News Category: Spine

Patients who have spine surgery (laminectomy and/or fusion) have different results depending on where the surgery was done. Those are the findings of a recent review of data collected from 13 spine centers in 11 different cities across the United States. Naturally, the reasons for these differences in outcomes are of interest but will have to wait for another study.

For now, this study shows that patients with stenosis (narrowing of the spinal canal) or degenerative spondylolisthesis (age-related fracture and slippage of the vertebra) who have the same surgery may not get the same results. And that is a significant finding. Let’s take a closer look at the details of this study.

The background information about these patients may be helpful. All had severe low back, buttock, and/or leg pain and were unable to walk very far. Conservative (nonoperative) care was unable to change their symptoms. The purpose of the surgery was to remove the bone putting pressure on the nerve tissue (laminectomy) and to stabilize the spine (fusion).

Most of the time this type of surgery is successful with good postoperative outcomes. But there are cases where there is no change in painful, limiting symptoms, and the patient ends up having another surgery.

There are many different reasons why some patients don’t fare well after these procedures. Sometimes the patient was misdiagnosed or the surgical technique failed. In other cases, the spine was unstable and this problem wasn’t addressed during the surgery. Many studies have shown that over time, adjacent segment disease (breakdown of the spinal segment next to the fusion site) is a problem.

Most of the studies reporting results of surgery for lumbar stenosis and degenerative spondylolisthesis are done at one single center. Often, there is only one surgeon performing all of the procedures being studied. This review is different because it reports on both short- and long-term outcomes across multiple centers with many surgeons.

In each of the nearly 800 similar cases, surgery performed varied slightly and the number of levels operated on was anywhere from one to three or more. Events associated with the procedures (e.g., length of time in the operating room, amount of blood lost, number of dural tears) varied from center to center. And there were significantly different reports on how long patients stayed in the hospital and the number of wound infections.

Long-term results (measured at one, two, three, and four years after surgery) were also significantly different across the spinal centers involved. For example, the number of patients who required another surgery ranged from five to 21 per cent. The level of pain and physical function reported by patients was also different.

The data was collected and analyzed in such a way as to make sure that these differences were directly linked with the effect of the center rather than being due to patient factors such as age, size, smoking history, socioeconomic status, or level of preoperative exercise. Factors that may be important (but as yet unproven) include: surgeon preference for certain techniques, patient genetics, neurobiological responses to the underlying condition, and differences in patient response to pain.

In summary, this study cannot answer the “why” of differences in response to surgery for these two conditions. But it does bring to our attention the fact that there are broad ranges of patient outcomes across centers for the same conditions using similar surgical approaches. This new information should be a springboard for the next study: to answer the “why” question. What characteristics of patient, surgeon, or center make for better patient results following surgery for spinal stenosis and degenerative spondylolisthesis?

Studying the causes and ways to avoid adjacent segment disease (ASD) of the cervical (neck) and lumbar (low back) spine has become a major focus of research these days. But with the ever changing surgical tools and techniques, it is difficult to compare studies from 10 years ago with current studies. And that dilemma will continue into the future as treatment strategies change with evolving technology.

Even so, efforts are being made to study the problem of adjacent segment disease (ASD) and ways to avoid it. Adjacent segment disease refers to breakdown of the vertebrae next to a spinal fusion or disc replacement implant. Focusing on the causes of the problem may help surgeons identify avoidance strategies.

Currently, there are three known causes of adjacent segment disease. They are: 1) the natural history (what normally happens) in the disc at the next level, 2) the biomechanical stress and increased motion placed on the next level because of the fusion, and 3) anatomical disruption of the vertebral segment at the next level from the surgery.

In this review article, surgeons from Walter Reed Military Medical Center and Thomas Jefferson University team up together to present the latest evidence on adjacent segment disease (ASD) and how to avoid it. They say that strategies to avoid ASD seem to be working better for the cervical spine than for the lumbar spine. And ASD may be less likely to develop after disc replacement compared with spinal fusion.

