Back Pain Exercises
Exercises to minimize problems with back pain
You can minimize problems with back pain with exercises that make the muscles in your back, stomach, hips and thighs strong and flexible. Some people keep in good physical condition by being active in recreational activities like running, walking, bike riding, and swimming. In addition to these conditioning activities, there are specific exercises that are directed toward strengthening and stretching your back, stomach, hip and thigh muscles.
Before beginning any exercise program, you should discuss the program with your doctor and follow the doctor's advice. It is important to exercise regularly, every other day. Before exercising you should warm up with slow, rhythmic exercises; if you haven't exercised in some time, you can warm up by walking. Inhale deeply before each repetition of an exercise and exhale when performing each repetition.
Exercises to strengthen your muscles
Wall slides to strengthen back, hip, and leg muscles
Stand with your back against a wall and feet shoulder-width apart. Slide down into a crouch with knees bent to about 90 degrees. Count to five and slide back up the wall. Repeat 5 times.
Leg raises to strengthen back and hip muscles.
Lie on your stomach. Tighten the muscles in one leg and raise it from the floor. Hold your leg up for a count of 10 and return it to the floor. Do the same with the other leg. Repeat five times with each leg.
Leg raises to strengthen stomach and hip muscles
Lie on your back with your arms at your sides. Lift one leg off the floor. Hold your leg up for a count of 10 and return it to the floor. Do the same with the other leg. Repeat five times with each leg. If that is too difficult, keep one knee bent and the foot flat on the ground while raising the leg.
You can also sit upright in a chair with legs straight and extended at an angle to the floor. Lift one leg waist high. Slowly return your leg to the floor. Do the same with the other leg. Repeat five times with each leg.
Partial sit-up to strengthen stomach muscles
Lie on your back with knees bent and feet flat on floor. Slowly raise your head and shoulders off the floor and reach with both hands toward your knees. Count to 10. Repeat five times.
Back leg swing to strengthen hip and back muscles
Stand behind a chair with your hands on the back of the chair. Lift one leg back and up while keeping the knee straight. Return slowly. Raise other leg and return. Repeat five times with each leg.
Exercises to decrease the strain on your back
Lie on your back with your knees bent and feet flat on your bed or floor. Raise your knees toward your chest. Place both hands under your knees and gently pull your knees as close to your chest as possible. Do not raise your head. Do not straighten your legs as you lower them. Start with five repetitions, several times a day.
Stand with your feet slightly apart. Place your hands in the small of your back. Keep your knees straight. Bend backwards at the waist as far as possible and hold the position for one or two seconds.
Back Pain in Children
Back pain in children is not like back pain in adults. Compared with an adult, a child with a backache is more likely to have a serious underlying disorder. This is especially true if the child is 4 years old or younger, or in a child of any age who has back pain accompanied by:
- Fever or weight loss
- Weakness, numbness, trouble walking or pain that radiates down one or both legs
- Bowel or bladder dysfunction
- Pain that interferes with sleep
Muscle strain in the middle or lower back gets better on its own with rest. Many teenagers may have "mechanical low back pain." This is often related to tight hamstrings and weak abdominal muscles. These individuals seem to do well with a physical therapy program stressing hamstring stretching and abdominal strengthening.
More serious causes of back pain need early identification and treatment or they may become worse. Always see a doctor if your child's back pain lasts for more than several days or progressively worsens.
The doctor begins with a complete history of the problem and physical examination.
History. Tell the doctor everything about your child and his or her back pain.
- Give the complete medical history: How is the child's overall health? Does he or she have any diseases or medical conditions? Is there any family history of disease? Has the child been in an accident?
- Describe the back pain and any other medical problems: What is the exact location of pain? Does it extend into the legs? Is there any numbness, tingling or weakness? Trouble with urination or bowel movements?
- Describe when/how the pain began: Was it sudden, or did it develop slowly over time? When does it hurt-all the time or only with movement? Does it hurt at night? What makes the pain better or worse?
- Tell the doctor if the child is involved in sports or other activities: What sports? How often does he or she train? Describe the playing surfaces.
Physical exam. The doctor carefully examines the child's musculoskeletal and nervous (neurological) systems. This may include checking:
- Alignment and mobility of the spine. The doctor feels each vertebra and looks for deformities.
- Posture, how the child walks (gait) and whether he or she can bend over to touch the toes, extend, and bend to the right and left.
- Nerves in the back. With the child lying face up, the doctor raises the legs (straight leg raising test). The doctor may also raise the legs with the child lying face down (reverse straight leg raising test).
- Size and tightness of muscles (i.e., hamstrings).
- Balance, flexibility, coordination and muscle strength.
- Muscle spasm and areas of tenderness.
- Reflexes and reactions to pain and light touch.
Imaging. The doctor may use one or several diagnostic imaging tools to see inside the body.
- X-ray. The doctor may take several X-ray pictures of the spine and pelvis from various angles.
- Bone scan. More sensitive than X-rays, bone scans use a substance the doctor injects into a vein to detect infections, tumors and fractures with a special camera.
- CT scan. Specialized X-rays that show a three-dimensional image, computed tomography (CT) scans let the doctor see bone injuries more clearly.
- MRI. Magnetic resonance imaging (MRI) scans use radio waves to let the doctor see the spinal cord, nerve roots, disks or other soft tissues.
Lab tests: Laboratory tests may include checking white and red blood cells (complete blood-cell count) and looking for system-wide inflammation (measuring erythrocyte sedimentation rate).
Most often, musculoskeletal strain is responsible for childhood and adolescent back discomfort. The pain frequently responds to rest, anti-inflammatory medications and an exercise program. Other more serious diagnoses must always be given consideration. Rounded back (Scheuermann's kyphosis), stress fracture of the spine (spondylolysis), slipped vertebrae (spondylolisthesis), infection and tumor are among these.
Rounded back. Scheuermann's kyphosis is a common cause of middle (thoracic) back pain in adolescents. Vertebrae become wedged, causing a rounded or hunched back. The curve may ache, and pain may get worse with activity. Boys get Scheuermann's kyphosis more often than girls do, usually around ages 14 to 17. Treatment is usually nonsurgical and includes:
- Using a brace as the child grows may improve the curve.
- If the curve is rigid, the child may need a series of casts.
- Exercises to stretch and strengthen muscles may ease pain, but will not change the rounded back.
Similar symptoms in the lower (lumbar) back may indicate another disorder, lumbar Scheuermann's disease. This may feel like a chronic backache. It most often affects boys ages 15-17 who take part in sports like weightlifting and football and those who do heavy labor.
Stress fracture of the spine. Spondylolysis, or stress fracture, may cause lower back pain in adolescents. Stress fractures may occur during adolescent growth spurts or in sports that repeatedly twist and hyperextend the spine (i.e., gymnastics, diving and football). Pain is usually mild and may radiate to the buttocks and legs. It feels worse with activity and better with rest. A child with spondylolysis may have a stiff-legged walk with short stride length. Girls are more likely to get stress fractures. Treatments include:
- Rest from activities that caused the stress fracture
- Nonsteroidal, anti-inflammatory drugs (NSAIDS)
- Strengthening exercises for back and abdominal muscles to help control symptoms
- Bracing for several months and follow-up doctor appointments with X-rays to watch for changes
- Surgery to treat painful spondylolysis that does not get better with conservative management
In a few cases, spondylolysis may lead to slipped vertebrae (spondylolisthesis).
Slipped vertebrae. Spondylolisthesis is the occurrence of one vertebra shifting forward on the next vertebra below. It usually occurs at the base of the spine (lumbosacral junction). In severe cases, the bone narrows the spinal canal and presses on nerves. Treatment may include:
- Restriction from vigorous physical activity in mild cases
- Surgery to stabilize the spine in serious cases
Infection. In young children, infection in a disk space (diskitis) can lead to back pain. Diskitis typically affects children aged 1-5, although older children and teenagers can also be affected. A child with diskitis may:
- Have pain in the lower back or abdomen and limited range of motion of the spine.
- Limp or refuse to walk.
- Squat with a straight spine to reach a toy on the floor, rather than bend over.
To treat diskitis, the child may need several days of bed rest and antibiotics taken through the blood stream (intravenous or IV) or in tablets. In some cases, older children may need casting or bracing to immobilize the spine (for comfort) if infection narrows the disk space. Rarely is surgical drainage of infection needed.
Tumor. On rare occasion, tumors can be responsible for back pain. Spinal tumors usually happen in the middle or lower back. Pain is constant and progressive; it is unrelated to activity and/or happens at night. Other symptoms vary, depending upon severity. The child may have:
- A "tight" back or muscle spasms. He or she may lean to one side when bending forward (painful curvature).
- Pain and/or weakness extending into the legs. The child may limp.
- Bowel and/or bladder dysfunction.
Cauda Equina Syndrome
Low back pain is common and usually goes away without surgery. But a rare disorder affecting the bundle of nerve roots (cauda equina) at the lower (lumbar) end of the spinal cord is a surgical emergency. An extension of the brain, the nerve roots send and receive messages to and from the pelvic organs and lower limbs. Cauda equina syndrome (CES) occurs when the nerve roots are compressed and paralyzed, cutting off sensation and movement. Nerve roots that control the function of the bladder and bowel are especially vulnerable to damage.
If you don't get fast treatment to relieve the pressure, CES may cause permanent paralysis, impaired bladder and/or bowel control, loss of sexual sensation and other problems. Even if the problem gets treatment right away, you may not recover complete function.
CES may be caused by a ruptured disk, tumor, infection, fracture or narrowing of the spinal canal. It may also happen because of a violent impact such as a car crash, fall from significant height or penetrating (i.e., gunshot, stab) injury. Children may be born with abnormalities that cause CES.
Diagnosis and treatment
Although you need early treatment to prevent permanent problems, CES may be difficult to diagnose. Symptoms vary in intensity and may evolve slowly over time. See your doctor immediately if you have:
- Bladder and/or bowel dysfunction, causing you to retain waste or be unable to hold it.
- Severe or progressive problems in the lower extremities including loss of or altered sensation between the legs, over the buttocks, inner thighs and back of legs (saddle area), and feet/heels.
- Pain, numbness or weakness spreading to one or both legs that may cause you to stumble or have difficulty getting up from a chair.
To diagnose CES, the doctor will probably evaluate your medical history, give you a physical examination and order multiple imaging studies.
Medical history: Describe your overall health, when the symptoms of CES began and how they impact your activities.
Physical exam: The doctor assesses stability, sensation, strength, reflexes, alignment and motion. He or she may ask you to stand, sit, walk on your heels and toes, bend forward, backward and to the sides, and lift your legs while lying down. The doctor might check the tone and numbness of anal muscles. You may need blood tests.
Imaging: You may get X-rays, MRIs (magnetic resonance imaging) and CAT scans (computerized tomography) to help the doctor see the problem.
If you have CES, you may need urgent surgery to remove the material that is pressing on the nerves. The surgery may prevent pressure on the nerves from reaching the point at which damage is irreversible.
