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First Report Comparing Spine Injuries During War on Terror

This is the first report published comparing penetrating with blunt spine injuries in U.S. servicemembers in Afghanistan and Iraq. High-velocity gunshot or shrapnel injuries to the spine entered into the Joint Theater Trauma Registry (JTTR) were included. Records were reviewed to find out more information such as demographics on the soldiers, mechanism of injury, location of injury, type of surgery done, and long-term injuries sustained.

This information is important to gather and analyze strictly from an historical perspective tracing trends and changes in wartime over the years. But more importantly, this type of analysis may help improve treatment for our injured soldiers who experience high-energy, penetrating injuries to the spine. Many of these wounds are extensive and cause multiple injuries that cannot be treated on the field of battle.

Although some servicemembers had both a penetrating and a blunt injury from improvised explosive devices (IEDs), only those individuals with one or the other were included in this study. Excluding patients with both types of spinal injuries allowed for a more direct comparison of one mechanism (blunt) to the other (penetrating). Injuries from C1 (top of cervical spine) down to the sacrum were included. Injuries to the coccyx (tail bone) were not included.

As the names suggest, a blunt injury occurs when the soldier is exposed to a blast from a bomb explosion. For those soldiers inside an armored vehicle, the force of the blast throwing them against the inside of the vehicle can cause a concussive (blunt) spinal injury. Penetrating injuries are more likely from gunshot wounds to the spine injuring the spinal cord.

These are not typical injuries seen in the civilian sector but rather, specific to military war-time efforts in Iraq and Afghanistan. Men are affected more often than women because fewer women are in direct combat roles compared with men.

Surgery to decompress the spine is more common in penetrating injuries of the spinal cord. With penetrating injuries from gunshot, there is a greater chance for significant damage to the spinal cord as the bullet tumbles and spins, picking up speed and force before impact. Current recommendations are to perform surgical decompression only when the servicemember is medically stable and does not have a complete spinal cord injury.

Neurologic recovery is less likely with penetrating spinal cord injuries. Both blunt and penetrating injuries often cause additional injuries to the head, face, chest, and abdomen. Of course, severing the spinal cord results in long-term paralysis. Death is a possibility but this database did not have information on the number of spinal cord injured-related deaths have occurred among US servicemen and women in the War on Terror.

Complications (mostly from surgery) affect up to 10 per cent of all servicemembers with spinal cord injuries. These include pneumonia, skin and wound infections, blood clots, and urinary tract infections.

The authors summarize by saying this study helped surgeons identify the two main mechanisms that contribute to spinal cord injuries in US servicemembers involved in Operation Iraqi Freedom and Operation Enduring Freedom. Understanding the need for surgery required by spinal cord injuries will help military medical personnel better plan for on-site triage, treatment, and transportation at the time of the injuries. Efforts to prevent long-term neurologic problems are another important outcome of this study.

They also saw from reviewing the records that surgeons involved in immediate care for these surgeons understandably do not chart details about the mechanism of injury and severity of bodily harm at the time of injury. Likewise, spinal cord injuries in servicemembers who die on the battle field go unreported. This means there is a loss of information that would otherwise be helpful in a retrospective (looking back) type of study like this one.

BMP is NOT Safe for All Fusion Patients

Since 2002 surgeons have had a special tool in their box of techniques for spinal fusion. And that is a substitute for bone graft called bone morphogenetic protein or BMP. Although more expensive, this product has two major advantages over bone taken from the patient: 1) patients no longer suffer pain and discomfort at the pelvic crest where donor bone has been taken from and 2) patients with poor bone growth due to diabetes or tobacco use can have a spinal fusion when necessary.

But now some serious complications and post-operative problems have been reported. So it’s time to take a second look at the safety of this bone substitute product. BMPs were first discovered in 1965 with more than 20 types now being studied. Only one (BMP-2) has been approved for use by the Food and Drug Administration (FDA) in spinal fusion surgeries.

When used as it was approved and intended, BMP stimulates safe and effective bone growth to aid in the fusion process. And that primary use for which it was intended is only anterior lumbar (low back) interbody fusion. Troubles begin when this product is used off-label such as for cervical (neck) fusion, especially anterior (from the front of the spine) procedures and posterior (from the back) lumbar fusion.

Massive soft tissue swelling, extra bone formation, seromas (fluid-filled pockets), and even cancer have been reported as emerging concerns with BMP-use. To aid surgeons in evaluating the real concern about BMP in spinal fusion, three surgeons from the University of Pittsburgh provide some perspective and insight into the safety issues that have come to light.

First, they suggest surgeons-in-training should all learn how to harvest and use iliac crest bone grafts. In other words, this type of self-donation should not be abandoned in favor of only using BMP. Second, BMP should be used as indicated until further studies expand its use. In other words, it should not be used as an off-label product. Third, surgeons are responsible to select patients carefully for spinal fusion. In other words, not everyone is appropriate for the primary surgical procedure. Surgical success is more likely when used for the right patients.

And finally, until perfected through studies, BMP should NOT be used in anterior cervical spine patients and certainly not for anyone who has a past (or current) history of cancer of any kind. Using BMP for the ease and convenience of the surgeon is not acceptable when there are safety concerns and risks of serious harm to the patient.

In summary, BMP has a high rate of fusion when used as intended (for lumbar spine fusions). But there is no evidence or proof of any kind that BMP is better than patient donor bone from the iliac crest in terms of fusion rate or outcomes (decreased pain). More long-term studies are needed before expanding the use of this product, to identify those procedures in which its use is both safe and effective, and to document potential complications.

Physician Referral Patterns to Physical Therapy

Physicians and physical therapists often work together to aid patients with low back pain (LBP). The optimal timing and pathway from physician to physical therapist remains to be determined.

In this study, therapists examine the type of physicians sending patients with low back pain to therapists and the outcomes of treatment. Type of physician refers to the type of medicine practiced such as the primary care physician, an occupational medicine physician, or specialist (e.g., orthopedic surgeon, neurologist, neurosurgeon, internal medicine).

The authors explored three things: 1) patient characteristics based on physician specialty, 2) link between physician type and patients’ final function, and 3) number of physical therapy visits (represents cost analysis). Patient characteristics included age, sex (male or female), level of activity and exercise, medications, and payer source. Other areas of interest also included how long the patients had their symptoms and length of time between physician examination and physical therapy referral.

After collecting and analyzing data on 7,971 patients, they found that physician referral does make a difference. Patients coming from primary care physicians and occupational medicine physicians had the best results. They finished therapy with more function, less pain, and in fewer visits compared with patients referred by other physician types.