Matching strategies with causes isn’t easy. For example, to know for sure if natural history (the natural tendency for the spine to degenerate over time without surgery) is the real problem is difficult to study. Providing needed surgery for one group of patients while comparing them to a control group (those who don’t have the surgery) isn’t ethical. So the true incidence of ASD linked with natural progression of disc degeneration is likely to remain unknown.

Studying the biomechanical changes at the adjacent levels is a bit easier. Researchers can measure the increased motion at the next vertebral levels and measure the increased pressure on the disc in between the vertebrae.

These kinds of changes are more likely after fusion (because of loss of motion) than with disc replacement where motion is preserved. Determining the exact biomechanical changes that contribute to ASD and finding ways to change that relationship are the focus of many current studies. To date, there has been a wide range of conclusions about this variable. Some studies show that the natural tendency for discs to degenerate over time is the main cause of the problem while others point to the change in biomechanics as the most important factor.

But there’s no mistaking the fact that the surgery has an effect as well. Whether fusion or disc replacement, the structures are changed, the normal anatomy is altered, and the result could be aggravation of the adjacent levels. Studies are needed to show what anatomic parts must be preserved and not disrupted during surgery to prevent adjacent segment disease. Likewise, determining technical strategies during the procedure that might help avoid adjacent segmental disease will be important.

In summary, studies of adjacent segment disease (ASD) for the cervical and lumbar spines continue to report a wide range of variable results. Working to find avoidance strategies based on known causes of ASD will remain the focus of ongoing research. Long-term results will be difficult to judge given the ongoing changes in technology and surgical techniques used in these procedures. But this should not deter surgeons from trying to develop effective avoidance strategies.

When all nonsurgical, noninvasive treatments have been tried without success for lumbar spinal stenosis, surgeons often try epidural steroid injections (ESI). But based on the results of a new study, it may be time to rethink that step.

Lumbar spinal stenosis (stenosis of the low back) is a common cause of back problems in adults over 55 years old. Symptoms of buttock or leg pain occur with or without back pain when the nerves in the spinal canal are compressed or pinched.

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, bone spurs may form and ligaments thicken closing around the spinal canal. Anything that narrows the spinal canal opening for the spinal cord and spinal nerves can put pressure against the nerves.

Many older adults never know they have this condition. They are said to be asymptomatic (without symptoms). But for those who do experience the back, buttock, and/or leg pain (and sometimes tingling/numbness), treatment is important. Most people want to avoid surgery, which is why they run the gamut of all conservative approaches ending with steroid injections.

But the question comes up: do epidural steroid injections (ESIs) really make a significant difference? Are patients improved enough to go this step? In this study, results for patients who received ESI for their symptomatic (with symptoms) lumbar stenosis were compared with outcomes of patients who did NOT receive the injection.

Everyone in both groups did have painful neurologic symptoms and had tried at least three months of nonoperative care without success. The type of conservative care they received included home exercise, nonsteroidal antiinflammatory drugs, education and counseling, and active physical therapy. All patients were enrolled in a larger (special) study known as SPORT (The Spine Patient Outcome Research Trial).

The researchers were very thorough in examining characteristics of patients and any factors that might affect the results. They looked at age, smoking status, general health, presence and types of other health problems, marital status, work or employment, income, education, race, body mass index, and many other variables.

Details of the symptoms and stenosis (location in the spine, severity, duration, affect on activities) were also recorded and analyzed. Anyone who ended up having surgery (from either group — those who had the steroid injection and those who didn’t) were also examined carefully. Information was collected on type of surgery, length of stay in the hospital, postoperative complications, additional surgeries, blood loss, and number of minutes in surgery.

In the end, they found that patients who had the epidural steroid injections (ESI) during their four year study period had significantly less improvement in symptoms over anyone else. That included patients who had surgery (and those who didn’t have surgery). The main conclusion of this study was that patients with lumbar spinal stenosis who have ESI have worse results than those who don’t have ESI.