Living with CES
Surgery won't help if you already have permanent nerve damage. In this case, you can learn how to make living with CES more tolerable. Some suggestions:
- In addition to medical personnel, you may want to get help from an occupational therapist, social worker, continence advisor or sex therapist.
- Involve your family in your care.
- To learn all you can about managing the condition, you may want to join a CES support group.
Managing bladder and bowel
Some bladder and bowel function is automatic, but the parts under voluntary control may be lost if you have CES. This means you may not know when you need to urinate or move your bowels, and/or you may not be able to eliminate waste normally. Some general recommendations for managing bladder and bowel dysfunction:
Bladder: Empty the bladder completely with a catheter 3-4 times each day. Drink plenty of fluids and practice regular personal hygiene to prevent urinary tract infection.
Bowel: Check for the presence of waste regularly and clear the bowels with gloved hands. You may want to use glycerin suppositories or enemas to help empty the bowels. Use protective pads and pants to prevent leaks.
Fracture of the Thoracic and Lumbar Spine
Fracture of one or more parts of the spinal column (vertebrae) of the middle (thoracic) or lower (lumbar) back is a serious injury usually caused by high-energy trauma like a car crash, fall, sports accident or act of violence (i.e., gunshot wound). Males experience the injury four times more often than females do. The spinal cord may be injured depending on the severity of the fracture. Symptoms include:
- Moderate to severe back pain made worse by movement.
- In some cases when the spinal cord is also involved, numbness, tingling, weakness or bowel/bladder dysfunction.
When you fracture the thoracic and lumbar spine, surgery or bracing is often necessary. Often, patients also have other life-threatening injuries. People with osteoporosis, tumors or other underlying conditions that weaken bone can get a spinal fracture with minimal trauma or normal activities of daily living.
Never attempt to move a person with a spinal injury, because movement can cause more damage. Call 911 immediately. Rescue workers know how to properly immobilize people with injuries and safely take you to the hospital for evaluation and treatment.
After checking heart rate, breathing and other vital signs, a doctor locates the fractured part(s) of the spine and determines the extent of damage. He or she finds out exactly how the vertebra broke (fracture pattern) and whether you have nerve (neural) injury and/or spinal instability.
The doctor considers what caused the injury, gives you a physical/neurological examination and takes X-rays to show inside the body.
History. Every detail you can recall about what caused the injury may help the doctor. Sometimes rescue workers or other witnesses can supply more information. Did an accident eject the patient from a vehicle? Was there windshield or steering column damage? Was the person using a lap and/or shoulder seat belt? Did an airbag deploy?
Examination. The doctor carefully removes your clothing and immobilizes the body with a spine board for complete physical examination. This may include checking for swelling, bruising and other signs of injury to the head, chest, abdomen and back; evaluating strength, motion and alignment of arms and legs; feeling for tenderness on each rib and along the entire length of the spine; testing the tone and sensation of rectal muscles; and other evaluations.
You may also need a neurologic examination. This may include tests of sensory (i.e., temperature, pain and pressure sensitivity), motor (i.e., muscle strength) and reflex (i.e., knee jerk) functions of the nervous system. If you have neurologic damage, certain tests can show whether you may recover some function (incomplete deficit) or not (complete deficit).
Imaging. X-rays of the entire spine from multiple angles may be necessary to see bone alignment and check for damage to soft tissue. Sometimes you may also need CT (computed tomography) or MRI (magnetic resonance imaging) scans to help the doctor better visualize the injury.
Doctors classify fractures of the thoracic and lumbar spine based upon pattern of injury:
- Compression fracture: While the front (anterior) of the vertebra breaks and loses height, the back (posterior) part of it does not. This type of fracture is usually stable and rarely associated with neurologic problems.
- Axial burst fracture: You lose height on both the front and back of the vertebra in this type of fracture, often caused by a fall from height in which you land on your feet.
- Flexion/distraction (chance) fracture: The vertebra is literally pulled apart (distraction), such as in a head-on car crash in which the upper body is thrown forward while the pelvis is stabilized by a lap seat belt.
- Transverse process fracture: This type of fracture results from rotation or extreme sideways (lateral) bending and usually does not affect stability.
- Fracture-dislocation: This is an unstable injury involving bone and/or soft tissue in which one vertebra may move off the adjacent one (displaced).
Treatment goals include protecting nerve function and restoring alignment and stability of the spine. The doctor determines the best treatment method based upon fracture type and other factors.
Non-surgical: Doctors usually treat compression and some burst fractures without surgery. If you have a simple compression fracture, you may need to wear a hyperextension brace for sitting and standing activities for 6-12 weeks. You should walk and do other exercises while healing and may take medication for pain. If you have a transverse process fracture, you may need to wear a thoracolumbar corset along with doing an aerobic walking program.
Surgical: Some injuries require more aggressive treatment. You may need steroids if the spinal cord is injured. You may need surgery if you have an unstable burst fracture, flexion-distraction injury or fracture-dislocation. Surgery realigns the spinal column and holds it together using metal plates and screws (internal fixation) and/or spinal fusion.
You've probably heard people say they have a "slipped" or "ruptured" disk in their neck or lower back. What they're actually describing is a herniated disk, a common source of neck, or lower back and arm or leg pain.
Disks are soft, rubbery pads found between the hard bones (vertebrae) that make up the spinal column. In the middle of the spinal column is the spinal canal-a hollow space that contains the spinal cord and other nerve roots. The disks between the vertebrae allow the back to flex or bend. Disks also act as shock absorbers.
Disks in the lumbar spine (low back) are composed of a thick outer ring of cartilage (annulus) and an inner gel-like substance (nucleus). In the cervical spine (neck), the disks are similar but smaller in size. A helpful comparison is a jelly donut: its thick outer portion represents the annulus, while the jelly is similar to the nucleus.
A disk herniates or ruptures when part of the center nucleus pushes through the outer edge of the disk. To continue with the donut analogy, the jelly pushes backwards toward the spinal canal. This puts pressure on the nerves. Spinal nerves are very sensitive to even slight amounts of pressure. Pain, numbness or weakness may occur in one or both legs.
In children and young adults, disks have high water content. As people age, the water content in the disks decreases. They become less flexible. The disks begin to shrink. The spaces between the vertebrae get narrower. The disk itself becomes less flexible. Conditions that can weaken the disk include:
- Improper lifting
- Excessive body weight that places added stress on the disks (in the lower back)
- Sudden pressure (which may be slight)
- Repetitive strenuous activities
Lower Back: Low back pain affects four out of five people. Pain alone isn't enough to recognize a herniated disk. See your doctor if back pain results from a fall or a blow to your back. The most common symptom of a herniated disk is sciatica-a sharp, often shooting pain that extends from the buttocks down the back of one leg. It is caused by pressure on the spinal nerve. Other symptoms include:
- Weakness in one leg
- Tingling (a "pins-and-needles" sensation) or numbness in one leg or buttock
- Loss of bladder or bowel control (If you also have significant weakness in both legs, you could have a serious problem. Seek immediate attention.)
- A burning pain centered in the neck
Neck: Like pain in the lower back, neck pain is also common. When pressure is placed on a nerve in the neck, it causes pain in the muscles between your neck and shoulder (trapezial muscles). The pain may shoot down the arm. Sometimes the pain causes headaches in the back of the head. Other symptoms include:
- Weakness in one arm
- Tingling (a "pins-and-needles" sensation) or numbness in one arm
- Loss of bladder or bowel control (If you also have significant weakness in both arms or legs, you could have a serious problem. Seek immediate attention.)
- Burning pain in the shoulders, neck or arm
To diagnose a herniated disk, give the doctor your complete medical history. Tell him or her if you have neck/back pain with gradually increasing arm/leg pain. Tell the doctor if you were injured. The doctor will physically examine you. This can determine which nerve roots are affected (and how seriously). A simple X-ray may show evidence of disk or degenerative spine changes.
MRI (magnetic resonance imaging) or CT (computed tomography) scans (imaging tests to confirm which disk is injured) or an EMG (a test that measures nerve impulses to the muscles) may be recommended if pain continues.
Conservative treatment is effective in treating symptoms of herniated disks in more than 90 percent of patients. Most neck or back pain will resolve gradually with simple measures.
- Bed rest and over-the-counter pain relievers may be all that's needed.
- Muscle relaxers, analgesic and anti-inflammatory medications are also helpful.
- You can also apply cold compresses or ice for no more than 20 minutes at a time, several times a day.
- After any spasms settle, you can switch to gentle heat applications.
Any physical activity should be slow and controlled, especially bending forward and lifting. This can help ensure that symptoms do not return. Take short walks and avoid sitting for long periods. For the lower back, exercises may also be helpful in strengthening back and abdominal muscles. For the neck, exercises or traction may also be helpful. It's essential that you learn how to properly stand, sit and lift. This can help you avoid future episodes of pain.
Treatment Options: Surgical
If conservative treatment fails, epidural injections of a cortisone-like drug may lessen nerve irritation and allow better participation in physical therapy. These shots are given on an outpatient basis over a period of weeks.
Surgery may be required if a disk fragment lodges in the spinal canal and presses on a nerve, causing significant loss of function. Surgical options in the lower back include microdiskectomy or laminectomy depending on the size and position of the disk herniation. In the neck, an anterior cervical discectomy and fusion is usually recommended. This involves removing the entire disk to take the pressure off the spinal cord and nerve roots. Bone is placed in the disc space and a metal plate may be used to stabilize the spine. On occasion, a smaller surgery may be performed on the back of the neck that does not require fusing the bones together. Each of these surgeries is performed under general anesthesia. It may be performed as an outpatient or require an overnight hospital stay. You should be able to return to work in two to six weeks.
How to Prevent Back Pain
Four out of five adults will experience significant low back pain sometime during their life. Work-related back injuries are the nation's number one occupational hazard, but you could suffer back pain from activities at home and at play, too.
Are you at risk?
You are most at risk for back pain if:
- your job requires frequent bending and lifting
- you must twist your body when lifting and carrying an object
- you must lift and carry in a hurry
- you are overweight
- you do not exercise regularly or do not engage in recreational activities
- you smoke
If you are a caregiver for an ill or injured family member, you are at greatest risk for back pain when:
- pulling the person who is reclining in bed into a sitting position
- transferring the person from the bed to a chair
- leaning over the person for long periods of time
The American Academy of Orthopaedic Surgeons has developed tips to help you reduce your risk of back pain. Whether you are lifting and moving a person or a heavy object, the guidelines are the same.
- Plan ahead what you want to do and don't be in a hurry.
- Spread your feet shoulder-width apart to give yourself a solid base of support.
- Bend your knees.
- Tighten your stomach muscles.
- Position the person or object close to your body before lifting.
- Lift with your leg muscles. Never lift an object by keeping your legs stiff, while bending over it.
- Avoid twisting your body; instead, point your toes in the direction you want to move and pivot in that direction.
