source of pain could be the joint capsule (outside the joint) or the joint articular (cartilage) surface (inside the joint)? None of the compressive tests really sort this out carefully enough.

That leaves us with the intraarticular injection as a potential gold standard diagnostic test. But the authors point out that the numbing agent can leak out of the joint affecting the nearby nerves and soft tissues. Thus, the injection cannot be designated as the single most reliable and valid test for SI problems either.

Until and unless scientists can figure out how to isolate individual structures in and around the SI generating pain, it remains certain that one individual diagnostic test just isn’t going to be possible. For now, it has been suggested that examiners use the provocation tests best known for their ability to recreate pain from the SI. The presence of a positive thrust test and positive compression test signal the need for further diagnostic workup with an intraarticular injection.

That brings us back to the International Association for the Study of Pain (IASP) and their criteria for the diagnosis of SI joint pain. These make a nice place to start, but there isn’t enough evidence to support them as reliable and valid diagnostic guidelines at this time.

When is the best time to intervene with back pain? Studies show that most people get better after an episode of acute low back pain. A small percent go on to develop chronic, costly, disabling low back pain. At what point should treatment be done for these folks? In this study, patients in the subacute phase of their first ever episode of low back pain are treated. In this case, subacute meant they all had back pain that lasted six to 10 weeks and were unable to do their job.

The study was conducted at a naval medical center, so the patients were all otherwise healthy adults between the ages of 18 and 50. They had back pain despite conservative care but were not candidates for surgery. No one in the study had back pain from a serious medical problem such as cancer, infection, or fracture.

There is some evidence that psychosocial factors are part of the reason patients develop chronic pain that ends in disability. It seems that the subacute phase is when these influences have their greatest effect. Psychosocial variables refer to beliefs, moods, and coping. To explore the effect of targeting psychosocial factors, the patients in this pilot study were divided into two treatment groups.

The first group received four one-hour sessions of behavioral medicine. The model of behavioral medicine puts the focus on self-management of pain, slowly increasing activity, reducing fear of movement or reinjury, and changing beliefs about pain. Anatomy of the spine and physiologic function were reviewed to help patients understand their back pain.

Patients in this group were given exercises and activities to complete at home. Vocational counseling and stress management were offered to those who needed it. The role of attitude, emotions, and interpersonal relationships as these relate to back pain were discussed.

The second group received four one-hour sessions of attention control condition. They received empathy, support, and assurance from counselors who listened to them. They were encouraged to go back to the orthopedic physician or physical therapist whenever they needed help to manage their pain and speed up recovery.

Patients in both groups also received two one-hour booster sessions. These maintenance sessions were designed to review what patients had learned. The goal was to keep them on track during the first weeks after therapy was completed.

To compare treatment outcomes between the two groups, patients completed several surveys before and after treatment. They rated their pain, level of disability in daily activities, and general health status. They also completed a questionnaire that assessed their pain beliefs and ability to function despite pain. The physician reviewed their medical records and rated their work disability.

This battery of tests was given to the patients six and 12 months after the start of their pain. The main outcome was defined as recovery when there was an absence of pain and no longer any disability limiting function. The tests had cut off scores to help in dividing patients into those who recovered and those who did not.

Recovery rates were three times higher in the behavioral medicine group than in the attention control group. More patients in the behavioral medicine group recovered at six months and were back to work full-time at their pre-back pain level of activity. Those who attended the booster sessions had even better results. Test results showed that patients in the behavioral medicine group also changed their attitudes about seeing pain as disabling.

The authors say that although this was a small study limited to military personnel, the results suggest that a behavioral approach may be a very useful way to move patients with subacute back pain toward recovery. Preventing chronic back pain from developing saves money but also saves people from suffering unnecessarily. Empathy and therapist support may be a feel good approach. But it appears that directive treatment guiding patients through rehab has better results.