A little closer look at the findings showed that patients who have higher function, who exercise at least three times a week, and who are covered by a health maintenance organization (HMO) or preferred provider organization (PPO) had better results at discharge. Patients with the poorest function were older, on Medicaid, and had a longer duration of symptoms.

Other studies have looked at outcomes based on patient work/employment status, type of insurance coverage (including worker’s compensation), and acute versus chronic low back pain. This is one of the first studies starting to look at patterns and sources of referral to physical therapy for this condition.

This study showed that referral source was associated with functional outcome and that patients referred by a specialist tended to have more chronic pain or a more complex clinical picture. Patients are referred sooner (during acute phase of pain) by occupational medicine physicians. That may explain why they respond better and faster compared with patients with chronic pain most often referred by specialist physicians.

The hope from studies like this is to facilitate patient referral from physician to therapist in order to improve patient outcomes. Earlier referral has been shown to reduce overall costs while helping patients reduce pain and improve function. Delays in referral with longer duration of symptoms and shift from acute to chronic status are linked with worse final outcomes.

The Economics and Treatment of Lumbar Spinal Stenosis

Spinal stenosis is an unfortunate condition associated with aging. Various factors combined together result in a narrowing of the spinal canal and openings for the spinal nerves to exit. Pressure on these sensitive nerve tissues causes low back (and often leg) pain and impaired quality of life. The personal and economic cost of this condition and what can be done about it are the focus of this review article.

Fortunately, many studies have been done to help surgeons identify the best way to treat this problem in older adults. The Spine Patient Outcomes Research Trial (called SPORT) has provided much of the evidence needed to provide effective treatment. And by effective, we mean both in terms of reducing pain and improving function as well as providing a cost effective treatment.

Let’s take a closer look at what is now known in terms of the management of this condition. The first step to managing this condition is usually conservative (nonoperative) care. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) are used to control pain and swelling.

NSAIDs combined with physical therapy may be all that some patients need. The physical therapist addresses posture, strength (especially core strength), and modification of activities. The therapist can teach patients positions and exercises to ease the symptoms. The therapist may use lumbar traction to gently stretch and lengthen the low back, taking pressure off the spinal nerves.

Some patients are given an epidural steroid injection (ESI). The spinal cord is covered by a material called 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 joints. This can reduce swelling and give the nerves more room inside the spinal canal.

When conservative care doesn’t work, then surgery may be advised. In fact, the results of the SPORT studies supports the use of surgery in such cases. When there is pain that doesn’t go away with nonoperative care, decreased quality of life, or loss of function, surgery may be the only answer. There are several different ways to approach the problem surgically. The most common technique is called decompression.

The surgeon performs either a laminotomy (shaving some of the bone away from the nerve tissue or removing a small amount of bone on one side of the lamina) or laminectomy (removing the bone from around the nerve tissue). The lamina is the covering layer of the bony ring of the spinal column. It forms a roof-like structure over the back of the spinal canal. Decompressive surgery takes the pressure off the spinal nerves.

Although surgery of this type is expensive (estimated in the SPORT study to be $77,600 per quality of life year), the gains made in pain control and improved health were worth it to the patients. Two years later, patients who had the surgery were still reporting positive results from the procedure. When the cost is spread out over the long-term, the economic benefit becomes clear.

There is one other minimally invasive surgical procedure for lumbar spinal stenosis still under investigation. A device called the X-STOP®. The X-STOP® is a metal implant made of titanium. The implant is inserted through a small incision in the skin of your back. It is designed to fit between the spinous processes of the vertebrae in the lower spine. It stays in place permanently without attaching to the spinal bone or ligaments.

There are several advantages of the X-STOP®. It can be inserted using local anesthesia on an outpatient basis. A small incision is made so the procedure is minimally invasive and no bone or soft tissue is removed. The implant is not close to nerves or the spinal cord. With the implant in place, the patient doesn’t have to bend forward to relieve painful symptoms. The X-STOP® keeps the space between the spinous processes open. With the implant in place, it is possible to stand upright without pinching the spinal nerves.

Research shows that these implants don’t work well for patients with severe stenosis. No improvement and a high revision rate have been reported for patients with severe stenosis. A 73 per cent satisfaction rate has been reported in patients with mild stenosis. And comparing use of the X-STOP® with no treatment has also been shown effective for the patients with the implant.

The problem of a degenerative spine resulting in stenosis is not one that is going to go away anytime soon. With the aging of our Baby Boom generation, surgeons can expect to see more (not less) of this condition.

Studies like the SPORT study will help guide treatment by showing the effectiveness of surgical management. Whereas the high cost of surgery may put some people off, the positive long-term results are very convincing. Nonsurgical care is the first line of treatment but patients should be told that it is not the end-of-the line, so-to-speak. Minimally invasive, surgical approaches are effective for many people at a cost that becomes “affordable” when pain is relieved, function is improved, and quality of life is restored.

Rare But Important Risk After Spine Surgery

If you have ever had surgery of any kind or even known someone else getting ready for surgery, one thing is always discussed preoperatively. And that’s the possible complications. Though most post-op problems are uncommon or even rare, it is still the responsibility of the health care provider to review all possibilities with patients. Infection, blood clots, heart attacks, stroke and even death are all listed for major spine surgery.

In this study from Taiwan, the risk of stroke following spinal fusion surgery is investigated. Taiwan has a unique study situation in that the entire one million population is covered by a government-run health insurance. Everyone has free and unlimited access to health care even if they are traveling or out of their own country and receive treatment overseas.

This type of system makes follow-up easier and more predictable. Even if a patient in a study like this goes somewhere else within the system, the records are still available for follow-up. Therefore, incidence rates calculated tend to be more accurate and estimates of stroke risk more reliable.

Out of one million people, there were 2,249 who had spinal fusion. This group was matched with a very similar group of 2,203 adults who did not have spinal fusion. When we say the groups were “matched” closely, it means they were the same ages, gender (male versus female), education level, income level, and living location (rural versus urban). They were also very similar in terms of general health and the presence of other health problems such as diabetes, high blood pressure, heart or lung disease, and so on.

The rates of stroke during a three-year follow-up were compared. They found no differences between the two groups (those who had spinal fusion surgery and those who did not). In fact, the spinal fusion group had slightly (though not significantly) lower rates of stroke.

The authors suggest some possible reasons for these results. Stabilizing the spine reduces pain and improves function. Patients who were previously inactive or sedentary because of back pain can increase their activity and exercise after spinal fusion. This effect could reduce the risk of stroke. Patients with health problems like diabetes or heart arrhythmias are treated for these problems before surgery. Controlling conditions like these that can contribute to stroke may be another preventive factor.