- When placing an object on a high shelf, move close to the shelf. Do not stand far away and extend your arms with the object in your hands.
- Maintain the natural curve of your spine; don't bend at your waist.
- When appropriate, use an assistive device such as a transfer belt, sliding board or draw sheet to move a person.
- Do not try to lift by yourself something that is too heavy or an awkward shape. Get help.
How to prevent back pain
- Use the correct lifting and moving techniques.
- Exercise regularly to keep the muscles that support your back strong and flexible.
- Don't slouch; poor posture puts a strain on your lower back.
- Maintain your proper body weight to avoid straining your back muscles.
- Keep a positive attitude about your job and home life; studies show that persons who are unhappy at work or home tend to have more back problems and take longer to recover than persons who have a positive attitude.
IDET (Intradiscal Electrothermal Annuloplasty)
Practically everyone suffers from back pain at some point. Sometimes the pain results from pressure on nerves, sometimes from spinal fractures, and sometimes from problems with the cushioning discs that separate the bones of the spine. Depending on the cause of the pain, treatment can be as simple as rest and exercise, or as complex as major surgery. Usually, simpler methods are tried first; if they are not successful in relieving the pain, more aggressive treatments can be used.
A relatively new treatment for back pain resulting from problems within the cushioning discs is intradiscal electrothermal annuloplasty, also called intradiscal electrothermal therapy (IDET). This outpatient procedure applies high heat directly to the inside of the disc. It is a less expensive and less invasive procedure than spinal surgery, but it is not appropriate for everyone who has low back pain.
Discs are cushioning tissues located between each vertebra of the spine. The disc has a soft center (nucleus) surrounded by tougher ligament tissue (annulus). As we age, the outer ligament tissue begins to fray and tear from use or injury. This allows nerves and small blood vessels from the soft center to seep into the injury site, triggering pain receptors in the ligament tissue. The result is discogenic back pain.
Discogenic pain differs from a ruptured or herniated disc because the pain originates within the disc and does not come from nerves or other structures. Discogenic pain is confined to the back and does not radiate down the legs.
In addition to interviewing you about the pain, the physician will take your medical history and give you a physical examination. Tests that can help determine the source of the pain include X-rays, magnetic resonance imaging (MRI), computed tomography (CT) scans and discography.
Discography is used to identify the painful disc. In this test, the physician pierces the disc with a thin needle and injects a contrast dye. X-rays show whether the dye enters the disc's outer tissues. Discography is called a provocative test because it will provoke pain in an injured disc.
IDET is usually reserved only for patients who have tried aggressive, non-operative techniques to relieve their pain without success. Because this is a relatively new procedure, you should make sure that the practitioner you see is adequately trained in using the equipment. The procedure itself takes about one hour to complete. A local anesthetic and intravenous pain relievers are used.
- The physician uses an X-ray machine (fluoroscope) to see the spinal structures.
- A hollow needle is inserted into the painful disc. A thin heating wire (electrothermal catheter) is passed through the needle into the disc, and maneuvered into place around the outer edge of the central nucleus.
- The wire is heated slowly to a temperature of about 194 degrees Farenheit (90 degrees Celsius) for about 15 minutes.
Heat can potentially contract and shrink the fibers that make up the disc wall, closing any tears.
Br> The heat can also potentially cauterize (burn) tiny nerve endings in the disc, making them less sensitive to pain.
- After the wire and needle are removed, there is a short observation period before the patient is released.
Although IDET is much less invasive than most back surgeries, it will still take several weeks for healing to occur. Pain relief is not immediate; pain may actually increase for a day or two after surgery. But gradually the pain from the procedure itself should diminish.
After the IDET procedure, you will need to rest for a few days and limit the time you spend sitting. You may need to wear a back support for several weeks. You will also need to participate in a physical therapy program. If your job is sedentary does not involve lifting or manual labor, you may be able to return to work in a week or so; otherwise it may be several months before you can resume your activities. You will not be able to participate in rigorous recreational activity or do any heavy lifting or twisting for at least six months after the procedure.
IDET is not recommended if you have severe disc degeneration, nerve compression, spinal instability and/or narrowing of the spinal column (spinal stenosis). IDET is not yet covered by many insurance plans.
The long-term results of this procedure are still unknown. IDET was introduced in 1997 and case series without controls have reported encouraging results. However, these results need to be confirmed in prospective, randomized trials. Additionally, there is debate about how the procedure actually works. Not every patient will benefit from IDET treatment. Some patients continue to experience back pain and may eventually have other surgical procedures.
Kyphoplasty is a minimally invasive spinal surgery procedure. It is used to treat painful progressive vertebral body collapse/fracture (VCFs). The VCFs may be caused by osteoporosis or the spread of tumor to the vertebral body.
Osteoporosis is age related softening of bones. It causes the building blocks of the spine to weaken and collapse. This results in severe pain and a progressive hunchback. Certain forms of cancer also weaken the bone and cause the same problems.
Kyphoplasty is not appropriate for:
- Patients with young, healthy bones or those who sustained a vertebral body fracture or collapse in a major accident
- Patients with spinal curvature such as scoliosis or kyphosis that is due to causes other than osteoporosis
- Patients who suffer from spinal stenosis or herniated discs with nerve or spinal cord compression and loss of neurological function not associated with a vertebral compression fracture
The kyphoplasty procedure involves the use of a balloon to restore the vertebral body height and shape. This is followed by bone cement to strengthen it. The procedure may be performed under intravenous sedation. The patient may need local anesthetic or general anesthetic. The patient lies face-down on the operating room table. Two X-ray machines are used to show the collapsed bones.
The surgeon makes two small (less than 3mm) incisions. He or she inserts a tube into the center of the vertebral body. Through this tube, balloons are placed in the center of the vertebral body. (See Figure 1.) Then the balloons are inflated. (See Figure 2.) This pushes the bone back towards its normal height and shape. It also helps create a cavity. The surgeon will fill the cavity with the bone cement.
Once the cavity is created, the surgeon removes the inflatable balloon bone tamp. He or she mixes the cement and fills the cavity in a slow and controlled fashion. (See Figures 3 and 4.) The cement hardens. Then the surgeon takes out the tubes. He or she closes the incisions with a single stitch. Patients usually go home the same day. Patients can go back to all normal activities of daily living as soon as possible. They have no restrictions.
Early results show kyphoplasty is a safe and effective method of vertebral reconstruction and stabilization in the treatment of osteoporotic VCFs. Like all surgeries, kyphoplasty does have risks.
Complications may require additional treatments. These may be medications or surgery. Kyphoplasty is associated with excellent pain relief due to the vertebral body collapse. Well over 95 percent of patients rate their treatment a success. They are able to return to all of their pre-VCF function. Patients typically do not need any form of physical therapy or rehabilitation after a kyphoplasty procedure. Because bone cement hardens within 15 minutes, there is really no healing that needs to happen from the patient's standpoint.
Occasionally, patients complain of persistent pain after kyphoplasty. This may be due to irritation of tissues involved in the procedure itself. It is more likely due to the underlying arthritis and degeneration of the spine.
- Pain due to the procedure will typically diminish within two weeks.
- If the pain is due to the arthritic degenerative changes in the spine, the usual treatment is medications and an ongoing exercise program.
Restoring vertebral body height and size is best accomplished when kyphoplasty is performed soon after the VCFs happen. (See Figures 5 and 6.) After kyphoplasty, severe osteoporosis may cause other fractures at other levels in some patients. All patients must take bone-strengthening medications during treatment. If more vertebrae collapse, kyphoplasty can also be used at those other levels. Kyphoplasty has a tendency to help prevent more fractures. It keeps the spine lined up in its native upright position.
- The usual risks of local or general anesthetics apply. These risks depend on the patient's overall health.
- There is a small risk of the bone cement leaking from within the boundaries of the vertebral body. In most cases, this rare event (occurrence less than 10 percent) does not cause any problems.
- In very rare circumstances the cement may irritate or damage the spinal cord or nerves. This can cause pain, altered sensation, or even, very rarely, paralysis (estimated risk is less than 1 in 10,000). Should the cement leak further, more significant surgery may be needed to stop the irritation of the nerves or spinal cord.
- There is also a very small chance of the cement traveling to lungs. There is an even smaller chance of the cement block becoming infected at the time of surgery or even years later.
Kyphosis (Curvature of the Spine)
Few things bother parents more than their child's posture. This is particularly true for an exaggerated rounding to the back. Some degree of curvature to the spine is normal. The term "kyphosis" (kI-fO-sis) is usually applied to the curve that results in an exaggerated "round-back." A variety of disorders may be responsible for this condition. Several are listed below.
Usually, a visit to the doctor is brought on by a scoliosis screening at school, concern about the cosmetic deformity of a rounded back or pain combined with poor posture. The doctor may ask the child to bend forward so that he or she can see the slope of the spine. X-rays of the spine will show if there are any bony abnormalities. X-rays will also let the doctor measure the degree of the kyphotic curve. Any kyphotic curve that is more than 50 degrees is considered abnormal.
Types of kyphosis
Postural kyphosis. Postural kyphosis is the most common type. It is often attributed to "slouching." It represents an exaggerated, but flexible, increase of the natural curve of the spine. This usually becomes noticeable during adolescence. It is more common among girls than boys. It rarely causes pain. Exercises to strengthen the abdomen and stretch the hamstrings may help take away associated discomfort. But exercises probably won't result in significant correction of the postural kyphosis. This condition does not lead to problems in adult life.
Scheuermann's kyphosis. Scheuermann's (shoe-er-mans) kyphosis is named after the Danish radiologist who first described the condition. Like postural kyphosis, it often becomes apparent during the teen years. However, Scheuermann's kyphosis will present with a significantly worse cosmetic deformity. This is particularly the case in thin individuals. Scheuermann's kyphosis usually affects the upper (thoracic) spine. It can also occur in the lower (lumbar) back area. If pain is present, it is usually felt at the apex of the curve. Activity can aggravate the pain. So can long periods of standing or sitting. Exercises and anti-inflammatory medication help ease the discomfort. When X-rays are examined, the vertebrae and disks will appear normal in postural kyphosis. But they are irregular and wedge-shaped in Scheuermann's kyphosis.
Congenital kyphosis. In some infants, the spinal column does not develop properly while the fetus is still in the womb. The bones may not form as they should. Several vertebrae may be fused together. Either of these abnormal situations may cause progressive kyphosis as the child grows. Surgical treatment may be needed at a very young age. This can maintain a more normal spinal curve. Consistent follow-up is required to monitor any changes.
Treatment will depend on the reason for the deformity. Most teens with postural kyphosis will do well throughout life. In some, their posture may improve over time. An exercise program may help with back pain, if present.
An initial program of conservative treatment is also recommended for patients with Scheuermann's kyphosis. This includes exercises and anti-inflammatory medications. If the child is still growing, the doctor may prescribe a brace. The child wears the brace until skeletal maturity is reached.