Orthopedic surgeons and other spine specialists have agreed that describing disc problems should be standardized. Several groups have proposed terms to describe disc pathology such as bulging, protrusion, extrusion, and sequestration. The American Society of Spine Radiology, American Society of Neuroradiology, and the Combined Task Force of the North American Spine Society are included in the groups advocating the standardization of terms. This study attempts to find out if these guidelines are being followed.

An ongoing clinical trial called SPORT (Spine Patient Outcomes Research Trial) provided the data for the study. Information was collected from 13 multidisciplinary teams treating spine patients in 11 states. MRIs used to make the diagnosis were read by a radiologist and the physician examining the patient. The results between these two groups were compared.

Most of the 396 patients enrolled in the study were working men with confirmed disc herniation at the L5-S1 level. The three areas or categories reviewed were spine level, morphology, and location. Although the majority of problems were in the L5-S1 area, some patients had changes at L2-3, L3-4, or L4-5 instead.

Morphology refers to the extent of disc damage. This ranges from mild bulge to protrusion (inner disc material pushing into the outer covering of the disc). More progressive damage leads to extrusion (inner disc material pushing through the outer disc covering) and finally, sequestration. Sequestration refers to disc fragment that breaks off and becomes a free-floating loose body in the spinal canal.

The location of most disc problems is usually posterolateral. This means the disc pushes back toward the spinal canal and off to one side or the other. Disc protrusion can be central (straight back), lateral (just to one side), or foraminal. Foraminal describes a disc that has moved into the space where the spinal nerve root exits the spine. Lateral and foraminal discs can occur on the right or left side.

MRIs were read by the spine specialist taking care of the patient (neurosurgeons, orthopedic surgeons, and nonoperative spine specialists). The same MRIs were also interpreted by radiologists. Each person looking at the MRIs filled out a form answering questions about the level, morphology, and location of the disc pathology. Then the answers were compared between the two groups.

For the most part, both groups agreed on the level of disc problems and the location within the level (central, right, left, posterolateral). In fact, agreement was calculated at 93.4 per cent. When there was disagreement about the vertebral level affected, it was usually because of a transitional vertebra confusing the numbering.

The biggest stumbling block was in describing the morphology (protrusion, extrusion, sequestration). Almost half the time, the radiologist didn’t describe the morphology at all. In cases where both groups described the abnormal disc, the clinician (attending physician) was more likely to give it a higher grade indicating a more severe progression of disease than the radiologist.

For example, the examining physician would label the morphology as a disc extrusion when the radiologist would call it a protrusion. In cases where the radiologist didn’t see a herniation, the morphology was labeled as a bulge. The attending physician would interpret that as a herniation.

A bulging disc describes the inner disc material (called the nucleus) as pressing against (but not into) the outer covering (called the annulus). With a herniation, the inner disc material has pushed into the outer covering. The reason for this difference in categorization may be because the clinicians were influenced by knowing the patient’s symptoms. It’s also possible that differences in training account for differences in the way clinicians interpret lumbar MRIs.

There were a few cases of human error where the reader labeled the side of involvement incorrectly (e.g., saying it was on the right when it was really on the left). This can affect treatment and result in a less successful response than hoped for — sometimes even sending the patient to surgery when conservative care failed to resolve symptoms. Obviously operating on the wrong side would not be good either. So the authors warn anyone reading MRIs that even experienced radiologists can make this mistake and to guard against it.

The authors conclude that radiologists are not routinely following the guidelines. Standardizing terminology used to describe disc pathology is important in providing studies that can be compared. Without this kind of cooperation, attempts to improve research and treatment results will be hampered. Lumbar spine MRI readers are strongly urged to follow these published guidelines.

Why do some people get back pain over and over while others recover without a single recurrence? That’s the question these scientists asked in a study from Australia. They suspected that activity of the deep muscles in the back might be different in some people. This could be causing return bouts of back pain.

In fact, one-third of all adults with low back pain will develop pain again. And that’s even after returning to normal function with apparent good recovery from the first episode. Studies have shown that there is a problem with muscle relaxation. Messages from the nervous system may get mixed up so that the muscles lose the ability to fine tune motion of the vertebrae.