A second observation from the study was related to patient crossover. Crossover refers to patients who start in one group (e.g., injection group) and end up going (crossing over) to the surgical group (or vice versa). In this study, the surgical group had better results than the injection group. So the patients who crossed over from originally being in the surgical group to the injection group may have had worse results than if they had stayed in the surgical group.

Patients in the ESI group who had the injection and then crossed over to have surgery also had worse results than the surgical group who did not have any injections. The surgery took longer for the ESI-crossover-to-surgery group. They were also in the hospital longer without any measurable benefit from the procedure.

Of course, with all that data collected, the authors went digging for an explanation. Other studies have suggested that earlier treatment with ESI might make a difference. Obesity and emotional instability have been linked with poorer results using ESI. Sometimes outcomes are significantly worse when patients have both stenosis AND lumbar disc degeneration.

The possible explanations they offered included: 1) adding fluid from the injection to an already narrow spinal canal may make the symptoms worse instead of better, 2) the steroid drug may damage nerve roots, and 3) the injected substances (numbing agent and steroid) may be viewed by the body as “toxic” and cause direct injury to nerve cells and/or scar tissue to form around the nerve tissue.

In the end, from this study it looks like epidural steroid injection for lumbar spinal stenosis may not be the best way to avoid surgery. Future studies may be able to determine who would be a good candidate for ESI before surgery (and who should go from conservative care to surgical care without ESI). Until patient selection for ESI versus surgery is clearly determined, patients should be advised that choosing ESI to avoid surgery isn’t always the best option.

Aches and pains seem to be part of the aging process for many people. Hip pain is especially common but doesn’t always come from the hip so diagnosis can be tricky. Likewise, knee and lower leg pain must be evaluated carefully because the origin can be the lumbar spine or hip. Pain that begins in one body part or region but is felt somewhere else is called referred pain.

In this study from Chiba University, Graduate School of Medicine in Japan, orthopedic surgeons review 420 patient records looking for clues to sort out lower leg pain. With patients who have both lumbar spinal stenosis (narrowing of the spinal canal or openings for the spinal nerves) and hip joint osteoarthritis — finding the origin of the pain can be a challenge.

They start by knowing that referred pain is always a possibility. So the patient’s evaluation must include clinical tests that focus on the low back, hip, and knee. The surgeon knows the typical pain patterns but when there is pain along the lateral (outside away from the other leg) side of the lower leg requires some additional testing.

The surgeon has at his or her disposal imaging studies such as X-rays, myelograms, CT scans, and MRIs. These are helpful but when someone has both stenosis and hip osteoarthritis, it might be necessary to perform some nerve injections. In this study, of the 420 patients who had lower leg pain from lumbar spinal stenosis, only four had back or hip pain with lateral leg pain.

Those four patients received a lidocaine (a type of novocaine) injection around the spinal nerve at the L5 level. In all four cases, the pain went away. That might confirm the problem was coming from pressure on the L5 nerve root from the stenosis. Especially because they also received an injection of lidocaine into the hip joint without a change in their pain.

But surgery to remove bone from around the nerve and fuse the lumbar spine did NOT relieve their pain. These four patients did have hip pain but they also had low back and severe leg pain. Clinical tests of the hip (e.g., Patrick and Friberg tests) were negative. Tests for sciatica and vascular compromise (loss of blood supply to the lower leg) were also negative.

Six to 12 months later (without knowing for sure if the origin of the lower leg pain was coming from the hip), surgery was done to replace the diseased hip joint. And guess what? All four patients experienced complete and long-lasting pain relief. How do the surgeons explain these results?

Anatomic studies in animals have shown that messages via the L4 to S1 level nerves do go to the posterior area of the hip capsule. In other words, it is possible that hip joint pain is transmitted along the L5 spinal nerve. This may be why the spinal nerve injection at L5 relieved the pain.

But if the pain was really coming from the degenerated hip, then why didn’t the lidocaine injection into the hip joint provide pain relief? The authors do not know but suspect perhaps there are central mechanisms, a term used to describe pain messages that are transferred via the spinal cord to the brain. Once the pain message is sent along this pathway, the body doesn’t seem to know how to turn the message off — even when pressure is
removed from the nerve.