Treatment Options: Surgical
Surgery may be recommended if the kyphotic curve exceeds 75 degrees. The goals of surgery are:
- Reduce the degree of curvature by straightening and fusing the abnormal spinal segments together
- Maintain the improvement over time
- Alleviate back discomfort, if present preoperatively
Low Back Pain
Low back pain is one of the most common afflictions in our society. Almost every person will have at least one episode of low back pain at some time in his or her life. The pain can vary from severe and long term to mild and short lived. It will resolve within a few weeks for most people.
The low back (lumbar spine) is made up of five bones (vertebrae). The lumbar discs are between these bones in the front of the spine. They function as shock absorbers and allow for motion of the lumbar spine. Behind the discs is the spinal canal (see Figures 1 and 2).
The spinal nerves run through this area and exit at each level of the spine. They are enclosed within the meninges, often referred to as the dural sac. The dural sac allows for the spinal nerves to travel through this area and stay within the spinal fluid. The lamina and the facet joints make up the back of the spinal canal. The lamina is a relatively flat area of bone that covers most of the back of the spinal canal. The facet (also called zygoapophyseal or Z) joints are more to the side in back, and also allow for motion of the lumbar spine. They connect each vertebra to the one above and below it. Sticking backward from the lamina at each level of the spine is the spinous process. These are the bones that can be felt when you touch your back. The discs and nerves are too deep to be felt. The spinous processes function as an attachment point for a number of muscles. Many muscle groups surround the spine. They function to move and support the spine.
Doctors have many ideas about what causes low back pain, but no explanation applies to everyone. It may be related to damage to or aging of the disc, muscular problems, arthritis of the spine, problems with tendons or ligaments in and around the spine or malpositioning of vertebrae. Low back pain is sometimes caused by:
- Excessive stress to the back, such as lifting something heavy.
- Minimal movement, such as bending or reaching for something.
Occasionally, it happens with no cause.
See your doctor to diagnose low back pain. Tell him or her your complete medical history. The doctor will examine you physically. Often the physical exam is completely normal except for pain with motion. The doctor checks for:
- Evidence of nerve problems. The doctor evaluates strength, sensation and reflexes. He or she may ask you to move your spine to see how limited the motion is.
- Another problem not related to the spine that could cause back pain, such as poor blood circulation. Tell the doctor what motions or positions hurt, and what helps relieve the pain.
If you have short-term (acute) back pain, the doctor may not order X-rays or other imaging studies; these are not likely to help in diagnosis or treatment. When X-rays are used, they are often normal or they show an abnormality that may or may not be related the pain. (For instance, it is very common to see some disc degeneration in X-rays of people with back pain. But it is also very common to see it in people who do not have back pain. It is difficult to tell whether the degeneration is actually the cause of the pain.) The same is true for magnetic resonance imaging (MRI) and computed tomography (CT) scans.
X-rays and other studies are more likely to be helpful when low back pain does not get better on its own after a few weeks or a person has evidence of more severe problems. Tell the doctor if you have a history of a previous cancer, fevers or chills that might be caused by an infection or a significant trauma like a fall or car accident that might have caused a fracture. Significant weakness on physical examination could also indicate problems. If a person is having trouble controlling their urine or bowels, the doctor will usually order X-rays and other studies more quickly.
The main purpose of X-rays is to look for an explanation for the pain. There are many findings that are considered to be nonspecific (they may or may not be related to the pain). Some of these non specific findings are disc space narrowing, spurring, spina bifida oculta (incomplete formation of the lamina and spinous process), mild scoliosis and a decrease in lumbar lordosis. Lumbar lordosis is the normal curvature of the spine when viewed from the side. When viewed from the front, the spine is normally straight. Discs are not visible on x ray, only the disc spaces.
MRI (magnetic resonance imaging) is often the next imaging test ordered if the physician feels it is indicated. With MRI the doctor can see the discs and the nerves. He or she can see the level of degeneration of the discs and whether there is any material that has gone outside of the normal confines of the disc (herniation). MRI is also very good at showing infections, tumors and fractures. Although an MRI can sometimes help the doctor determine the source of a back problem, it also often shows nonspecific findings.
The doctor may also order CT scans which are similar to three dimensional X-rays, bone scans to look for areas of possible infection, tumor or fracture and tests to see how well nerves in the arms and legs conduct electrical signals (EMG/NCV tests). If osteoporosis is a concern, bone density studies may be ordered as well. Osteoporosis by itself should not cause back pain, but fractures due to osteoporosis can.
Low back pain can happen after an injury, especially if there is a fracture of the spine. Some other factors associated with low back pain are smoking and long term exposure to vibration. Obesity may also be related. Factors such as posture, the type of work one does, diet and amount of exercise are not closely related to low back pain.
Doctors do not know why some people with acute back pain go on to suffer from long term (chronic) low back pain. They also don't know why some people go on to feel quite well between episodes of severe pain.
The symptoms of low back pain vary in some ways and are similar in others. Most people find that reclining or lying down will improve their pain and after their initial severe episode, many will be able to rest at night without severe pain. Most people are worse when they bend over to pick something up. Some get relief from arching backward (extending the back). Leg pain also can be part of the problem. The pain is most common in the back or outer side of the thigh, and can go all the way to the foot. Pain that goes to the foot is called sciatica because it is pain that follows the course of the sciatic nerve. Sciatica is often made worse by coughing or sneezing.
With an acute episode, back pain can be very severe for a few days or a week, and then will often improve. By 2 weeks to 4 weeks, the large majority of people are much better. Individuals vary greatly in length of time between episodes, length of each episode and intensity of each episode, and how they cope with the pain.
Treatments for back pain are multiple and varied. At times counseling and education about the problem to ease a person's anxiety is enough to make it tolerable until the episode resolves. A few days of rest can often calm the pain down as well. Prolonged bed rest (more than 2 days to 3 days) is no longer generally recommended. Medications such as non steroidal anti inflammatory drugs (NSAIDS) or acetaminophen (Tylenol) can be helpful. Occasionally stronger medications such as muscle relaxants and narcotics are used for a short period.
Although there is minimal scientific evidence of their effectiveness in treating low back pain, back braces are commonly used. Most common is a corset type brace that can be wrapped around the back and abdomen. People who use them sometimes report feeling better supported and more comfortable. Although there is little definite proof that they help, there is also little risk to using them.
A number of treatments called passive modalities are also used frequently. These are treatments in which the patient isn't required to actively do anything. Passive modalities include heat, cold, massage, ultrasound, electrical stimulation, traction and acupuncture. All of these measures can help some people with back pain. How long the benefit will be or what the chances are of receiving benefit from any of these treatments isn't completely known.
Another form of passive treatment is spinal manipulation. There are many different practitioners of spinal manipulation, each with their own style of manipulation. This has also at times improved symptoms of back pain.
Injections are sometimes used as well. The most commonly used medications are local anesthetic and/or steroids. They are usually given either in the area that is felt to possibly be the source of the pain, such as in to a muscle or facet joint, or around the nerves of the spine (an epidural or nerve root injection). Injections are occasionally placed into the disc, but this is done far less frequently.
The next more invasive type of procedure that is done for low back pain is the procedure aimed at removing or destroying the area that is felt to be causing the pain. Some examples of this are intra discal electrothermy (IDET) in which a coiled wire is placed in to the disc and then heated, and radiofrequency ablation (RFA). These are more invasive and because they do damage tissue, have higher risk and potential for longer-term side effects than the other treatments. If successful, they can help a person avoid a larger surgery, but there is still controversy over exactly when and to whom these procedures should be offered.
What is generally felt to be most appropriate and effective for most people with back pain is a good course of exercise and stretching. Restoring motion and strength to a painful lumbar spine can be very helpful at improving pain. Although there is controversy as to what are the best spine exercises, it is generally agreed that exercise should be both aerobic (aimed at improving heart and lung function) as well as specific to the spine. Aerobic exercises include walking, jogging, swimming, bicycling etc.
Instruction in lifting techniques can be helpful as well. Improperly bending over to lift can cause a large increase in strain on the low back. Proper lifting keeps the back straight while you bend with the knees.
Treatment Options: Surgical
Indications for surgery: Surgery for low back pain should only be performed when a number of conditions have been met. The first is that nonsurgical treatment options have been tried and have failed. Surgery should not be done if an exercise program is effective but the person does not want to do it. The second condition is that the surgeon feels there is enough possibility that the individual patient will have a good chance of having a successful result with surgery. An example of this would be a person with severe degeneration at one level of their spine and normal findings at the other levels. Another factor that goes along with this is that low back pain, like many other pain problems, can be worse during times of stress. It may not be a good idea to commit to an operation like this when there are other major stressful events going on in one's life. Occasionally, the back problem can become more tolerable once the stress is reduced. The final factor is that the patient must decide if they are having enough of a problem to undergo an invasive procedure that is not guaranteed to work.
Surgical options: Historically, the most commonly performed operation for back pain has been spinal fusion. There are a variety of ways this is done but the basic idea is to take the painful segment of the spine and get it to become a solid piece of bone. This will eliminate motion and, in theory at least, if it doesn't move, it shouldn't hurt. This can be done through the back (posterior) or through the front (anterior), or sometimes both ways. Spinal fixation of some sort is often combined with some form of bone graft or bone substitute. Bone graft can either be obtained from another part of the skeleton such as the pelvis (autograft) or be donated bone that is processed and used in a spine fusion (allograft). The results of spine fusion for low back pain vary. A good result is a decrease in pain. It is very rare for someone to be completely out of pain after a spine fusion. Full recovery can take more than a year.
A newer technique that has recently been introduced in to the United States is disc replacement. The procedure involves removing the disc and replacing it with artificial components, similar to what is done in the hip or the knee. Doing this lets the segment of the spine keep some flexibility and hopefully maintain more normal motion. The recovery time may be shorter than with spine fusion because the bone does not have to solidify. Although it has been used in Europe for a number of years, it has only recently been used in the United States. Early results are promising.
Currently disc replacements are done through an anterior approach and are primarily done on the lower two discs of the lumbar spine.
Research on the Horizon/What's New?
A great deal of research is being performed to help doctors understand and treat low back pain. Some of the more exciting research includes new forms of disc replacement that someday may be injectable, and research into gene therapy that may someday allow doctors to alter the aging process of the spine.
Low Back Pain Exercise Guide
Regular exercises to restore the strength of your back and a gradual return to everyday activities are important for your full recovery. Your orthopaedic surgeon and physical therapist may recommend that you exercise 10 to 30 minutes a day one to three times a day during your early recovery. They may suggest some of the following exercises. This guide can help you better understand your exercise and activity program, supervised by your therapist and orthopaedic surgeon.
Initial Exercise Program
Ankle Pumps - Lie on your back. Move ankles up and down. Repeat 10 times.
Heel Slides - Lie on your back. Slowly bend and straighten knee. Repeat 10 times.