People who smoke or use tobacco products are asked to stop prior to surgery. Some may not go back to this habit, thus improving their chances of better health afterwards. And surgeons do screen patients before surgery in order to select those who are more likely to have a positive result. Anyone with significant health problems may not be accepted for surgery. The healthier and more active someone is before surgery, the more likely they will have fewer complications and better results after surgery.

In summary, this was the first study to evaluate the risk of stroke after spinal fusion surgery. They did not find an increased risk of stroke. In fact, they report that stroke as a postoperative complication is rare following spinal fusion. It is possible to conclude that patients at increased risk for stroke should not be kept from having spinal fusion surgery if they need it. The positive results from the procedure (including increased activity and exercise) could improve their overall health and reduce risk for many other health conditions.

The authors point out several areas for future study related to this topic. First, there are many different ways to perform spinal fusion. There are different spinal levels and number of levels fused. These factors may affect how long someone is in surgery, how much blood is lost, and postoperative recovery. Any of these variables may influence the risk of stroke or other complications and should be investigated.

Likewise, as improved surgical techniques are developed, it has become safer for a larger number of older adults to have spinal fusion surgery. The increased age of patients having spinal fusion surgery may change the incidence of stroke following this procedure. Future studies are needed to keep an eye on this possibility as well.

Neck and Back Pain: How Much Is It Costing Us?

Public health policies are influenced by the kinds of health problems Americans report. Evidence from research is a second driving factor in how common conditions like neck and back pain are treated. One way to reduce medical costs is to analyze where money is being spent and look for trends in care and utilization of medical services.

Treatment of back and neck (spine) problems accounts for billions (not just millions, but billions) of dollars every year. Low back pain alone accounts for 90 billion dollars in diagnosis and treatment. It is estimated that another 20 billion can be chalked up to lost wages and lost productivity. And those figures don’t include similar costs associated with neck pain and problems.

Given that up to 80 per cent of all adults will have back pain at least once (and often more than once) in a lifetime, this problem has grabbed the attention of health care policy makers. It’s their job it is to hold costs down without compromising care or outcomes (results).

When care exceeds recommendations made based on evidence, then health care policy makers get concerned. In this report, money spent on spine problems (including both the neck and back) is linked to specialty services that don’t necessarily improve results. Expensive MRIs and other imaging tests, referrals to orthopedic surgeons and neurologists, visits to the emergency department, and unnecessary lab testing make up some of the specialty costs that might be considered unnecessary.

In addition to expanded diagnostic tests thanks to improved technology, more aggressive marketing of medical supplies has driven some costs up. And the rising costs of care associated with these services don’t come with improved results.

On the other hand, dollars spent on spine care provided by general practitioners (GPs), chiropractors, and physical therapists have not gone up. This is contrasted with evidence that these services provide improved outcomes. Future research is needed to determine what is the most cost effective treatment (i.e., least cost and most benefits).

With the continued rise in health care costs, finding ways to improve results of treatment for spine problems (again, at a lower cost) is important to health care policy makers. It may be necessary to limit patient access to specialty care by restricting (rather than expanding) reimbursement. Policies that encourage better reimbursement can be put in place as more research is done to identify effective spine care.

Why Do Spinous Process Fractures Occur in the Spine After X-Spacers?

In this study, surgeons at Tufts University School of Medicine discover an important reason why half of their patients receiving an X-STOP® device end up with a fracture of the spinous process.

The X-STOP® is a metal implant made of titanium. It is a minimally invasive procedure for the treatment of mild lumbar spinal stenosis (LSS). The implant is inserted through a small incision in the skin of the low back. It is designed to fit between the spinous processes of the vertebrae in the lower back. It stays in place permanently without attaching to the bone or ligaments in the back.

Spinal stenosis describes a clinical syndrome of buttock or leg pain. These symptoms may occur with or without back pain. It is a condition in which the nerves in the spinal canal are closed in, or compressed. The spinous process is the piece of bone that sticks out behind the vertebra. It is the bump you feel down the back of your spine.

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. This helps explain why lumbar spinal stenosis (LSS) is a common cause of back problems in adults over 55 years old.

The X-STOP® procedure has been very successful for carefully selected patients with LSS. And now, thanks to this study, surgeons may be able to screen patients for a specific risk factor that is associated with spinous process fractures after X-STOP® surgery. The single factor predictive they discovered for spinous process fracture was the presence of lumbar spondylolisthesis.

Spondylolisthesis describes a condition in which one lumbar vertebra has slipped forward over the vertebra below. This slippage causes a narrowing of the spinal canal and traction (pulling) on the nerve tissue. Although their study was small (only 39 patients), the high rate (52 per cent) of spinous process fractures after X-STOP® implantation was significant.

The surgeons aren’t exactly sure why spondylolisthesis would increase the risk of fracture. They suspect that the change in alignment with the vertebra shifted forward may have something to do with it. The contact points (where the implant rests against the spinous process) may be further back in patients with spondylolisthesis. This placement is against a weaker part of the spinous process contributing to fracture.

Other factors explored for potential cause of fractures included patient age, gender (male or female), body mass index (BMI), and bone density. The researchers did not find any difference in these risk factors between patients with fractures and those without. Surgical level and number of levels treated were also evaluated for possible links to fracture risk. There weren’t enough patients in the study to make any firm conclusions about these two possible risk factors.

In summary, stenosis and spondylolisthesis in the same patient may be a reason NOT to use the X-STOP® device. The high rate of spinous process fractures as a complication of the X-STOP® procedure may be a reason to try a different surgical approach. In fact, the presence of spondylolisthesis in anyone with lumbar spinal stenosis may be considered a contraindication for this device. Contraindication means a reason not to use these implants.

The authors suggest future studies address the following concerns: 1) this was a small study; results may be different with a larger group, 2) the fracture rate was consistent no matter which type of X-STOP® was used. So it’s not likely to be caused by the implant itself but may be the way it is inserted; this should be further investigated, and 3) perhaps there are other biomechanical or patient factors responsible for these results. More study is needed to explore these concerns.

One final note of importance: fractures of the spinous process did not show up on X-rays for any of the patients who did, in fact, have a spinous process fracture. CT imaging was needed to truly see fractures of this type.

Results of Three Different Surgical Techniques for Cervical Spine Fusion

Patients faced with a fusion procedure of the cervical spine (neck) for degenerative spine disease have several options to choose from. Fortunately, the surgeon will guide each person through the process. But who guides the surgeon in selecting the “just right” or “best” procedure for the patient?

They rely on high-quality studies published in the last few years. By keeping abreast of the latest medical and surgical journals, surgeons can benefit from tips offered by other surgeons or reports of trends in treatment results.