The authors conclude by suggesting that lower leg pain can be a challenge to diagnose and treat effectively in older adults who have both lumbar spinal stenosis and hip osteoarthritic degenerative changes. Either or both problems can cause referred pain to the lateral lower leg area. Step-by-step evaluation is recommended with conservative care first before considering surgery. The decision to do surgery (lumbar spine decompression versus hip replacement) remains a challenge without clear guidelines to follow.

Mechanical low back pain continues to confound health care professionals and researchers alike. Efforts to understand causes, effects, and find the best treatment are ongoing. In this study from Sweden, physical therapists compare the usefulness of two specific tests of disability: fingertip-to-floor and straight leg raise tests.

Both tests have been shown to measure a specific physical disability. But is either test a better measure of treatment outcomes? Can physical therapists use these tests to predict who will get better and by how much? That is a broad question when dealing with all low back pain patients. So they narrowed their focus to a subgroup of just patients with radicular pain (back pain with pain down the leg).

Each of the 65 patients in the study was diagnosed with acute or subacute low back pain (meaning their painful symptoms were fairly new: less than 13 weeks). Disability was measured using a well-known self-reported survey (the Roland Morris Disability Questionnaire or RMDQ).

The RMDQ assesses daily activities on a scale from no disability to severe disability. Everyone filled out the questionnaire at the beginning (baseline), after one month, and after one-year. Each patient also had a positive slump test to verify the presence of radicular pain. And a measure of fingers-to-floor was taken for each one.

As the name suggests, the fingers-to-floor test is done in the standing position. The person bends as far forward as possible reaching toward the floor with the fingers. The number of inches or centimeters from the tip of the index finger to the floor is the test result.

The slump test involves assuming a “slumped” position: sitting with spine flexed forward (bent over) and head and neck forward flexed (chin to chest). Once in this position, the therapist directs the patient to lift and straighten the leg with ankle dorsiflexion (toes pulled toward face). Reproducing pain down the leg is a positive slump test. It is an indication that the sciatic nerve is being stretched or compressed (though it does not reveal the cause of the nerve tension).

In the meantime, everyone was treated by one physical therapist for an average of six sessions. Some patients had as few visits as two while others had as many as 16. The therapist described the techniques used as including the McKenzie method (specific movements and exercises), manual (hands on) therapy, and stabilizing (core training) exercises.

There were two major findings from this study. First, change in fingers-to-floor was associated with improvements in daily function (as measured by the Roland Morris Disability Questionnaire). Second, patients who had improvements in the fingers-to-floor measurement in the first 30-days of treatment had the best long-term results.

The authors of this study direct their final thoughts to physical therapists evaluating and treating patients with acute or subacute mechanical low back pain. They suggest using the slump test to find the subgroup of patients with radicular pain. They suggest using the fingers-to-floor as a measure of change and a predictor of who will improve with treatment. The fingers-to-floor is a more valid test to predict change in disability over time than the straight leg raise test.

Adults suffering from pain, loss of function, and poor quality of life have three basic treatment options: conservative care and rehabilitation, spinal fusion, or the newer option of disc replacement. In order to find out how to advise their patients, surgeons from The Netherlands conducted an extensive survey of the published studies comparing these three approaches.

Current clinical practice seems to be moving away from spinal fusion and more toward lumbar disc replacement for symptomatic degenerative disc disease. The implants were first invented and designed to help with the problem of adjacent spinal disease that often occurs at the level above or below a fused segment.

But do they really protect the spine as intended? That’s one question that needs to be answered. They are expensive and long-term results are limited. So before surgeons shift completely from fusion to disc replacement, it’s a good idea to take a look at the current evidence.

After an extensive search on-line, the authors found seven studies that compared results of disc replacement, fusion, or rehabilitation. Combining all the patients in all seven studies, there was a total of 1301 people included. Only one of those studies really looked at rehabilitation.