Abdominal Contraction - Lie on your back with knees bent and hands resting below ribs. Tighten abdominal muscles to squeeze ribs down toward back. Be sure not to hold breath. Hold 5 seconds. Relax. Repeat 10 times.
Wall Squats - Stand with back leaning against wall. Walk feet 12 inches in front of body. Keep abdominal muscles tight while slowly bending both knees 45 degrees. Hold 5 seconds. Slowly return to upright position. Repeat 10 times.
Heel Raises - Stand with weight even on both feet. Slowly raise heels up and down. Repeat 10 times.
Straight Leg Raises - Lie on your back with one leg straight and one knee bent. Tighten abdominal muscles to stabilize low back. Slowly lift leg straight up about 6 to 12 inches and hold 1 to 5 seconds. Lower leg slowly. Repeat 10 times.
Intermediate Exercise Program
Single Knee to Chest Stretch - Lie on your back with both knees bent. Holdthigh behind knee and bring one knee up to chest. Hold 20 seconds. Relax.Repeat 5 times on each side.
Hamstring Stretch - Lie on your back with legs bent. Hold one thigh behind knee. Slowly straighten knee until a stretch is felt in back of thigh. Hold 20 seconds. Relax. Repeat 5 times on each side.
Lumbar Stabilization Exercises With Swiss Ball - Abdominal muscles must remain contracted during each exercise. See "Abdominal Contraction" exercise from initial exercise program. Perform each exercise for 60 seconds. The further the ball is from your body, the harder the exercise.
Lie on your back with knees bent and calves resting on ball.
1. Slowly raise arm over head and lower arm, alternating right and left sides.
2. Slowly straighten one knee and relax, alternating right and left sides.
3. Slowly straighten one knee and raise opposite arm over head. Alternate opposite arms and legs.
4. Slowly "walk" ball forward and backward with legs.
Sitting on ball with hips and knees bent 90 degrees and feet resting on floor.
1. Slowly raise arm over head and lower arm, alternating right and left sides.
2. Slowly raise and lower heel, alternating right and left sides.
3. Slowly raise one heel and raise opposite arm over head. Alternate opposite arm and heel.
4. Marching: Slowly raise one foot 2 inches from floor, alternating right and left sides.
Standing with ball between your low back and wall.
1. Slowly bend knees 45 to 90 degrees. Hold 5 seconds. Straighten knees.
2. Slowly bend knees 45 to 90 degrees while raising both arms over head.
Lie on your stomach over ball.
1. Slowly raise alternate arms over head.
2. Slowly raise alternate legs 2 to 4 inches off of floor.
3. Combine 1 and 2, alternating opposite arms and legs.
4. Bend one knee. Slowly lift this leg up, alternating right and left legs. Be careful not to arch your low back!
Advanced Exercise Program
Hip Flexor Stretch - Lie on your back near edge of bed, holding knees to chest. Slowly lower one leg down, keeping knee bent, until a stretch is felt across top of the hip/thigh. Hold 20 seconds. Relax. Repeat 5 times on each side.
Piriformis Stretch - Lie on back with both knees bent. Cross one leg on top of the other. Pull opposite knee to chest until a stretch is felt in the buttock/hip area. Hold 20 seconds. Relax. Repeat 5 times each side.
Lumbar Stabilization Exercises With Swiss Ball
Lie on stomach over ball.
1. "Walk" hands out in front of ball until ball is under legs. Reverse to starting position.
2. "Walk" hands out in front of ball until ball is under legs and slowly raise alternating arms over head.
3. "Walk" hands out in front of ball and slowly perform push-ups.
Aerobic Exercises - Maintain spine in neutral position while stabilizing with abdominal muscles to protect the low back during aerobic exercise. 1. Stationary bike for 20 to 30 minutes. 2. Treadmill for 20 to 30 minutes.
Low Back Surgery
Low back problems may make it difficult for you to perform daily activities and may affect your ability to move freely. You may even feel pain while resting or lying down.
Medication, changes in daily activity and exercise may all play a role in improving your mobility and relieving your pain. Most low back pain problems, such as that caused by improper lifting, will disappear in a few days or weeks with care that doesn't require surgery.
Other pain, caused by the wear-and-tear of daily living that affects the vertebrae and disks in your back, may require surgery. You and your orthopaedic surgeon will discuss what is the best treatment for you.
This information will help you understand how your spine works, the causes of some back and leg pain and the benefits and limitations of surgery to relieve pressure on nerves in your spine and/or to stabilize your spine. You'll learn what is involved in making the decision for surgery, what to expect during and after surgery and how to avoid complications after surgery.
How the Normal Spine Works
Normal body movement, walking, standing, sitting, twisting and bending, is possible because of the unique structure of the spinal column.
There are 24 vertebrae in three upper segments of the spinal column. These three segments create three natural curves of the back: the curves of the neck area (cervical), chest area (thoracic) and lower back (lumbar). The lower segments of the spine (sacrum and coccyx) are made up of a series of vertebrae that are fused together.
Between the vertebrae are disks, which are cushioning pads that absorb pressure and allow spine movement.
The spinal column is held in alignment or balance by ligaments, cartilage and muscles that surround and protect the spinal cord membranes and the nerves that branch out to your legs, arms and all parts of your body.
Displacement (herniation) of the disk can lead to low back pain as well as pain and numbness in the legs (sciatic pain) and weakness of the muscles in one or both legs.
When the vertebrae are aligned, a canal is formed by the vertebral arch (lamina) that contains the spinal cord. Nerves pass through openings (foramina) of the adjoining vertebrae and into your arms and legs.
The muscles and ligaments attached to the vertebrae need to be kept in good condition to enable the spine to withstand the stresses of daily activity. A well-balanced, flexible spine is less likely to develop low back pain and is less likely to require medical treatment.
Common Causes of Low Back Pain
As a result of wear and tear on the spine, ligaments and disks, the disk may begin to protrude or collapse and put pressure on the nerve root leading to a leg or foot, causing pain in those areas (sciatica).
The problem can be aggravated by associated conditions, such as narrowing (stenosis) of the canal or shifting of the vertebra (spondylolisthesis), one upon the other.
You also may have low back pain from improper lifting of an object, a fall or sudden twisting. Most back pain from these causes is due to overuse of muscles and disappears in a few weeks.
Is Low Back Surgery for You?
If you have persistent back pain or pain in your thigh, buttock or leg; numbness or tingling in your leg; and/or weakness in your leg, and it doesn't respond to conservative, nonoperative treatment, your family doctor can refer you to an orthopaedic surgeon for an evaluation.
You and your orthopaedic surgeon will determine whether you would benefit from low back surgery which relieves pressure on the nerves in the spinal cord and/or stabilizes the spine.
The Orthopaedic Evaluation
The orthopaedic evaluation consists of four components:
- A medical history, in which your orthopaedic surgeon gathers information about your general health and asks about your symptoms.
- A physical examination to assess the stability, strength, alignment and motion of your back, as well as a neurological evaluation.
- Diagnostic tests such as X-rays, which may be obtained to evaluate the bones and structure of your spine. An MRI (Magnetic Resonance Imaging) may be arranged to provide more detailed information about the spine. MRIs are not X-rays and use no radiation to create images. A myelogram also may be requested. (A myelogram uses X-ray imaging and an injected dye to define bony and soft tissue structures affecting the nerve root.) Other imaging studies such as a CAT scan also may be ordered which provides details about the bones and soft tissues not seen on regular X-rays.
- Discussion by you and your orthopaedic surgeon of the findings of the physical and diagnostic examination and the treatment for your condition. Initially, medication and physical therapy may be prescribed to reduce inflammation at the site of the pain and to strengthen the muscles supporting the spinal column. If you are overweight, a weight reduction program may be suggested. In addition, you will be encouraged to begin a regular aerobic exercise program once your problem has been corrected.
Preparing for Surgery
You may be asked to stop taking certain medicine or to stop smoking. Depending on your age and general medical fitness, you may be asked to undergo a general medical checkup by your family doctor.
Medication Some medicines may interfere with or affect the results of your surgery. They may cause bleeding or may interfere with the effects of your anesthesia. These medications include aspirin and nonsteroidal anti-inflammatory drugs. Your doctor may ask you to stop taking the medication before your surgery.
Donating Blood Donating blood usually is not necessary for most low back surgery that does not include fusing vertebrae together. However, there is always a chance that some blood loss will occur during surgery. Your doctor will discuss the advantages and disadvantages of donating your own blood compared with using someone else's blood. If you decide to donate your own blood, your doctor may prescribe an iron supplement to help build up your blood before surgery.
Advance Planning You will be able to walk after surgery, but you may need to arrange for some help with washing, dressing and household activities, such as cleaning, laundry and shopping, for a few days after your return home. Your orthopaedic surgeon will probably recommend that you don't drive a car for a period of time after surgery. You will need to arrange for transportation to and from your hospital appointments and to other places that you need to go during this time. You should consult your doctor before taking car trips.
Patients usually are admitted to the hospital on the day of surgery. After admission, you will be taken to the preoperative preparation area where you will be interviewed by a doctor from the anesthesia department, who will review your medical history and physical examination reports. You and your doctor will discuss the type of anesthesia to be used. (Sometimes this is done during an outpatient visit up to seven days before your surgery.) The most common types of anesthesia used for low back surgery are general (you are asleep for the entire operation) or spinal (you may be awake but have no feeling from your waist down).
The surgical procedure usually takes one to three hours, depending on your problem. Your orthopaedic surgeon will remove a portion of bone and ligament overlying the nerve roots and will remove displaced disk material to relieve pressure on the nerve roots. Fusion is sometimes done at the same time, if an instability (spondylolisthesis) is present.
When your surgery is completed, you will be moved to the recovery room, where you will be observed and monitored by a nurse until you awake from your anesthesia. You will have an intravenous (IV) line inserted into a vein in your arm. You also may have a catheter inserted into your bladder to make urination easier.
When you are fully awake and alert, you will betaken to your hospital room. Your IV and catheter will be removed soon after.
Your Hospital Stay
You will feel some pain at the site of your surgery. Your doctor will prescribe pain medicines to help reduce this discomfort. You will be encouraged to breathe deeply and to cough frequently to avoid fluid build-up in your lungs. You may be given a small machine called an incentive spirometer (blow bottle) to help you.
You will be encouraged to begin walking on the same evening after your surgery or the next day to help speed your recovery. If your doctor orders a brace or support, you and your family members will be taught how to put it on and take it off.Physical Therapy
A physical therapist may instruct you on how to walk up and down stairs without assistance, how to sit properly and how to maintain good spinal balance. You also should exercise your legs in bed to help prevent blood clots. A follow-up program of physical therapy may be prescribed, depending on the situation.Possible Complications After Surgery
The incidence of complications after low back surgery is low. Major complications that can occur include, but are not limited to, infection, heart attack, stroke, blood clots and recurrent disk herniations. Although rare, new nerve damage can occur as a result of this surgery. These complications may result in pain and prolonged recovery time.