In this study from Prague (Czech Republic) three interbody fusion techniques are compared: 1) autograft stand-alone, 2) autograft with anterior (front of the spine) plate, and 3) polyetheretherketone (PEEK) cage filled with betatricalcium phosphate and supported by an anterior plate. Each of these approaches has its own benefits and disadvantages, which the authors discuss in detail. They also provide a written description of each procedure technique (no photos or drawings included).

The main purpose of cervical spine fusion is to stabilize the spine in order to reduce pain. Each of these three methods accomplishes this task in slightly different ways. And as this study shows — with slightly different results measured at the end of two years. Let’s take a closer look.

Briefly, group one had the disc removed (discectomy) and bone graft from the pelvis packed into the front of the empty disc space. Group two had the same type of discectomy and the same graft technique but with the addition of a metal plate screwed into the front of the vertebrae. Group three had a discectomy and instead of a bone graft pack, a metal cage filled with bone material was placed in the disc space. Group three also had an anterior plate.

In all cases, the fusion was successful. That’s good! But what about the neck pain, neurologic function, and pain that typically occurs at the fusion donor site? Well, at first everything was the same among all three groups. But over time, there were some differences that developed.

For one thing, the stand alone grafts (Group one with no reinforcing anterior plating) started to lose height in the spine. This was compared with at least 10 per cent more height gained and maintained in the other two groups. In general, the overall results in group one (remember, this is the stand-alone graft without plating) were worse with lower patient satisfaction compared with the other two groups.

In group three, the artificial bone graft gave just as good of results as the two groups with real (human) bone material. That is good news because scientists have been working a long time to find a successful substitute for human bone. Substitute bone eliminates the long-term pain and discomfort that often occurs with bone graft taken from the patient’s hip.

And there’s an added benefit of interbody (between vertebral bones) cages. Cages used in between the vertebral bones support the load and maintain spine height. In this study, results were even better with the added plate along the front of the spine (present in groups two and three).

Until a better stand-alone technique is found, anterior plating will continue to be used in cervical spine fusion procedures. The goal for the future is to develop a cage or other fusion device that doesn’t require the additional plating. This would decrease or even eliminate problems with plating such as difficulty swallowing and degeneration that often occurs at the spinal level next to the fused area.

MRI For Low Back Pain: When Is It Too Early?

Workers who have an acute low back injury with pain while on the job are often anxious to get back to work. Current Clinical Practice Guidelines (CPGs) recommend that only certain patients require X-rays. This is also true for other imaging studies such as MRIs in the first six weeks after injury. Even so, research shows a high rate of early MRI among Workers’ Compensation patients.

This is the first study to look at factors that might account for the early use of imaging for injured workers. Over 1,800 working adults who filed a claim for a back injury were included. All kinds of data about the workers was collected and analyzed. For example, age, race/ethnicity, level of education and income, and marital status were some factors considered.

Other characteristics that might influence the decision for early imaging were also considered. These included general health, job satisfaction, previous Worker Compensation claims, and type of employment. And finally, information on injury severity, level of pain, and patient-reported disability were also evaluated.

As it turns out, the authors of this study were able to identify what they called red flags for serious back pain. These are patients who are more likely to need early imaging studies. Age (younger than 20 and older than 50) was one important clinical characteristic. Spinal tumor, bone fracture, or infection were the main concerns. Any other signs or symptoms common with these three conditions were also considered red flags.

A second important finding from this study was more specific to the question of: Who is getting an early MRI for acute low back pain? The answer: men, workers with high levels of fear of reinjury, and greater injury severity and disability. Workers who had the lowest rate of early MRIs were first seen for their low back pain by a chiropractor. In contrast, workers who went to a medical doctor (general practitioner, neurologist, or orthopedic surgeon) were the most likely to receive an early MRI.

How did the authors explain their findings? First, some medical doctors routinely order MRIs right away — even though current evidence doesn’t support this practice. Second, chiropractors rely on X-rays taken in their offices rather than on MRIs provided somewhere else. And third, workers who are afraid to go back to work for fear of reinjury make up a large percentage of patients who have an MRI for an acute episode of injury-related back pain.

The results of this study point out again that medical costs can be lowered by following evidence-based recommendations. All physicians have access to the Clinical Practice Guidelines (CPGs) on Low Back Disorders published by the American College of Occupational and Environmental Medicine. In the case of mechanical low back pain from acute injury, conservative care is recommended. Early imaging is not advised unless there are red flags or neurologic signs and/or symptoms.

Exercises for Neck Pain

Physical therapists often work with patients who have chronic neck pain from minor injuries. Most often, serious athletes and “wanna be” athletes (also known as “weekend warriors”) are affected. These are folks with minor sprains, strains, or contusions who develop loss of motion and motor control — sometimes without realizing it. Pain and stiffness are the two symptoms noticed first.

Exercises have been developed by therapists to help improve neck mobility, endurance, and strength. In this article, one therapist from the University of Wisconsin – La Crosse provides a written and visual summary of these exercises. Photographs showing specific positions and techniques are included.

The exercises go beyond just the basic pain relief and restoration of motion and function. There are deep neck muscles that can still be misfiring or not contracting at all. Neck stability and even vision depend on the finely coordinated activities of neck muscles, eyes, and cervical vertebrae (neck bones). Exercises to improve recruitment of the cervical muscles to address these more subtle and sometimes hidden deficits are also included.

The therapist will guide individual patients through an exercise program specific to that person. It’s not a good idea to just jump into an exercise routine and go full tilt ahead. The neck is especially a sensitive and delicate area that can be easily over stretched and flared up. The author provides the therapist with some reminders and guidelines for progressing exercise intensity, volume, and frequency.

Other areas must be assessed and addressed, too. For example, shoulder and trunk muscles might be involved requiring attention. Weakness in the muscles of these structures can contribute to neck pain. In some cases, the patient holds his or her head at an angle without even realizing it. They may have lost the natural function referred to as head/neck repositioning acuity. There are exercises to improve these deficits as well.

And finally, the therapist working with athletes will prescribe exercises that are sport specific, in other words, a program that will prepare the athlete for activities required by their sport. Changing speed quickly, agility to sprint easily, and the strength and endurance needed for the entire game or set all require different exercise programs.

In summary, anyone with neck pain (whether a top athlete, weekend warrior, or nonathlete) can benefit from specific exercises to address the problems they are facing. Pain, stiffness, loss of motor control, poor muscle contraction, and even dizziness can be addressed with exercises to improve repositioning acuity and postural stability.

Trigger Points as Pain Generators in Chronic Whiplash

One way to break the pain-spasm cycle of chronic whiplash known as whiplash-associated disorders (WAD) is to treat the trigger points in the muscles. This is the finding of a new study from the University of Granada Department of Physical Therapy in Spain.