Analysis of findings showed that patients improved no matter what type of treatment was applied. Patient satisfaction was greater in the group who had a total disc replacement. As intended, these implants did allow patients more natural motion.

But using a five-point criteria for assessing these studies, they found all had low quality evidence. None of the studies looked at subsequent adjacent segment disease, which is the main reason the implants were developed in the first place. The follow-up was two years or less, so long-term results aren’t really available. And many of the studies are funded by disc manufacturers, so there is a need for unbiased research without conflicts of interest.

The authors suggest strongly to orthopedic surgeons: be prudent in your use of disc replacements. Watch the reported results with a critical eye. Until high-quality studies with long-term results are available, it should not be assumed that “newer is better.” In other words, this new direction away from spinal fusion toward disc replacement hasn’t been adequately proven as the best approach.

What are the chances a professional athlete having a diskectomy will be able to get back on the playing field (or court) and how long does it take? These are the two important questions this study answers. The authors (orthopedic surgeons at a spine center) looked back at the medical records of 85 players who had this type of surgery for a herniated disc. This group of patients included football players, basketball players, baseball players, and hockey players.

It is understandable that a professional athlete facing this type of surgery wants to know up front, “How long is it going to take to heal and get back to the game?” No surgeon has a crystal ball to predict the exact answer. But the results of this study might help provide some guidance in at least giving estimates of average return time.

For all of the players in this study, diagnosis was made with MRIs. The surgery was performed using a microscopic technique after they failed to get relief or improvement with a nonsurgical approach. Each player had the disc removed from a single spinal level. The most common area injured was in the lumbar spine: either L45 or L5S1. L5S1 refers to where the last lumbar vertebra joins the sacrum.

As it turns out, return to sports is a progressive phenomenon. At the end of a year, there are many more back in action compared with the first three months. On average, it took the players in this study about six months to return to their preinjury level of participation.

To be more specific: half of the group returned to play after three months, 72 per cent at six months, 77 per cent at nine months, and 84 per cent at the end of one year (12 months). The authors report that from their study, the average chance of returning to sports after microdiskectomy in the lumbar spine was 89 per cent.

The researchers did take a look to see if the spinal level affected made a difference in return to sport rates: it didn’t. They compared sports to see if one type of ball player was likely to return sooner than another. Although more baseball players returned faster and more basketball players returned than in any other sport, there wasn’t a statistically significant difference.

The conclusion of this study was that surgeons counseling professional athletes about disc surgery can offer this information:

According to this new study from the University of Utah, early referral to physical therapy for mechanical low back pain is linked with: 1) lower overall health care costs, 2) fewer doctor visits, 3) less use of advanced imaging (CT scans, MRIs), 4) reduced risk of surgery and injections, and 5) decreased use of narcotic (opioid) medications.

The study was done by reviewing patient records from a national database of employer-sponsored health plans. Although the study was conducted by physical therapists, they had no influence on who among the 32,070 patients studied was sent to physical therapy (PT). They were just reporting trends observed from analyzing the data.

Of the 32,070 patients who were diagnosed with low back pain as the main complaint, seven per cent were referred to PT. About 1100 patients received early PT (within 14 days of their doctor visit). The remaining 975 patients were categorized as delayed PT. They were sent to PT between 15 and 90 days after the primary care index (first) visit.

To get a better sense of national trends, the researchers analyzed characteristics of the individual patients. They looked at age, sex (male or female), and copayment for the first medical visit for low back pain. They also compared insurance plans (PPO, HMO, POS, HDHP, other), employment status, and geographic area where the patients lived. PPO stands for preferred provider organization. HMO is a health maintenance organization. POS is point-of-service and HDHP refers to high-deductible health plan.

What they found was if you live in the Northeast or West (United States), are covered by a preferred provider plan, and not taking narcotic medications, then you would be more likely to see a physical therapist early in the episode of your back pain. With early PT, you would be less likely to have surgery or injections and the cost savings would be nearly $3,000.00.