Your Recovery at Home
After your discharge from the hospital, you will need to follow your doctor's orders exactly to ensure a successful recovery. You should arrange for transportation home that will allow you to ride in a leaning back or lying down position. You may do as much for yourself as you can as long as you maintain a balanced position of your spine. You shouldn't stay in bed during the day. Don't hesitate to ask for help from your family members or friends if it is needed. If necessary, arrangements can be made for a home health aide.
Wound Care Your wound may be closed with stitches (sutures) or staples, which will be removed approximately two weeks after surgery. If the wound is clean and dry, no bandage is needed. If drainage continues after you are home, the wound should be covered with a bandage and a call made to your surgeon.
Diet Some loss of appetite is common. Eating well-balanced meals and drinking plenty of fluids is important. Your doctor may recommend iron supplement pills or vitamins before and after your surgery.
Activity Loss of energy is frequently experienced after major surgery, but this improves over time. An exercise program designed to gradually increase your strength and stamina may be prescribed. Initially, your doctor will recommend that you should only participate in walking. Later, he or she will encourage you to swim or use an exercise bike or treadmill to improve your general physical condition.
Avoiding Problems After Surgery
It is important that you carefully follow any instructions from your doctor relating to warning signs of blood clots and infection. These complications are most likely to occur during the first few weeks after surgery.
Warning signs of possible blood clots include the following:
- Swelling in the calf, ankle or foot
- Tenderness or redness, which may extend above or below the knee
- Pain in the calf
Occasionally, a blood clot will travel through the blood stream and may settle in your lungs. If this happens, you may experience a sudden chest pain and shortness of breath or cough. If you experience any of these symptoms, you should notify your doctor immediately. If you cannot reach your doctor, someone should take you to the hospital emergency room or call 911.
Infection following spine surgery occurs very rarely. Warning signs of infection include:
- Redness, tenderness and swelling around the wound edges
- Drainage from the wound
- Pain or tenderness
- Shaking chills
- Elevated temperature, usually above 100 degrees if taken with an oral thermometer
If any of these symptoms develop, you should contact your doctor or go to the nearest emergency room immediately.
After you have recovered from your low back surgery, you may continue to have some achy pain in your lower back; this may be persistent. You can reduce the pain by staying in good physical condition. If you are overweight, you should enroll in a program to help you lose weight and keep it off.
Your doctor will evaluate you after your surgery to make sure that your recovery is progressing as expected.
Your orthopaedic surgeon is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.
Lumbar Spinal Stenosis
The lumbar spine (lower back) provides a foundation to carry the weight of the upper body. It also houses the nerves that control the lower body. With aging, the discs in the front of the spine become dehydrated. The joints in the back of the spine become overgrown due to arthritis. These degenerative changes are the result of the normal "wear-and-tear" associated with aging. Over time these changes can also lead to narrowing, or stenosis, of the spinal canal.
Narrowing of the lumbar spinal canal pinches the nerves that control muscle power and sensation in the legs. Sometimes the pinched nerves become inflamed and cause pain in the buttocks and/or legs. These changes also can diminish the ability of the spine to carry the load of the upper body. They can lead to the forward slippage of one vertebra on another. This slippage, called "degenerative spondylolisthesis," can cause both back and leg pain.
Your orthopaedic surgeon can diagnose lumbar spinal stenosis using a combination of:
- Your symptoms
- Physical examination
- Plain X-rays
- Magnetic resonance imaging (MRI)
X-rays can show the presence of arthritis and slippage of the vertebrae. An MRI is used to determine whether nerves are being pinched. For people who cannot get an MRI (for example, people with pacemakers), a special test called a computed tomography (CT) myelogram may be necessary. This test requires the injection of a dye into the spine to make the nerves visible.
Lumbar spinal stenosis is usually caused by the wear-and-tear changes of aging. It usually affects middle-aged and older adults. People who are born with narrower spinal canals are more likely to develop this problem.
The best way to avoid the symptoms of lumbar spinal stenosis is to stay as physically fit as possible. Regular exercise can improve endurance and keep the muscles that support the spine strong. Avoiding weight gain can decrease the load that the lumbar spine has to carry. Patients should also avoid cigarette smoking. Both the smoke and the nicotine cause the spine to degenerate faster than normal.
Typically patients with lumbar spinal stenosis have a long history of pain in the back, buttocks or legs that gradually becomes worse. The symptoms are usually worsened by standing or walking upright. This results in an achy pain, tightness, heaviness and a sense of weakness in the buttocks and/or legs. These symptoms are generally relieved by sitting down or leaning forward. Although patients are unable to walk for very long, they may be able to ride an exercise bicycle for much longer. Some patients also find that it is easier to walk while leaning forward on a shopping cart. This position tends to create more space in the spinal canal. Leaning onto the handlebars of a bicycle creates the same effect. This relieves some of the pressure on the nerves.
Non-surgical options to relieve the symptoms of lumbar spinal stenosis include:
A program of physical therapy with activity modifications. A program of gentle physical therapy may help. This program usually includes:
- Aerobic conditioning--the exercise bicycle is a good way for patients with lumbar spinal stenosis to workout without pain. Pool exercises can help people who cannot do aerobic exercises on land.
- Strengthening exercises
- Other modalities
Anti-inflammatory medications--such as ibuprofen and naproxen--may be prescribed. These medications decrease pain and inflammation. Although they can be helpful, these medicines can have serious side effects. Prolonged use can lead to gastrointestinal ulcers, bleeding and kidney problems. Some of them may also increase the risk of heart attacks or strokes.
Epidural steroid injections. These injections deliver anti-inflammatory medication directly into the spinal canal and to the area of the inflammation. These injections are more effective than the medications taken by mouth. They may also have fewer side effects.
These injections deliver steroid medication straight to the nerve roots that are being pinched. Such steroid injections can give relief for weeks to months. They allow the patient to participate in more aggressive rehabilitation. In some cases, they may enable a patient to postpone or avoid surgical treatment altogether.
Bracing is generally not recommended for long-term use. If used for too long, bracing can lead to deconditioning of the muscles that support the back. Acupuncture or chiropractic manipulation can also be attempted.
All these nonsurgical treatments are aimed at decreasing inflammation. They also decrease the symptoms that patients experience. However, these treatments do not improve the narrowing of the spinal canal.
Treatment Options: Surgical
Most people with lumbar spinal stenosis do not require surgery. However, if patients are experiencing severe pain that limits their activities of daily living and their ability to have a good quality of life, surgery may be recommended. In general, surgery is only considered as a last resort if all attempts at non-surgical therapies are unsuccessful and if the overall potential benefits of surgery are greater than the potential risks. Surgery may be recommended on an urgent basis if a patient has severe weakness or loss of bowel and bladder control.
The surgical procedure for lumbar spinal stenosis involves removing the bone and soft tissue that are pinching the nerves. This is called "decompression" or "laminectomy." Some patients require only a decompression. However, patients with slippage of the spine or a curvature of the spine may require a stabilization procedure called fusion. In this procedure, two or more vertebrae are fused together using a bone graft harvested from the hip.
Fusion eliminates motion and prevents the slippage or curvature from worsening after surgery, which would cause more back and/or leg pain. Your surgeon may use screws and rods to hold the spine in place while the body heals the bone together (see Figure 2). Using screws and rods increases the rate of fusion and enables the patient to get out of the postoperative brace sooner. Overall the results of surgery are good to excellent in about 80 percent of patients. Patients tend to see better improvement of leg pain than back pain. Most patients are able to resume a normal lifestyle after a period of recovery from surgery.
There are some risks to surgery, including:
- Blood clots
- Reaction to anesthesia
- Tear of the sac covering the nerves (dural tear)
- Failure to relieve symptoms
- Return of symptoms after some time
- Failure of the bone fusion to heal
- Failure of screws or rods
- Need for further surgery
- Injury to the nerves
The risks of surgery depend on the patient and the exact procedure being performed. Elderly patients have higher rates of complications from surgery. So do overweight patients, diabetics, smokers and patients with multiple medical problems.
After surgery, patients may be hospitalized for several days, depending on the patient and the procedure performed. Relatively healthy patients who only have a decompression procedure may be able to return home the same day. They usually return to normal activities after a few weeks.
Patients who have a fusion procedure are hospitalized for several days. They usually receive an outpatient physical therapy program. A lumbar corset or brace may also be prescribed after surgery. They return to normal activities after two to three months. Older patients who need more physical therapy may be transferred from the hospital to a rehabilitation facility.
Research on the Horizon/What's New?
There are two areas of research that may change the way patients with spinal stenosis are treated. First, surgeons are developing ways to perform decompression procedures through smaller incisions. These techniques may cause less pain after the operation. They may allow quicker return to normal activities. Researchers are studying whether these new techniques are as effective and safe as the traditional procedures.
Surgeons are also beginning to use manufactured bone-forming proteins to fuse the spine. These proteins replace harvesting bone from the patient's hip. Harvesting a bone graft usually requires another skin incision. It can cause pain after the operation. However, the use of bone-forming proteins in the back of the spine for first-time surgeries is currently considered experimental. It is not approved by the U.S. Food and Drug Administration.
Preventing Back Pain at Work and at Home
Plan ahead what you want to do and don't be in a hurry. Position yourself close to the object you want to lift. Separate your feet shoulder-width apart to give yourself a solid base of support. Bend at the knees. Tighten your stomach muscles. Lift with your leg muscles as you stand up. Don't try to lift by yourself an object that is too heavy or an awkward shape. Get help.
To lift a very light object from the floor, such as a piece of paper, lean over the object, slightly bend one knee and extend the other leg behind you. Hold on to a nearby chair or table for support as you reach down to the object.
Whether you're lifting a heavy laundry basket or a heavy box in your garage, remember to get close to the object, bend at the knees and lift with your leg muscles. Do not bend at your waist. When lifting luggage, stand along side of the luggage, bend at your knees, grasp the handle and straighten up.
While you are holding the object, keep your knees slightly bent to maintain your balance. If you have to move the object to one side, avoid twisting your body. Point your toes in the direction you want to move and pivot in that direction. Keep the object close to you when moving.
If you must place an object on a shelf, move as close as possible to the shelf. Spread your feet in a wide stance, positioning one foot in front of the other, to give you a solid base of support Do not lean forward and do not fully extend your arms while holding the object in your hands.
If the shelf is chest high, move close to the shelf and place your feet apart and one foot forward. Lift the object chest high, keep your elbows at your side and position your hands so you can push the object up and on to the shelf. Remember to tighten your stomach muscles before lifting.
When sitting, keep your back in a normal, slightly arched position. Make sure your chair supports your lower back. Keep your head and shoulders erect. Make sure your working surface is at the proper height so you don't have to lean forward.
Once an hour, if possible, stand and stretch. Place your hands on your lower back and gently arch backward.