Trigger points (TrPs) are hyperirritable spots in the muscle caused by muscle immobilization (e.g., in a cast or splint or in response to pain after an accident) or overuse (repetitive motion). When active, these points create painful muscles and limited range-of-motion. Trigger points develop along with whiplash-associated disorder as a result of something called central sensitization.

Central sensitization is a hyperexcitability of the central nervous system. In other words, when present, TrPs “revv” up the engine of the nervous system and it doesn’t slow down when the foot is taken off the accelerator. But there may be more to it than that as some research has shown a bidirectional mechanism. Input from TrPs to the nervous system increase pain sensitivity and vice versa. Increased sensitivity of the nervous system to stimuli may actually create the TrPs.

To understand more about the role of TrPs in whiplash-associated disorder (WAD), this group of physical therapists compared two groups of patients. Group one had a high level of whiplash-associated disability from a car accident that occurred in the last 30 days. Group two were sex- and age-matched controls who did not have a whiplash injury.

Everyone was tested for TrPs in the neck, face, and upper shoulder areas. Active neck motion was recorded and the participants rated their pain and disability. Pressure pain threshold (PPT) was also measured on both sides of the neck at C56, the second finger, and the tibialis anterior muscle of the lower leg/ankle. Pressure pain threshold is a measure of how much pressure it takes to create a painful response. Small amounts of pressure that result in high levels of pain is referred to as pressure pain hypersensitivity.

They found four major discoveries: 1) People with higher levels of neck pain were more likely to have trigger points and more of them. 2) The number of days from the accident was a factor. 3) Decreased neck motion was linked with TrPs. But which came first (the altered neck motion and then the TrPs or the TrPs and then the decreased neck motion) remains unclear. 4) Higher pressure pain sensitivity over the cervical spine (neck) is linked with more trigger points.

These findings support the idea that active TrPs generate pain in people with neck pain from a whiplash injury. The natural conclusion is that treating TrPs may be one way to reduce pain for individuals with whiplash-associated disorder. Future studies are needed to test out this theory.

Not all face, neck, and shoulder muscles were tested in this study so further studies are also advised to search for all likely TrP areas. Other factors that must be studied in relation to whiplash-associated disorders and trigger points (TrPs) include the influence of the joints, psychologic effects from the accident, and posttraumatic stress.

Technical and Metabolic Risk Factors Found in Vertebral Compression Fractures

Severe pain, loss of mobility and independence, disability, hospitalization, depression, and decreased quality of life are all possible consequences of vertebral compression fractures. Even with today’s improved treatment for this problem, one out of every five adults who experience a vertebral compression fracture will suffer another one within the next 12 months.

What can be done to stop this potentially devastating health problem? Vertebral compression fracture refers to a mini-collapse of a vertebra in the spine. Tiny fracture lines in the bone (usually the front half of the vertebra) result in the bone taking on a wedge- or pie shape when viewed on X-rays from the side.

This type of fracture is most common in older adults who have osteoporosis (decreased bone mass or brittle bones). Just the weight of the body and pressure from postural changes (stooped head and shoulders) can put enough pressure (or compression, hence the name compression fracture) on the bone to cause a collapse.

It makes sense then to explore ways bone metabolism might contribute to the development of vertebral compression fractures. One specific measure that can be used is the level of vitamin D, a vitamin known to be important in the building of strong bones.

In this study, researchers from the Athens, Greece Laboratory for the Research of Musculoskeletal System take a closer look at the role of hypovitaminosis D as a risk factor for second (or third) vertebral compression fractures in postmenopausal women after having a kyphoplasty procedure. The balloon kyphoplasty procedure is designed to restore height of the fractured and collapsed vertebra.

Two long needles are inserted through one or both sides of the spinal column into the fractured vertebral body. These needles guide the surgeon while drilling two holes into the vertebral body. The surgeon uses a fluoroscope (special 3-D real-time X-rays) to make sure the needles and drill holes are placed in the right spot.

The surgeon then slides a hollow tube with a deflated balloon on the end through each drill hole. Inflating the balloons restores the height of the vertebral body and corrects the kyphosis deformity. Before the procedure is complete, the surgeon injects bone cement into the hollow space formed by the balloon. The cement is injected a little bit at a time until the cavity is filled. They try to keep most of the cement in the front three-fourths of the vertebral body. This fixes the bone in its corrected size and position and supports the front part that has collapsed the most.

This procedure halts severe pain and strengthens the fractured bone. However, it also gives the advantage of improving some or all of the lost height in the vertebral body, helping prevent or correct kyphosis. It does not, however, prevent a second or subsequent fracture from occurring at the next (adjacent) level. In fact, there is some concern that the kyphoplasty might actually increase the risk of another vertebral compression fracture.

Another possible reason for recurrent vertebral fractures is bone metabolism. Decreased bone mineral density from altered bone metabolism may be an important risk factor in compression fractures. To test this idea out, these researchers measured bone mineral density and bone turnover after 98 kyphoplasty procedures performed in 40 women. Blood levels of calcium and phosphate were measured along with parathyroid hormone levels (important in maintaining good calcium levels in the blood) and vitamin D.

Patients who developed a second vertebral fracture were compared with those who did not. X-rays were taken at regular intervals during the first 18 months after the kyphoplasty procedure. Other possible variables were evaluated, too such as age, body mass index, history of tobacco use, and the use of antiosteoporosis medications.

Bone mineral density was not statistically different between the two groups. Even so, 22.5 per cent of the entire group developed a second compression fracture. What made the difference between the two groups (those who did fracture versus those who did not)?

The women who did experience further fractures had lower levels of vitamin D (metabolic factor) and experienced cement leakage (technical factor) into the disc area from the first kyphoplasty. The cement increases how stiff the treated vertebra becomes, which then increases the load placed on the next vertebra. The women who did NOT have a second compression fracture were more likely to be taking calcium and Vitamin D supplementation along with antiosteoporosis medication.

The authors suggest two things as a result of their findings in this study. First, patients with vertebral compression fractures should be evaluated for bone metabolism before treatment begins for the fracture(s). Other risk factors for possible recurrent fractures should be noted (e.g., decreased vitamin D levels). And every effort should be made to prevent cement leakage during the procedure.

Returning to the Operating Room After Spinal Surgery

It’s an unfortunate fact that patients can end up back in the hospital after spinal surgery. Sometimes there’s an infection that must be taken care of. In other cases, implants used to hold the spine together during the healing/fusion phase have to be revised. Medical complications such as blood clots, heart problems, breathing difficulties, or gastrointestinal problems can also bring patients back for early readmission after surgery.