Two groups of subjects were compared. One group had low back pain on one side (unilateral) that came and went. During the testing period, they were symptom-free. The second (control) group were healthy adults with no history of back pain.

Using electromyography (EMG) to record the electrical activity of the muscles, the researchers compared the activity of short versus long muscle fibers of back and shoulder muscles. Recordings of muscle activity were taken from both sides of the spine. Surface and needle electrodes were used to get accurate EMG readings.

Measurements were taken as the subjects moved their arms forward 45-degrees. Arm movement was used because past studies have shown that such movement causes activity in the back muscles. This testing procedure gives a reliable way to measure changes in motor control of deep muscles that control spinal motion.

EMG makes it possible to tell exactly when the muscle starts to respond and the pattern of muscle activity. They were specifically looking at the response of the lumbar multifidus muscle in the back in relation to the deltoid muscle of the shoulder. They expected to find different muscle activity patterns between the two groups of patients.

What they found was that when the control group moved their arms, short muscle fibers of the multifidus started firing earlier than long muscle fibers. But in the group with recurrent low back pain, there was no difference in when the short versus long fibers were activated on the involved side. The nonpainful side for the patients behaved normally (i.e., the same as in subjects in the control group).

What does this mean? It looks like changes in motor control of the back muscles of people with low back pain may be why they get back pain again. Alteration in the timing of the short fibers on the side of the symptoms may be the key. Proper timing of deep muscle contraction in the spine is essential for normal spinal movement and spinal stability.

Without the normal firing sequence of muscles, motor planning is altered. As a result, the nervous system sets up a pain pattern. But what causes this change in motor planning? Is there some kind of damage to the muscle itself? Or is it because the person alters the way he or she moves to avoid pain and protect the spine?

It’s possible that our beliefs about pain and the desire to avoid pain may actually be able to influence motor control at the level of the muscles. This study was unable to answer these questions. But it was the first study to clearly show a connection between abnormal motor control and recurrent back pain. And they clearly showed that just because back pain goes away doesn’t mean the muscles have returned to normal. For patients with recurrent back pain, in between episodes, their back muscles aren’t firing normally. This puts them at risk for reinjury or another acute episode of pain.

The benefit of this information is that we can now try changing spinal function by restoring normal motor control and movement strategy of the spinal muscles. This is of particular interest to physical therapists who are movement experts. They can help patients regain normal movement patterns.

Finding ways to fine tune segmental motion should include looking at patient beliefs about their back pain. The goal is to correct protective postures and movement strategies used by some individuals in an attempt to prevent future episodes of back pain. This may be necessary when those strategies are what put them at risk of recurrence in the first place.

Chronic low back pain can lead to disability and loss of work. Some doctors prescribe strong (narcotic) pain relievers called opioids in an effort to help people get back to work. But critics of this approach say there’s no proof that opioid use improves outcomes. In fact, there’s some evidence that opioid therapy may actually be linked with increased risk of work loss.

Experts in the area of social science tell us that people who lose their jobs can suffer severe problems. They start out in a state of fearful distress that quickly becomes a despairing attitude of giving up. The loss of income makes things even worse. To test the effect of opioid use on work loss, two groups of Worker’s Compensation claimants were compared.

Everyone included in the study had filed a Worker’s Comp claim for low back pain. One group was provided with opioid therapy. Some were taking weak (Class III or IV) opioids. Others were given strong (Class II) opioids. The opioid group was further divided into two subgroups based on whether or not they took opioids for up to 90 days or for more than 90 days. The second (reference) group had filed a Worker’s Comp claim for low back pain but no one in the group was taking opioid-based medications.

Analysis of the data collected for the two main groups showed a significant link between opioid use and work loss. Workers taking any kind of opioid were 11 to 14 times more likely to suffer work loss compared to the reference (no opioid) group. Workers using strong (Class II) opioids were six times more likely to experience chronic work loss. The time frame used for this study was 90 days or more. And the overall costs for the opioid group was much higher than for the nonopioid group.