A second feature of the study was to compare cost savings for patients depending on how they were treated. There are Clinical Practice Guidelines (CPGs) based on research evidence that dictate how patients with mechanical low back pain should be treated. Health care providers who follow those guidelines (guided exercise and self-management) were referred to as adherent.

The second category (nonadherent) described patients who received care outside the guidelines such as hot packs, cold therapy, ultrasound. Costs associated with care according to the Guidelines were lower than nonadherent care. Each patient in the adherent group (treated according to the Guidelines) saved (on average) $1,374.00.

In summary, patients receiving early physical therapy for low back pain (within two-weeks of the episode) are less likely to need more invasive treatment with injections or surgery. Costs are less compared with patients referred later, especially if treatment follows the current published Clinical Practice Guidelines. Type of health care provider/coverage is also a factor in who is referred to physical therapy for this problem (PPO referrals were greater than HMO).

The value of physical therapy in the treatment of low back pain remains an area of debate and study. This study did not examine which patients should be referred to physical therapy or the patient outcomes for those who were referred early versus late. Further studies are needed to help determine who should be referred and how soon after diagnosis.

Events that occur before, during, and after surgery can cause problems for patients. These factors are referred to as preoperative, intraoperative, and postoperative variables. Identifying such risk factors can help reduce the number of days patients are hospitalized with complications. And that translates into less pain and suffering and lower costs.

In this study, predictive factors are investigated for patients having a single-level spinal fusion of the lumbar spine. Just over 100 patients had a minimally invasive procedure using the transforaminal lumbar interbody fusion (TLIF) approach. One surgeon performed all of the fusions.

By looking back at the patients’ medical records, the surgeon and his team could see the patients naturally fell into two groups: those patients who were hospitalized for less than 24 hours (group one) and those who were in the hospital for more than a day (group two). But what made the difference between these two groups? That was the important question.

There are many, many possible reasons why someone might develop problems and need longer hospitalization. Age, sex (male or female), body size, use of narcotic medications to control pain, and general health are preoperative factors to consider. Type of anesthesia used, number of minutes under anesthesia, blood loss, blood pressure, and administration of fluids (e.g., crystalloids, colloids) are intraoperative factors. And pain, blood values (e.g., hemoglobin, hematocrit, creatinine), use of narcotics, and formation of problems such as blood clots, kidney failure, heart attacks, or breathing problems were the types of postoperative factors examined.

After analyzing all the data on each patient in both groups, there were a few helpful findings. Patients requiring more than 24 hours to recover had longer surgical times and higher use of narcotic pain killers before surgery. The longer operative time is important because the patient’s body temperature drops as a result of the anesthesia. Decreased body temperature has been linked with heart attacks, death, infection, and problems stabilizing blood.

This factor (longer operative time) is important for the surgeon to keep in mind. And also for the surgeon, another significant predictive factor of a longer hospital stay was the use of crystalloids and colloids and the ratio between them. These fluids are used to help keep the patient hydrated and replace fluids lost due to bleeding.

The longer the operative time, the more fluids are “pushed” so-to-speak. This finding suggests that a more “restrictive” use of fluids may be better than a “liberal” amount. And other studies have shown better postoperative results with fewer lung problems when lower amounts of fluids are given during the surgery.

Another finding from this study was labeled as “surprising” by the surgeon. Patients who used more (not less) narcotic medications before surgery had faster postoperative recovery and thus shorter hospital stays. This led to the thought that perhaps preoperative pain control is protective — keeping the nervous system from setting up a pain response to the surgery. If that is the case, surgeons can administer oral narcotics as more of a pre-emptive strike to lower the overall pain experience before and after surgery. The end result is a happier, healthier patient. A small financial investment before surgery (i.e., the cost of the drug) can mean a large (thousands of dollars) post-operative savings.

In summary, the surgical team can take some steps to improve results for patients undergoing a transforaminal interbody fusion of the lumbar spine. Narcotic use before surgery for better pain control, fluid balance during and after surgery, and careful attention to blood values after surgery (e.g., hemoglobin, creatinine) can help keep the hospital stay under 24 hours.