In this study, surgeons from New York University Hospital for Joint Diseases went back through their patient records for a two year period of time to see how often these unplanned readmissions occurred and why. Patients included in the study had one of 12 common spine procedures (e.g., spinal fusion, kyphoplasty, laminectomy). There were a total of 3673 people operated on with 156 of these patients requiring return to the hospital. That works out to be a 3.8 per cent overall readmission rate.

Most of the readmissions (90 per cent) were unplanned. In the remaining 10 per cent, the patient was scheduled for a two-part (staged) procedure and came back for the second surgery. Lumbar stenosis (narrowing of the spinal canal) and disc herniation were the two most common problems patients were being treated surgically.

Taking a closer look at the data collected, the authors divided the readmissions into two groups: those who had surgical complications and those who had nonsurgical complications. Infection was definitely the biggest problem for both groups.

Surgical complications occurred most often in patients who had more spinal levels fused (average of six spinal segments). There were difficulties with implants (plates, screws) caused by infection or wound drainage in a smaller number of patients. Nonsurgical complications were most often related to GI problems and systemic illness with a few cases caused by heart, lung, or neurologic conditions.

The next step is to find ways to reduce early readmissions following spinal surgery. A closer analysis of all the factors present in patients who do go back to the hospital might reveal some helpful clues. For example, there may be certain aspects of the surgical procedure that is contributing to the high rate of infection. Or patient factors such as general health, pre-existing conditions (heart disease, cancer) and obesity may make a difference.

In addition to screening patients more carefully before surgery, closer postoperative monitoring may be a useful way to reduce readmissions. The data from this study do support the idea that medical complications after surgery are a big factor. And this may be one cause hospital staff can change with coordinated efforts and planning.

Relationship Between Low Back Pain and Metabolic Syndrome in Japanese Adults

Is there a link between metabolic syndrome and low back pain? Any condition that can reduce or restrict physical activity has the potential to contribute to weight gain, diabetes, and low back pain. In this study from Japan, researchers investigate the relationship and prevalence between metabolic syndrome and low back pain.

Metabolic syndrome is a combination of medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes. Different groups (e.g., American Heart Association, International Diabetes Federation, National Cholesterol Education Program) have varied criteria to define metabolic syndrome. Most at least include these three: 1) raised blood pressure, 2) central obesity (increased waist circumference), and 3) abnormal cholesterol levels.

Residents from two cities in Japan between the ages of 40 and 74 were included in the study. Anyone in the group of 2,650 people who reported low back pain lasting more than 24 hours or severe enough to seek medical help were placed in a group for analysis. The low back pain group was then compared to the group of individuals who did not report any low back pain.

The researchers collected many pieces of information about each person in the study to use when analyzing risk factors for low back pain. Body mass index, smoking status, alcohol use, general health, and level of physical activity were included. Sex (male or female), occupation, and a test for depression were additional bits of data collected.

Statistical analysis showed that obese women with metabolic syndrome were more likely to develop low back pain compared with obese men with metabolic syndrome. This difference looked more like a tendency toward low back pain among women than a significant trend.

Why the difference between men and women? Scientists suspect female-specific hormones and menopausal status have something to do with it. Women who are postmenopausal are also older, have reduced estrogen levels, and elevated blood pressure. Lower estrogen levels also contribute to decreased bone density, which in turn, can lead to low back pain.

The authors couldn’t say for sure that low back pain is a factor that leads to the development of metabolic syndrome. Nor could they prove the opposite: that metabolic syndrome leads to low back pain. Their study does show that metabolic syndrome occurred more often in the women in their study who did have low back pain.

They conclude that women who have low back pain should be evaluated for the presence of metabolic syndrome. Treatment to address the metabolic problems may contribute to protecting and restoring normal musculoskeletal function among Japanese adult women.

The Cost Of Other Health Problems After Spinal Surgery

Many people in need of spinal surgery also suffer from other health problems such as high blood pressure, diabetes, cancer, obesity, neurologic problems and many others. These additional conditions are referred to as comorbidities. Patients often have more than one comorbidity. And then there are the complications that can occur after surgery. Comorbidities and complications take their toll on patients but can also add quite a bit to the hospital bill and cost of health care overall.

In this study from the University of Pennsylvania, the effect of comorbidities and complications (both minor and major) are examined. The researchers determined which problems are the most significant but also looked at the costs. You may not think someone else’s problems after surgery affect you, but as a taxpayer, many of these costs come from folks on Medicare. From a societal perspective, these costs are paid for by me and you. And that makes it everyone’s business.

Before looking at the specific results of this study, consider some of the points the authors make. First, the number of people seeking treatment for spine problems is increasing every year. So is the age of the patients looking for help. Along with an increased number of older adults in need of spinal surgery, there has been a steady rise in health care costs. The complexity of many procedures has also increased, which also pushes costs higher.

Efforts are being made to contain costs. Hospitals, private payers, and government are starting to take a closer look at what’s going on and how to cut costs. This study is an example of those efforts. The focus here is on patient characteristics that affect the cost of spinal care. Along with known risk factors such as obesity and smoking, other areas of health concerns were included.

Data on 226 patients undergoing spinal surgery for a variety of reasons was collected. Age, sex (male or female), body mass index (BMI, an indicator of obesity), number and type of comorbidities, type of procedure, and type and number of complications were reported and analyzed.

They found that although high blood pressure (hypertension) was the most common comorbidity, the problems that caused the most difficulty were pulmonary (blood clots, pneumonia), improper positioning of hardware used in spinal fusions, new neurologic problem (caused by the surgery), and wound infection.

Costs started escalating when a problem developed as a result of being in the hospital. This is referred to as a hospital-acquired condition or HAC. Those additional costs spiraled upwards as complications increased in number or severity. Longer hospital stays require more care and greater use of resources. The result is an increase in the cost to insurance companies (or payers like Medicare). Likewise, when the costs are greater than the reimbursement, then hospitals take a financial hit, too.

The question arises: should patients with multiple health problems be refused surgery? This study actually shows that the majority of problems were caused by the hospitalization and/or the surgery itself. And many of the problems required an additional surgery further raising costs associated with hospital acquired conditions.

What can be done to change all this? The authors do not offer any immediate solutions. They suggest the move to electronic medical records will make it possible to track costs and risk factors more closely. Likewise, any interventions applied to the problem can be analyzed to find the most efficient and effective course of action for each problem. Being able to identify patients at risk and predict the likelihood of a complication may help target those patients for prevention. As this study shows, much of the burden for change lies with improving internal measures (e.g., surgeon technique, hospital care) to reduce complications.