If you suddenly start feeling pain in your lower back or hip that radiates down from your buttock to the back of one thigh and into your leg, your problem may be a protruding disk in your lower spinal column pressing on the roots to your sciatic nerve. Sciatica (lumbar radiculopathy) may feel like a bad leg cramp that lasts for weeks before it goes away. You may have pain, especially when you sit, sneeze or cough. You may also feel weakness, "pins and needles" numbness, or a burning or tingling sensation down your leg. See a doctor to have your condition diagnosed and start a course of treatment.
You're most likely to get sciatica when you're 30-50 years old. It may happen due to the effects of general wear and tear, plus any sudden pressure on the disks that cushion the vertebrae of your lower (lumbar) spine. The gel-like inside (nucleus) of a disk may protrude into or through the disk's outer lining (annulus). This herniated disk may press directly on nerve roots that become the sciatic nerve. The nerve may also get inflamed and irritated by chemicals from the disk's nucleus. About one in every 50 people experience a herniated disk. Of these, 10-25 percent have symptoms lasting more than six weeks. About 80-90 percent of people with sciatica get better, over time, without surgery.
The condition usually heals itself if you give it enough time and rest. Tell your doctor how your pain started, where it travels and exactly what it feels like. A physical exam may help pinpoint the irritated nerve root. Your doctor may ask you to squat and rise, walk on your heels and toes or perform a straight leg raising test or other tests. Most cases of sciatica affect the L5 or S1 nerve roots. Later, X-rays and other specialized imaging tools such as MRI (magnetic resonance imaging) may confirm your doctor's diagnosis of which nerve roots are affected.
Treatment is aimed at helping you manage your pain without long-term use of medications. First, you'll probably need at least a few days of bed rest while the inflammation goes away. Nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen, aspirin or muscle relaxants may also help. You may find it soothing to put gentle heat or cold on your painful muscles. Find positions that are comfortable, but be as active as possible. Motion helps to reduce inflammation. Most of the time, your condition will get better within a few weeks. Sometimes, your doctor may inject your spine area with a cortisone-like drug. As soon as possible, start physical therapy with stretching exercises to help you resume your physical activities without sciatica pain. To start, your doctor may want you to take short walks.
You might need surgery only if after 3 months or more of treatment you still have disabling leg pain. A part of the herniated disk may be removed to stop it from pressing on your nerve. The surgery (laminotomy) may be done under local, spinal or general anesthesia. You have a 90 percent chance of successful surgery if most of your pain is in your leg. Avoid driving, excessive sitting, lifting or bending forward for at least a month after surgery. Your doctor may give you exercises to strengthen your back.
Following treatment for sciatica, you will probably be able to resume your normal lifestyle and keep your pain under control. However, it's always possible for your disk to rupture again. This happens to about 5 percent of people with sciatica.
In rare cases, a herniated disk may press on nerves that cause you to lose control of your bladder or bowel. If this happens, you may also have numbness or tingling in your groin or genital area. This is an emergency situation that requires surgery. Phone your doctor immediately.
What is scoliosis?
Everyone's spine has natural curves. These curves round our shoulders and make our lower back curve slightly inward. But some people have spines that also curve from side to side. Unlike poor posture, these curves can't be corrected simply by learning to stand up straight.
This condition of side-to-side spinal curves is called scoliosis. On an X-ray, the spine of an individual with scoliosis looks more like an "S" or a "C" than a straight line. Some of the bones in a scoliotic spine also may have rotated slightly, making the person's waist or shoulders appear uneven.
Who gets scoliosis?
Scoliosis affects a small percentage of the population, approximately 2 percent. However, scoliosis runs in families. If someone in a family has scoliosis, the likelihood of an incidence is much higher - approximately 20 percent. If anyone in your family has curvature of the spine, you should be examined for scoliosis.
Children - The vast majority of scoliosis is "idiopathic," meaning its cause is unknown. It usually develops in middle or late childhood, before puberty, and is seen more often in girls than boys. Though scoliosis can occur in children with cerebral palsy, muscular dystrophy, spinal bifida and other miscellaneous conditions, most scoliosis is found in otherwise healthy youngsters.
Adults - Scoliosis usually develops during childhood, but it also can occur in adults. Adult scoliosis may represent the progression of a condition that actually began in childhood, and was not diagnosed or treated while the person was still growing. What might have started out as a slight or moderate curve has progressed in the absence of treatment.
In other instances, adult scoliosis can be caused by the degenerative changes of the spine. Other spinal deformities such as kyphosis or round back are associated with the common problem of osteoporosis (bone softening) involving the elderly. As more and more people reach old age in the U.S., the incidence of scoliosis and kyphosis is expected to increase.
If allowed to progress, in severe cases adult scoliosis can lead to chronic severe back pain, deformity, and difficulty in breathing.
The importance of early detection - tips for parents
Idiopathic scoliosis can go unnoticed in a child because it is rarely painful in the formative years. Therefore, parents should watch for the following "tip-offs" to scoliosis beginning when their child is about 8 years of age:
- uneven shoulders
- prominent shoulder blade or shoulder blades
- uneven waist
- elevated hips
- leaning to one side
- Any one of these signs warrants an examination by the family physician, pediatrician or orthopaedist.
Some schools sponsor scoliosis screenings. Although only a physician can accurately diagnose scoliosis, school screenings can help alert parents to the presence of its warning signs in their child.
In planning treatment for each child, an orthopaedist will carefully consider a variety of factors, including the history of scoliosis in the family, the age at which the curve began, the curve's location and severity of the curve.
Most spine curves in children with scoliosis will remain small and need only to be watched by an orthopaedist for any sign of progression. If a curve does progress, an orthopaedic brace can be used to prevent it from getting worse. Children undergoing treatment with orthopaedic braces can continue to participate in the full range of physical and social activities.
Electrical muscle stimulation, exercise programs, and manipulation have not been found to be effective treatments for scoliosis.
If a scoliotic curve is severe when it is first seen, or if treatment with a brace does not control the curve, surgery may be necessary. In these cases, surgery has been found to be a highly effective and safe treatment.
Scoliosis is a common problem that usually requires only observation with repeated examination in the growing years. Early detection is important to make sure the curve does not progress. In the relatively small number of cases that need medical intervention, advances in modern orthopaedic techniques have made scoliosis a highly manageable condition. Orthopaedists, specialists in diseases of the muscles and skeleton, are the most knowledgeable and qualified group of physicians to diagnose, monitor and treat this condition.
Your orthopaedist is a medical doctor with extensive training in the diagnosis, and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.
This information has been prepared by the American Academy of Orthopaedic Surgeons, in cooperation with the Scoliosis Research Society (SRS), and is intended to contain current information on the subject from recognized authorities. However, it does not represent official policy of the Academy and SRS and its text should not be construed as excluding other acceptable viewpoints.
Scoliosis in Children and Adolescents
Many schools regularly conduct scoliosis screenings among students. Usually these screenings occur during the middle school years. If your child receives a referral for scoliosis based on a school screening, here are some facts you should know. Scoliosis:
- Is a sideways curvature of the spine that makes the spine look more like an "S" or "C" than a straight "I".
- Can cause the bones of the spine to turn (rotate) so that one shoulder, scapula (wingbone), or hip appears higher than the other.
- Can run in families. However, the exact cause of most cases of scoliosis is not known (idiopathic).
- Can occur at any age. Adolescent idiopathic scoliosis occurs after the age of 10. It is the most common type. Infantile scoliosis occurs in children less than 3 years old. It may result from a birth defect, disease of the nerves and muscles (such as muscular dystrophy or cerebral palsy), injury, infection or tumors. Juvenile scoliosis occurs in children between the ages of 3 and 10 years old. It is not common.
- Does not usually cause any pain.
- Small curves occur with similar frequency in boys and girls, but girls are more likely to have a progressive curve that will require treatment.
Diagnosis of scoliosis:
- Requires a thorough medical history to determine if any other problems may be causing the spine to curve.
- Includes a comprehensive physical examination. The doctor will ask your child to bend forward, which will show any deformities. He or she will also check for any limb-length discrepancies, abdominal muscle strain or other potential causes.
- Is confirmed with an X-ray of the spine. The physician will measure the degree of the curve as shown on the X-ray. The type of treatment required depends on the kind and degree of the curve, the child's age, the number of years of growing until the child reaches skeletal maturity and the type of scoliosis.
If left untreated, scoliosis exceeding 50 degrees can be problematic in the long-term. Progressive deterioration of the curve can occur, which in some cases can lead to diminished lung capacity and the development of restrictive lung disease. Cosmetic concerns are significant to many patients. The incidence of back pain among patients with scoliosis approximates that of the general population.
Observation: This option is appropriate when the curve is mild (less than 20 degrees) or if the child is near skeletal maturity. However, the doctor will want to recheck the curve on a regular basis to see that it is not progressively getting worse. You may be asked to return every 3 to 6 months for re-examination. Most cases of scoliosis referred through school screening will fall into this category.
Bracing: The goal of bracing is to prevent curves from getting worse. Bracing can be effective if the child is still growing and has a spinal curvature between 25 and 45 degrees. There are several types of braces, most being underarm. Your orthopaedist will recommend a brace and tell you how long it should be worn each day. Wearing a brace does not affect participation in sporting activities. Time out of brace is allowed for these activities.
Treatment Options: Surgical
Surgery: If the curve is more than 45 degrees and the child is still growing, the doctor may recommend surgery. If growth is finished, surgery may still be recommended for curves that exceed 50-55 degrees. Before the operation, your child may be asked to donate blood (which will be used during the surgery as needed). The surgery requires a bone graft from the hip, ribs or a bone bank. A series of rods, hooks, screws or wires are used to straighten the spine. Following surgery, patients are walking without a brace by the second or third day, are discharged from the hospital within a week and can rapidly resume their daily activities. A return to some sports is possible in 6 to 9 months.
Spinal fusion is a "welding" process by which two or more of the small bones (vertebrae) that make up the spinal column are fused together with bone grafts and internal devices such as metal rods to heal into a single solid bone. The surgery eliminates motion between vertebrae segments, which may be desirable when motion is the cause of significant pain. It also stops the progress of a spinal deformity such as scoliosis. A spinal fusion takes away some of the patient's spinal flexibility. Most spinal fusions involve relatively small spinal segments and thus do not limit motion very much. Spinal fusion is used to treat:
- Injuries to spinal vertebrae.
- Protrusion and degeneration of the cushioning disk between vertebrae (sometimes called slipped disk or herniated disk).
- Abnormal curvatures (such as scoliosis or kyphosis).
- Weak or unstable spine caused by infections or tumors.
More than 325,000 spinal fusions were performed in 2003. About 137,000 procedures involved the upper (cervical) spine. About 162,000 involved the lower (lumbar) spine. (Source: National Center for Health Statistics, Centers for Disease Control and Prevention; 2003 National Hospital Discharge Survey).
Bone is the most commonly used material to help promote fusion. Generally, small pieces of bone are placed into the space between the vertebrae to be fused. Sometimes larger solid pieces of bone are used to provide immediate structural support. Bone may come from:
- The patient (autogenous bone).