The authors concluded that the use of opioids may be a factor in work loss. The data here confirmed that the odds of chronic disability and work loss were much higher for claimants taking any strength opioids. But the severity of pain could be just as important. And pain translates to disability when it interferes with family life, sleep, and everyday activities. Adding opioids as a means of controlling pain doesn’t solve these problems.

The authors point out some of the advantages and disadvantages of a study like this. Using data from a Worker’s Comp claim database allows for long-term follow-up at a relatively small cost. The patients represent the average worker. Other studies from academic medical centers may have a better response to treatment just because they are in a special study. That seems to boost their motivation (moreso than for people in a Worker’s Comp claim).

The disadvantages are many and varied. For example, patients are classified based on reimbursement. The way the data is collected doesn’t make it possible to assess or measure the results of treatment. This approach doesn’t always give an accurate picture of what’s wrong with the patient. Likewise, no one asks the worker (claimant) how severe their back pain is or if treatment relieved the pain. Other important information may also be missing from the files.

For example, some workers may return to their jobs even if pain is still present. Measuring work loss can be a challenge. This is especially true if the claim isn’t settled. Workers may disappear from the system because disability prevents them from returning to their former job or taking another one.

Future studies are needed to review the relationship of opioid use with chronic work loss. Designing studies with fewer confounding (confusing) factors may help shed more light on this topic. Studying groups who are not Worker’s Comp claimants might reveal a different story altogether.

If you have back and leg pain from a herniated disc, is it better to have surgery that takes the whole disc out (aggressive discectomy) or are the results just as good with a conservative approach (take out only the disc fragment)? That’s the topic of this study.

The authors reviewed all of the published data from the last 40 years. This type of study is called a systematic review. They only included studies that directly compared these two open-incision discectomy techniques.

Patients all had low back and leg pain. The leg pain is referred to as radiculopathy. A more common name is sciatica. It is caused by pressure on the spinal nerve root or chemical irritation of the nerve root from the herniated disc or disc fragments. Studies using more recently developed minimally invasive approaches were not included.

They tried to answer four questions. 1) Which has better short-term (up to 28 days) results: aggressive or conservative discectomy? 2) Which has better medium-length results (up to two years after the surgery)? 3) How do the results compare after two years? 4) Which one has a higher rate of a second (recurrent) disc herniation?

As a surgeon (or patient) trying to decide which surgical approach is best, the answers to these four questions could be very helpful. After conducting the search, the authors summarized each study in a table. The name of the article, authors’ names, and publication citation were provided for 25 publications.

There were initially 621 studies that had some reference to open surgical treatment for disc herniation. But after reviewing them more carefully, only the 25 chosen directly compared aggressive versus conservative discectomy or reported the results of one of these approaches.

Level of evidence (from one to five/high-to-low quality), brief description of the study, and conclusions were presented. Strengths and weaknesses and critiques of the article were incorporated in the table. Most of the articles were really a level IV evidence, which means they were case studies, not randomized controlled (high-quality) studies. In fact, only one study was at the level II evidence and none were the highest quality (level I).

Just finding out that the level of evidence comparing these two studies is so limited was a valuable result of this study. It helped point out the need to design and carry out randomized trials. High-quality trials are needed to really get a handle on how the results of these two procedures compare.

What can be said is that there isn’t any good evidence to say that an aggressive approach is better than a more conservative one. Only taking out disc fragments (rather than removing the entire disc) takes less time in the operating room and gets people back to work faster than the more aggressive removal of the entire disc.

Taking a closer look at medium- and long-term results showed that there was no advantage to the more aggressive approach. Patients in both groups had equal improvement in function and the same incidence of recurrence early on. Recurrence refers to cases where the same disc herniated again. There was some indication that the further out the patient was from the surgery, the more likely a reherniation might occur with the conservative approach.

Any further conclusions just can’t be made from the data collected so far. And it should be kept in mind that these conclusions were made from the currently available low-level quality of evidence. Choosing the conservative approach follows the guidelines for best practice based on what evidence there is, but this choice comes with the potential risk of reherniation requiring additional surgery.