What’s Happening with Cervical Disc Replacements?

Much has happened in the last few years related to disc replacements for the neck called cervical disc arthroplasty. The first FDA-approved studies on the subject have been published for three different devices: the Prestige System, the ProDisc-C system, and the Bryan disc. Since the first cervical disc replacement didn’t come out until 2007, the results so far are fairly limited. Later implant systems weren’t available until 2009, so research data is fairly limited as well.

What do we know so far? Short- and mid-term results are very favorable. Patients are able to get pain relief and return of motion and function. Results are measured using a specific Neck Disability Index (NDI) and assessment of neurologic function after surgery. A report of any adverse events, implant failures, or need for a second surgery is also reviewed.

One of the key areas of interest in these studies is the rate of adjacent-level degeneration. There is a belief and hope that disc replacement will reduce the risk of deterioration at the spinal level above and below the new disc. Disc replacements allow for continued neck motion so that force and load transmitted through the neck are not transferred to the adjacent segment.

It is believed that this scenario is more likely after a fusion procedure (compared with a disk replacement). But proving that normal neck joint motion prevents or reduces adjacent segment degeneration remains a goal for the industry.

Some experts have even suggested that the natural history of degeneration isn’t stopped by replacing the disc. Patients with degenerative disc disease seem to continue experiencing an ongoing progressive disease process no matter whether they have disc replacements or spinal fusion. It’s possible we may not be able to stop the disease but even slowing it down would benefit many people.

It should be noted that all the studies published so far were paid for and funded by the industry that makes the implants. Results should be analyzed carefully. Most of the studies done so far have compared the results of a disc replacement with the results of discectomy (disc removal) and fusion surgery. Trials comparing the cost and effectiveness of one disc device to another have not been reported yet.

In the future, we can expect to see continued changes and improvements in the technology behind cervical disc replacement. Answers are still needed to the question of whether cervical disc arthroplasty have similar problems to other joint replacements (e.g., wear and debris creating an inflammatory response).

Indications and precautions for the use of cervical disc replacements are also under investigation. Currently, anyone who is a candidate for a discectomy and fusion is also likely to do well with disc replacement. Patients with bone deformities, severe spinal joint arthritic changes, or osteoporosis (brittle bones) may be excluded from having a disc replacement. A history of prior neck surgery, bone or disc infection, and cancer metastases may also prevent a patient from having a disc replacement at this time.

Sixty-Year Review of Lumbar Fusion

In this article, surgeons from several large U.S. orthopedic departments take a look back over the last 60 years of spinal surgery for lumbar fusion. What started out as a simple posterior fusion of the vertebrae bones for a wide variety of problems has been streamlined to a procedure called interbody fusion used for lumbar instability.

Techniques and surgical approaches (anterior, posterior, transforaminal, or combination) have changed over the years. Interbody (circumferential) fusion has become mainstream. The introduction of a minimally invasive method has minimized surgical trauma and reduced hospital time, blood loss, and complications.

The authors provide a historical review of each type of fusion (e.g., open versus minimally invasive, different ways to do an interbody fusion) and type of complications with each. Technical challenges and effectiveness of each procedure are also reviewed.

Newer approaches to fusion such as the XLIF, ALIF, and AxiaLIF are discussed. XLIF is actually a trade name that refers to a direct lateral lumbar interbody fusion. ALIF stands for anterior lumbar interbody fusion. In this operation, the surgeon reaches the spine through the abdomen. The axial lumbar interbody fusion (AxiaLIF) is used to fuse the last lumbar vertebra (L5) to the sacrum (S1).

A very helpful table is included that summarizes the methods of interbody fusion and compares the advantages and disadvantages of each one. Some of the techniques developed more recently don’t have enough studies done yet to come to any conclusions. What they have been able to tell so far can be summed up as follows:

Transforaminal and posterior interbody fusions seem to have about the same results in terms of stabilizing the spine. The transforaminal technique has fewer complications and less blood loss.

Anterior interbody fusion can be done with a mini-open incision or laparoscopically. Outcomes are the same in terms of spinal stabilization but the laparoscopic technique has more problems and takes longer.

Minimally invasive is superior to the mini-open incision when measured by amount of blood loss, length of hospital stay, intensity of back pain after surgery, and time in the operating room.

Despite advantages of some surgical approaches over others, the results are fairly comparable with high rates of fusion and good clinical results (e.g., pain relief, improved function).

After reviewing many studies on lumbar fusion from 1950 to 2010, it is clear that more level one studies are needed to directly compare different fusion methods. There is not enough evidence at this point to say one approach is superior to the others. Tissue engineering and tissue regeneration may eventually replace surgical fusion. Such advanced biologic techniques could eliminate nerve or other soft tissue damage caused by currently used surgical methods.

Rate of Reoperation After Cervical Fusion

There is a curious observation about patients who have a cervical spine fusion procedure when those patients are part of a Food and Drug Administration (FDA) study. They have a higher reoperation rate compared with people who have a cervical fusion outside of an FDA study.

To be more specific, the cervical fusion patients in this study received the standard anterior cervical discectomy and fusion (ACDF) procedure. Two groups of fusion patients were compared. One group was part of the FDA investigational studies comparing results of ACDF (the control group) with disc replacement. The second group were patients who had the same ACDF procedure as part of their regular clinical treatment (not as a control group or experimental group).

It is suspected that just being part of an investigational study comparing disc replacement to cervical fusion is enough to produce the difference in results. In other words, being a patient in an FDA study is a risk factor for a second surgery.

Why is that? There are several theories to help explain these differences. First, surgeons working within an FDA study may be quicker to intervene when the results aren’t satisfactory. A second surgery is scheduled sooner than it would be out in a private orthopedic practice.

Second, in the FDA study, the surgeons were only allowed to make corrections at one level, whereas fusion surgeries in real clinical practice could have two or more spinal levels fused. The result is a more stable spine for the group outside the FDA and higher reoperation rates for the FDA participants.

The FDA patients who needed a multi-level fusion but only got a single-level fusion went into the procedure (and came out of the surgery) with greater instability compared with those individuals who only needed a single-level fusion and got it.

What is the value of this information? There is some concern that recommendations made based on FDA studies may direct clinical practice in error. Artifically inflated reoperation rates might lead to investigators recommending disc replacement over fusion. A higher reoperation rate in the FDA fusion group doesn’t reflect or match the reoperation rate after fusion in usual clinical practices. Just being in the control group could be the trigger for poor results. We don’t know for sure yet.

Where do we go from here? There is a need to establish some basic guidelines (“criteria”) for when someone should have a reoperation following spinal fusion. Right now, there are multiple factors that influence the decision to reoperate after the first fusion procedure. For example, the surgeon may respond more to the patient’s complaints of pain and disability than to the results seen on X-rays.