- A bank of bone harvested from other individuals (allograft bone).
Autogenous bone is generally considered superior at promoting fusion. But drawbacks to using it include extra surgery to remove bone from the patient's body such as the hip or pelvis. Allograft bone is available from bone banks. Other bone graft substitutes are being developed, but have yet to be proven as cost effective substitutes for autogenous bone graft for general use.
After the fusion procedure has been performed, the adjacent spinal segments are held immobile to allow fusion to progress. Immobilization is achieved through internal fixation devices or external bracing or casting. Both forms of immobilization may be necessary at times.
Risks for any surgery include bleeding and infection. Additional risks for spinal fusion surgery include urinary difficulties (retention) and temporary decreased or absent intestinal function. Patients can best prepare for spinal fusion surgery by:
- Thoroughly consulting with their doctor before surgery.
- Banking their blood.
- Achieving good nutritional status before and after surgery.
- Following a recommended exercise program before and after surgery.
- Maintaining a positive mental attitude.
- Stopping smoking.
There is usually pain for the first few days after surgery. Pain medication will be given regularly, perhaps by a patient-controlled analgesia (PCA). The patient will probably have a urinary catheter.
The fused spine must be kept in proper alignment. The patient will be taught how to move properly, reposition, sit, stand and walk. While in bed, the patient will be instructed to turn frequently using a "log rolling" technique in which the entire body is moved as a unit, not twisting the spine. The patient may be discharged from the hospital with a back brace or cast. The family will be taught how to provide care at home.
Spinal Surgery for Fractured Vertebrae
In older people with soft or brittle bones (osteoporosis), the bones of the spine (vertebrae) sometimes fracture or collapse. This causes pain and a "hunchback" appearance that get worse as time goes on. Certain forms of cancer also weaken the vertebrae and cause the same problems. A relatively new treatment for these conditions is a type of spinal surgery called "kyphoplasty" (ki'-fo-plass-tee).
What is the surgical procedure?
Kyphoplasty requires only two small incisions in the back. You can usually go home the same day. You may receive a general anaesthetic. This means that you will be completely unaware of what's going on. Or you may have an intravenous local anaesthetic. This numbs only the area of the surgery. Your surgeon or the anesthesiologist will discuss which is best for your case.
The surgery is performed on your back. You will lie face down on the operating table. The surgeon will make two small cuts, insert tubes through the openings, and then push tiny balloons through the tubes into the fractured vertebrae. The surgeon uses an X-ray machine to track the progress of the balloons.
When the balloons are in place, they are gently inflated. This pushes the bones back toward their normal height and shape. Pushing the vertebrae up leaves cavities within the bones. After removing the balloons, the surgeon use bone cement to fill the cavities. The tubes are removed as soon as the cement has hardened. This takes about 15 minutes. The incisions are so small that the surgeon will close them with a single stitch.
After kyphoplasty, you will not have any restrictions on what you can do. Your physician will encourage you to resume all your normal activities as soon as possible.
What results can I expect after kyphoplasty?
Early results on other patients have shown that kyphoplasty is a safe and effective method of reconstructing and stabilizing collapsed vertebrae in the spine resulting from osteoporosis or cancerous tumors. Most patients have excellent pain relief and straighter backs. This may result in added height. More than 95 percent of patients rate their treatment as successful and report that they are able to return to all their pre-fracture activities. Most patients do not need physical therapy or any other form of rehabilitation. They should take bone-strengthening medication during treatment.
A few patients complain of persistent pain after kyphoplasty. Sometimes the area is painful because the tissues have been irritated by the procedure. If this is the case, the pain should get better within two weeks. Other patients may have underlying degenerative arthritis in the spine. With these patients, the usual treatment is medication and an ongoing exercise program. If you have persistent pain after kyphoplasty, talk to your doctor about what can be done to relieve it.
For the best results, kyphoplasty should be performed as soon as possible after spinal bone collapse or fracture. The results are less predictable in older fractures but in certain circumstances may still be beneficial.
If you have severe osteoporosis, spinal bones that were not treated could collapse or fracture at other levels of the spine. If this happens, you can have another kyphoplasty to treat these bones. However, kyphoplasty tends to help prevent further fractures by keeping the spine aligned in its proper upright position.
What are the risks with kyphoplasty?
The use of anaesthetics carries some risks in all surgeries. The risks depend on your overall health.
There is a slight possibility that bone cement will leak outside the vertebrae. This happens in less than 10 percent of patients. In most cases, it does not cause any problems. Very rarely, the cement may irritate or damage the spinal cord or nerves. This can cause pain and/or altered sensation. The risk of paralysis as a result of leaking cement is estimated to be less than one case in 10,000 cases. Though it is seldom required, surgery could be necessary to remove any cement that has leaked.
There is also an extremely small chance that cement could travel to the lungs and an even smaller chance that the cement block could cause infection at the time of surgery or even years after surgery. These complications would be treated with medications and/or surgery.
Who should not have kyphoplasty?
Kyphoplasty is recommended for older patients with vertebral collapse or fracture due to osteoporosis or tumor only. It is not suitable for:
- Patients with young, healthy bone
- Young patients whose fractures or collapse of the vertebrae are due to high energy accidents or injury
- Patients with spinal curvature, such as scoliosis or kyphosis, due to causes other than osteoporosis
- Patients with spinal stenosis or herniated discs with nerve or spinal cord compression and loss of neurological function
Spondylolysis and Spondylolisthesis
The most common X-ray identified cause of low back pain in adolescent athletes is a stress fracture in one of the bones (vertebrae) that make up the spinal column. Technically, this condition is called spondylolysis (spon-dee-low-lye-sis). It usually affects the fifth lumbar vertebra in the lower back, and much less commonly, the fourth lumbar vertebra.
If the stress fracture weakens the bone so much that it is unable to maintain its proper position, the vertebra can start to shift out of place. This condition is called spondylolisthesis (spon-dee-low-lis-thee-sis). If too much slippage occurs, the bones may begin to press on nerves and surgery may be necessary to correct the condition.
Genetics: There may be a hereditary aspect to spondylolysis. An individual may be born with thin vertebral bone and therefore be vulnerable to this condition. Significant periods of rapid growth may encourage slippage.
Overuse: Some sports, such as gymnastics, weight lifting and football, put a great deal of stress on the bones in the lower back. They also require that the athlete constantly over-stretch (hyperextend) the spine. In either case, the result is a stress fracture on one or both sides of the vertebra.
- In many people, spondylolysis and spondylolisthesis are present, but without any obvious symptoms.
- Pain usually spreads across the lower back, and may feel like a muscle strain.
- Spondylolisthesis can cause spasms that stiffen the back and tighten the hamstring muscles, resulting in changes to posture and gait. If the slippage is significant, it may begin to compress the nerves and narrow the spinal canal.
X-rays of the lower back (lumbar) spine will show the position of the vertebra.
The pars interarticularis is a portion of the lumbar spine. It joins together the upper and lower joints. The pars is normal in the vast majority of children.
If the pars "cracks" or fractures, the condition is called spondylolysis. The X-ray confirms the bony abnormality.
If the fracture gap at the pars widens, then the condition is called spondylolisthesis. Widening of the gap leads to the fifth lumbar vertebra shifting. It shifts forward on the part of the pelvic bone called the sacrum. The doctor measures standing lateral spine X-rays. This determines the amount of forward slippage.
If the vertebra is pressing on nerves, a CT scan or MRI may be needed before treatment begins to further assess the abnormality.
Initial treatment for spondylolysis is always conservative. The individual should take a break from the activities until symptoms go away, as they often do. Anti-inflammatory medications such as ibuprofen may help reduce back pain. Occasionally, a back brace and physical therapy may be recommended. In most cases, activities can be resumed gradually and there will be few complications or recurrences. Stretching and strengthening exercises for the back and abnormal muscles can help prevent future recurrences of pain.
Periodic X-rays will show whether the vertebra is continuing to slip.
Treatment Options: Surgical
Surgery may be needed if slippage continues or if the back pain does not respond to conservative treatment and begins to interfere with activities of daily living. A spinal fusion is performed between the lumbar vertebra and the sacrum. Sometimes, an internal brace of screws and rods is used to hold together the vertebra as the fusion heals.
More than 31 million visits were made to physician offices in 2003 because of back problems (Source: National Center for Health Statistics; Centers for Disease Control and Prevention; 2003 National Ambulatory Medical Care Survey.) Eight out of 10 people will experience back pain at some point in their lives. Low back pain is one of the most frequent problems treated by orthopaedic surgeons.
What is the lower back?
Your lower back is a complex structure of vertebrae, disks, spinal cord, and nerves, including:
- five bones called lumbar vertebrae - stacked one upon the other, connecting the upper spine to the pelvis
- six shock absorbers called disks - acting both as cushion and stabilizer to protect the lumbar vertebrae
- spinal cord and nerves - the "electric cables" which travel through a central canal in the lumbar vertebrae, connecting your brain to the muscles of your legs
- small joints - allowing functional movement and providing stability
- muscles and ligaments - providing strength and power and at the same time support and stability
How does the spine work?
The lower or lumbar spine is a complex structure that connects your upper body (including your chest and arms) to your lower body (including your pelvis and legs). This important part of your spine provides you with both mobility and strength. The mobility allows movements such as turning, twisting or bending; and the strength allows you to stand, walk and lift. Proper functioning of your lower back is needed for almost all activities of daily living. Pain in the lower back can restrict your activity, reduce your work capacity and diminish your quality of life.
What are the common causes?
Low back pain can be caused by a number of factors:
- Protruding Disk
- Osteoporosis and Fractures
- Low Back Sprain and Strain
The muscles of the low back provide power and strength for activities such as standing, walking and lifting. A strain of the muscle can occur when the muscle is poorly conditioned or overworked. The ligaments of the low back act to interconnect the five vertebral bones and provide support or stability for the low back. A sprain of the low back can occur when a sudden, forceful movement injures a ligament which has become stiff or weak through poor conditioning or overuse.
Back pain caused by lifting can be prevented if you use proper lifting techniques and exercise regularly to improve your muscle strength and overall physical condition. The normal effects of aging that result in decreased bone mass, and decreased strength and elasticity of muscles and ligaments, can't be avoided.
However, the effects can be slowed by:
- exercising regularly to keep muscles that support your back strong and flexible
- using the correct lifting and moving techniques
- maintaining your proper body weight; being overweight puts a strain on your back muscles
- avoid smoking
- maintaining a proper posture when standing and sitting; don't slouch
Staying in shape
You can reduce the risk of back pain if you stay in good physical shape.
Recreational activities such as swimming, bike riding, running or walking briskly will keep you in good physical condition. There also are specific exercises that are directed toward strengthening and stretching your back, stomach, hip and thigh muscles as well as exercises to decrease the strain on your lower back. Consult your physician about a proper exercise program.