You may have heard of someone being turned down for surgery because they were overweight or too heavy. Maybe this has even happened to you. Is it really justified? Are patients really at increased risk for problems during and after surgery just because they are obese? Is there any evidence to support this kind of guideline?

In this study, surgeons focus on obese and morbidly obese patients with low back pain who are having a lumbar spinal fusion. They looked at complications, final outcomes, and effect on body weight of having spinal fusion surgery in 63 patients who were considered obese.

Obesity is determined by a measure called the body mass index (BMI). A person’s BMI can be calculated using a mathematical equation of the ratio between height and weight. Anyone with a BMI of 30 kg/m2 or higher is classified as obese.

Morbidly obese is a separate category for those individuals who are 20 per cent or more above the optimal weight for their height and body type. Their BMIs can exceed 40 kg/m2. Patients with a lower BMI (35 to 40 kg/m2) can also be considered morbidly obese if they have one or more significant comorbidities. Comorbidity refers to other health problems such as diabetes, heart disease, high blood pressure, asthma, sleep disorders, and so on.

What are the surgical team’s concerns about operating on someone who is medically obese? There can be difficulties getting a clear airway to allow the patient to breathe while being anesthetized. Folds of fat and flabby soft tissue collapse against the airway preventing intubation (placement of a breathing tube down the trachea).

It can be equally difficult to gain access to a blood vessel to start an intravenous (IV) line. Positioning the patient can be a tremendous challenge. And studies have confirmed the link between obesity and the increased incidence of complications (including death) during and after the surgery.

Back pain patients who are obese have a special dilemma. They can’t lose weight because they can’t exercise. They can’t have bariatric surgery such as stomach banding or gastric bypass procedures because of the back pain. They are really caught in a catch-22 situation. There is an assumption that if they didn’t have back pain, then they would exercise and lose weight. Is that really the case? That’s one of the things the authors of this study put to the test.

All the patients in this study had a BMI of 30 or higher and one or more (up to six) levels of lumbar vertebrae fused. There were different reasons why these patients had chronic low back pain requiring lumbar spinal fusion. Lumbar canalstenosis (narrowing of the spinal canal), degenerative disc disease, scoliosis, and instability after a previous (laminectomy) surgery were the most common problems. Laminectomy refers to the removal of a section of vertebral bone called the lamina. Cutting away the bone helps take pressure off the spinal cord or spinal nerve roots.

Data collected on this group of patients included time in surgery, blood loss during surgery, and length of hospital stay. Information on the number and type of preoperative comorbidities and postop complications was also summarized. Pre- and post-study weights were recorded. Follow-up lasted at least 18 months for everyone. Some people were followed for as long as three years.

Weight loss was not a part of the pre- or post-operative plan. The study did not include any counseling or effort in this direction. It was noted that almost everyone in the study had attempted one (if not many more) efforts to lose weight (unsuccessfully).

The authors reported that surgery did not take longer in patients whose BMIs were higher. The surgical time was really linked with the number of segments fused. Blood loss was linked with several factors including body weight, number of levels fused, and preoperative hemoglobin levels. Positioning may have an impact on blood loss in the obese population because pressure on the belly can cause greater blood loss. Whenever possible, the patient should be placed in such a way that the abdomen hangs free.

No one had a net loss of weight as a result of their lumbar spinal fusion. This was true despite the fact that they did report reduced pain levels. Early on after surgery, about half the group gained weight while the other half lost weight. A few stayed the same. Over time, the BMI did not change significantly for anyone in the study.

Complications after surgery such as infection (wound, skin, urinary tract), nonunion, spinal fluid leaks, and low blood pressure were as high as 50 per cent. But the rates were not higher among the morbidly obese patients compared to the obese patients. The authors explained that they included minor and major complications, so the overall number of problems (referred to as the complication rate) was possibly inflated by the definition of complication.