Finding a way to describe a “failed” first fusion procedure that could be used in all studies would be very helpful. If each surgeon identifies what he or she views as a “failure” but it’s not routinely the same from study to study, then the results measured in terms of reoperation rates isn’t possible. Studies are needed to establish “thresholds” for reoperation (i.e., at what point would reoperation always be recommended no matter what study the person is in?).

Although this study does not have all the answers yet, it does raise some interesting observations and suggestions about the use of anterior cervical discectomy and fusion inside and out of the FDA. Further evaluation of these differences are needed.

Making the Decision About Spinal Surgery Based on Risk for Complications

Surgeons don’t perform spinal surgery on just anyone without a strong chance that the procedure will help the patient. Possible complications are always considered ahead of time. And if a patient has too many risks, surgery may not be advised. In this study, surgeons from the University of Washington in Seattle explore various risks for medical complications after spine surgery.

Relying on surgeons and even patients to remember what happened for each person after surgery is not the most accurate way to identify common risk factors after spinal surgery. Even chart reviews are not always as complete as needed. That’s why this study used national databases of information (e.g., Medicare, Worker’s Compensation, National Inpatient Sample) collected on thousands of patients.

There are some disadvantages in using a national database to conduct research. Although the number of patients included tends to be large, not all the pertinent information is gathered. For example, details of the surgery are not collected (e.g., number of spinal levels affected, whether the procedure was a fusion or nonfusion, if hardware was used such as metal plates, pins, or screws).

Even so, the amount of data that is collected can be very helpful. Demographic factors such as age; gender; use of tobacco, alcohol, or other drugs; and diagnosis can be factored in. Body mass index (an indication of obesity), presence of other health problems (e.g., diabetes, high blood pressure, heart disease, history of cancer) can also be considered.

In this study, they also looked at area of the spine operated on (cervical, thoracic, lumbar, sacral) and the underlying pathology (degenerative, trauma, tumor, infection, fracture). The surgical approach (anterior, posterior, combined) was also recorded and compared with the number and type of complications after surgery. All patients were followed for at least two years after the first spinal surgery.

The most common problem after spinal surgery was pulmonary complications (e.g., acute respiratory distress syndrome, pneumonia). This was followed by hematologic complications (e.g., blood loss requiring transfusion, blood clots), urologic problems (e.g., urinary tract infections), and cardiac complications (heart attack, arrhythmias, heart failure).

Other problems involving the gastrointestinal (GI) system or neurologic complications though less common were also reported. GI bleeding, colitis, or ascites (fluid in the abdomen) were the most common adverse events. Neurologic problems stemmed most commonly from strokes, delirium, electrolyte imbalances, and seizures.

After gathering and analyzing all the data, they found the two strongest risk factors for complications after spinal surgery were age (older than 65) and extent of surgery (invasiveness). Surgical invasiveness refers to the number of spinal levels involved, the amount of hardware used, and the approach (anterior, posterior, both). A special scoring system was used to calculate level of invasiveness for each procedure.

Two other risk factors affecting almost all the body systems were hypertension (high blood pressure) and anemia. History of diabetes, heart disease, and thoracic surgery were major risk factors affecting four of the six major organ systems included in this study. Patients who had cardiac or pulmonary complications were four to 10 times more likely to die during the first two years after surgery.

Surgeons involved in spinal surgery may find the charts and tables provided in this article useful. Significant risk factors for medical complications are listed for each system (cardiac, pulmonary, GI, neurological, hematological, urological). Likewise, the risk of death based on individual patient risk factors is also provided. A complete breakdown of each system, type of complications, and incidence is presented in detailed tables.

What’s the take home message from this study? First, complications after spinal surgery are more serious than previously believed AND they happen more often than remembered or reported. Second, patient selection based on risks for complications should be an important part of the pre-operative work up. The decision to have surgery, the type of surgery, and the invasiveness of the procedure can be influenced in part by considering potential complications.

Return to Work as a Measure of Outcomes for Low Back Pain

In this study, researchers from two large health care organizations predict prognosis for patients with acute low back pain based on return to work. This is a new way to look at recovery as most other studies use pain and function as the main measures of outcome for recovery.

Over 600 people participated in the study. Each one had an episode of acute low back pain (with or without sciatica/leg pain) in the last 30 days. They were later contacted by phone (six months later and again two years later) to ask about their experience. As part of the survey, they reported their work status (full-time, part-time, unemployed and seeking work, not seeking work, retired).

Other data collected for review and study included how long the back pain lasted, level of pain intensity, and number of days in bed and/or off work. Each individual was also asked to rate their recovery as they viewed it on a scale from much worse to fully recovered.

To give you an idea of how many people suffer an episode of back pain — in one year’s time, 42,650 people were seen at this health care facility for low back pain. The 600 patients in this study volunteered to participate and also met a series of additional requirements in order to be included. Everyone in the study was given usual care consisting of spinal manipulation, acupuncture, yoga, exercises, massage, or physical therapy.

Analysis of the data showed that prognosis when based on whether or not the person returned to work was much less favorable than when using other measures (e.g., pain, disability). Instead of the previously reported 10 per cent of patients who went from having acute low back pain to chronic pain, 13 per cent had chronic pain at six months and even more (19 per cent) had chronic low back pain at the end of two years.

Many of the remaining patients who did return to work did so with continued pain and physical limitations. Forty-one per cent (41%) reported having to change positions often just to get comfortable while 31 per cent tried to avoid bending or kneeling down. Other activities that posed problems for the group included turning over, walking quickly, getting up from a chair, or using stairs without a handrail.

In observing the results of the data, the authors make several other comments. First, there were quite a few people who were up and down with their back pain. Almost half of the group (47 per cent) had some additional recurrences of low back pain during the six months following their first episode. Second, patients with low back pain and sciatica (leg pain) were more likely to have a poor outcome. And third, results vary depending on the exact wording used to define acute and chronic low back pain.

Our knowledge of back pain, its natural consequence, and prognosis depend on research results. The authors suggest future understanding of this common problem is going to depend on finding some common ground to use when conducting studies. Right now, there is no consensus (agreement) and no consistent use of measures for outcomes, definitions of acute versus low back pain, or inclusion/exclusion criteria for patients participating in studies.

The problems of going back to work while still in pain and continuing to work despite symptoms and disability need to be addressed. The fact that people often still have back pain six months after the first episode and that increases the risk of developing chronic back pain also needs attention. Efforts are needed to find ways to prevent back pain, recurrent back pain, and chronic back pain.