The authors conclude that anyone with a BMI of 30 or higher requires careful consideration and monitoring when having surgery. The surgeon must go into the lumbar spinal fusion procedure with the knowledge that obese patients have a greater risk of postoperative complications. These problems may not be related to their body size as much as the number of segments being fused. Overall results may be better if the obese or morbidly obese patient has bariatric surgery first before spinal surgery.

The sciatic nerve travels underneath the piriformis muscle in the deep buttock area. In some people, the nerve passes through the muscle belly. Prolonged or repeated contractions of the piriformis muscle compresses or irritates the sciatic nerve enough to cause pain, numbness, and tingling in the buttock. The symptoms may travel down the leg along the pathway of the sciatic nerve. This condition is called piriformis syndrome.

Treatment for piriformis syndrome starts with analgesics (pain relievers) and physical therapy. The therapist helps the patient change posture that might be contributing to the problem. Stretching the piriformis muscle often helps, as well as mobilizing the sciatic nerve. The therapist guides the patient through these steps, but in some cases, the painful symptoms persist.

Doctors turn to injections of the piriformis next. Steroids, local anesthetics (numbing agents), and botulinum toxin (BOTOX) may be used. BOTOX is a paralyzing agent that works temporarily to help stop muscle contractions of the piriformis.

It’s best to use guided injection for this treatment. Computed tomography (CT scans) or fluoroscopy (real-time X-ray) show the surgeon where the needle is in relation to the soft tissues and bones. But not all centers have such advanced technology available. And even if they do, the cost may be prohibitive for such a minor procedure.

This is where nerve stimulation can help guide the injection. The authors of this study made careful assessment of the patient’s anatomy and found the ideal place to insert the needle through the buttocks. A drawing of the landmarks used to find the insertion point is provided. The tip of the needle was placed just behind the sciatic nerve. The needle was connected to a nerve stimulator.

The nerve was stimulated using this technique. When the surgeon could tell he was on the sciatic nerve by stimulating it, then he moved the needle back a few centimeters into the piriformis muscle. A special dye was injected to make sure the piriformis muscle was being injected.

This low-cost, low-tech method of identifying the right anatomical spot for the injection was tested first on a small (pilot) group of 18 patients. Once the researchers were sure the method worked, they did a larger double-blind study with 80 people. Double-blind means that the patients and the staff giving the injections did not know which injection the patient was getting.

The patients were divided into two groups randomly. One group received a numbing agent (bupivacaine) combined with saline (a salt solution). The second group was injected with bupivacaine and a second agent (clonidine). Clonidine is actually a blood pressure medication. But it works for pain because it also blocks pain messages from being delivered to the brain via the spinal cord.

Based on results, the patients could have up to four injections. Success was measured by pain scores recorded by the patient while walking, sitting, and lying down. They kept a diary and filled out charts to write down when they needed additional pain relievers, what type they took, how much pain they were in (intensity), and how long the pain lasted (duration).

The patients who got bupivacaine combined with clonidine clearly had the best results. Almost half of this group was pain free by the end of the first week (after only one injection). This compared with none in the group receiving just the bupivacaine.

A second injection gave even more patients in the bupivacaine/clonidine group pain relief. Only two patients in the bupivacaine/saline group reported reduced pain after the second injection. At the end of four weeks, 92 per cent of the bupivacaine/clonidine group was pain free (compared to only 24 per cent in the bupivacaine/saline group). And the bupivacaine/clonidine group used far fewer extra pain medications compared with the bupivacaine/saline group.

There are many theories as to why the addition of clonidine makes such a difference. Some experts suggest it has an impact on the immune system, reducing local inflammation of the sciatic nerve. Others think clonidine can alter nerve impulses, possibly even affecting how the spinal cord works.

It’s also possible that the effect takes place in the piriformis muscle, not in the nervous system. Injection leads to muscle relaxation, which then takes pressure off the entrapped nerve. Even a short period of time with the nerve and motor unit interrupted could alter the pain-spasm cycle. And in the meantime, blood flow is restored allowing tissue healing.

The authors concluded that nerve stimulator guidance of injections for piriformis syndrome can be done safely and yield very good results. The combined bupivacaine clonidine solution works better than just bupivacaine alone. Repeated injections may be needed. Using clonidine also has few to no side effects.

Steroid injections into the epidural space have been used for pain coming from herniated discs as well as pain from spinal stenosis (narrowing of the spinal canal). This space is the area between the bony ring of the spine and the covering of the spine called the dura. The dura is the sac that encloses the spinal fluid and nerves of the spine.

When doing an epidural steroid injection, the doctor inserts a needle through the skin so that the tip of the needle is in the epidural space. The epidural space is normally filled with fat and blood vessels. Fluid such as the lidocaine and cortisone that is injected during an injection is free to flow up and down the spine and inside the epidural space to coat the nerves that run inside the spinal canal.

The steroid injection is an antiinflammatory combined with a numbing agent. The dual effect is to reduce swelling around the spinal cord or spinal nerves and stop painful messages from being sent to the brain.

Surgeons are fine-tuning the use of steroid injections to get the best results — quick pain relief that is long-lasting. There are several openings in the bones that surround the epidural space where a needle can be placed. An epidural steroid injection can be performed by placing the needle in one of several openings. In this study, they compared the results of two different techniques used to administer the injection for two different problems.

Although the steroid injection has the same biologic effects on local cells and tissues, where it is injected determines what areas are bathed in the drug. For example, discs tend to push backwards, putting pressure on the spinal cord from the front or anterior epidural space. The logical place to inject the steroid mixture is in the area where the spinal nerves are being compressed irritated.

The best approach to steroid injection for the disc has been transforaminal. The needle is placed at an angle just underneath the pedicle in an area called the safe triangle. The pedicle forms a bridge of bone in the vertebral arch around the spinal cord. The surgeon guides the needle into the epidural space along this pathway using a special type of X-ray called fluoroscopy.

An alternate approach is the interlaminar technique. In this technique, the needle is placed between two spinous processes (the bumps along your back) or laminae (columns of bone that are part of the vertebrae) so that the injection spreads into both sides of the epidural space.

The interlaminar technique works well for spinal stenosis because the fluid goes into both sides of the epidural space. And usually the spinal canal is too small all the way around the spinal cord. The transforaminal technique only injects the steroid into one half of the epidural space. That works fine for herniated discs if the disc is pressing back and off to one side or the other.

In this study, they tried doing a transforaminal injection from both sides at the same time. In this way, it was possible to deliver the steroid into both sides of the epidural space. Patients with spinal stenosis or herniated disc were randomly placed in one of two groups: one group received steroid injection via the interlaminar approach and the other group received a steroid injection via the transforaminal approach. The patients did not know which type of epidural steroid injection they received.

A special dye was also injected into the epidural space to show just exactly where the steroid spread inside the epidural space. If pain was not reduced to a five or less (on a scale from zero to 10), the inection was repeated two weeks later.

The overall results showed that pain was less for those in the transforaminal injection group. And among the transforaminal group, a more significant improvement was seen in the spinal stenosis patients. Patients with herniated discs got the same benefit no matter which approach was used. When injected from both sides at the same time, the transformainal approach was a better choice for patients with spinal stenosis.

It’s possible that the reason for this difference has to do with the amount scar tissue and fibrosis that’s present in spinal stenosis compared with herniated disc patients. When placed bilaterally, the transforaminal injection allowed a higher concentration of steroid to reach the anterior epidural space.

The interlaminar technique is affected more by the soft tissues along the back side of the epidural space. There’s hypertrophy (thickening) of the posterior longitudinal ligament and the bone in this area. The steroid fluid can’t always get past these structures when injected from behind. This isn’t a problem when the steroid is injected from the side (as with the transforaminal approach).

The authors state that patients with back pain from a disc herniation or spinal stenosis can benefit from steroid injections for short-term pain relief. The technique may not make as much of a difference in cases of disc herniation. But the transforaminal approach definitely works better than the interlaminar technique for patients with spinal stenosis.

Muscle weakness of the tibialis anterior muscle can cause the foot to drag when walking. The tibialis anterior picks the ankle up and pulls the foot toward the face. Degenerative conditions of the lumbar spine such as disc herniation or spinal stenosis (narrowing of the spinal canal around the spinal cord) have been linked with foot drop.

It’s a fairly rare condition. Some studies have been done but no one has really explained what happens and why. Could it be prevented? Is surgery needed? How soon should surgery be done? These are the questions the authors of this study attempt to answer.

They offer us information gleaned from a review of the charts of 28 patients with foot drop from disc herniation or spinal stenosis seen in their clinic over a period of 10 years’ time. Everyone in the study had spine surgery to correct the problem. What did they learn from looking back at these patients after the fact?

The chart review recorded information on each case about a variety of possible predictive or prognostic factors. Such things as affected spinal level, duration of symptoms before surgery, presence of other health conditions such as diabetes, and type of operation done were looked at. They also paid attention to muscle strength tested before surgery and any weakness observed after surgery. As with most studies, they also collected data about the patient including age and gender.

Patients with herniated discs had MRIs done before surgery to determine the level of disc affected and the amount of damage done. The surgeon also recorded observations made during the operation. The number of nerve roots (and which ones) compressed by the herniated disc was reported. For patients with stenosis, the same process was done to discover how much the canal size was reduced by and at what levels.

For all patients, before surgery, the strength of the tibialis anterior was graded (on a scale from zero to five) between zero and three. Zero means there isn’t even so much as a twitch in the muscle. One means it’s possible to feel or see a muscle contraction but there’s no movement. A grade of two tells us the patient had full motion so long as the muscle so long as there wasn’t any gravity and or resistance. A grade of three means there was full motion against gravity but only if there was no resistance to the movement.

The reason the mechanism behind a loss of tibialis anterior strength is difficult to determine is because there isn’t just one nerve that goes to this muscle. It appears from other studies that most patients have footdrop when the L5 nerve root is affected. But there are a fair number of people with L4 nerve root irritation or compression who also develop foot drop. And sometimes the S-1 nerve root is affected, too.

So, here’s what they found about each group in this study. Most of the patients with herniated discs were affected at the L5-S1 level. Some (but not as many) patients had disc herniation at the L3-4 or L4-5 levels. More than half of the disc group had compression of multiple nerve roots (not just one). They also had a free floating piece of disc called a sequestrated fragment pressing on the nerves contributing to this multi-level phenomenon.

Most of the disc patients recovered strength of the tibialis anterior after surgery. They scored a four or five on the manual muscle test, indicating near normal or normal function. For those who still had a three or less on the manual muscle test, there was no apparent predictive factor before surgery. In other words, there was no way to tell before surgery who would recover and who wouldn’t.

As far as the group with stenosis goes, the upper lumbar levels were affected most often (L2-3, L3-4). Most often, multiple levels were involved. Far fewer patients in this group recovered their tibialis anterior strength after surgery. The strength of the tibialis anterior (and the extensor hallucis longus — the big toe muscle) was correlated with recovery. Patients with a higher muscle grade before surgery for stenosis were more likely to get full recovery compared with stenosis patients who had lower muscle test scores.

What does this all mean? The authors sorted through all the data and concluded that foot drop in patients with a herniated disc occurs most often when a piece of the disc breaks off and ends up putting pressure on more than one nerve root. Tibialis strength before surgery was a better predictor of recovery in stenosis patients. But disc patients were much more likely to recover muscle strength after surgery than stenosis patients.

This information gives surgeons a better idea of how to plan treatment for patients with foot drop from either of these two degenerative spinal conditions. Preventing permanent foot drop and restoring full function requires careful attention and early intervention.

More study is needed to determine whether earlier intervention with stenosis patients would make a difference. Since there was a significant correlation between preoperative strength and prognosis for stenotic patients, it’s possible that surgeons could use preoperative tibialis anterior strength as a guide to planning surgery.