Lumbar

The lumbar region of the spine, or lower back, contains some of the strongest bones in the body, as they support much of your body's own weight. It is also a very common area for injuries. Some lower back pain results from muscle injury, such as a sprain or strain. Pain from nerve root compression is most common in the lumbar region.

Herniated Lumbar Discs

Between every vertebra is a soft cushion called an intervertebral disc. A herniated disc is the most common cause of lower back pain. Careful diagnosis is key. Differentiating between muscle pain and a herniated disc is the job of a physician. Your job as a patient is to accurately describe your pain to your doctor.

The disc is made up of two components. There is a central jelly-like component and an outer, thick cartilaginous component. If you get a tear in the outer thick part, then that jelly-like center can come out. This can put pressure on the nerve which originates in that vertebra, and it can also irritate the nerve chemically. That is why you get a severe pain right away, but as that chemical irritation washes out, that can ease up. And normally it is pressure on a single nerve because one particular nerve originates, or begins, at each vertebra.

The problem may result from wear and tear on the disc that develops over time and is then triggered by an episode. In certain cases, one severe traumatic episode can, in itself cause a herniated disc; however there is usually some kind of underlying abnormality that causes a herniated disc.

Some factors that can cause a herniated disc are:

Back pain should first be treated conservatively with nonsteroidal anti-inflammatory medication, such as ibuprofen. If conservative therapy fails, your doctor can consider something like an epidural steroid injection. This treatment is done in the operating room, where an injection of steroid medication is placed in the space around the nerves to help decrease the inflammation, which may relieve the pain. If steroid injections do not help, your doctor may consider surgery.

The golden rule is, unless there's a neurological deficit, surgical intervention should not be considered for at least six weeks. It is said that 80% of the world's population will have back pain at some time in their lives. Probably 80% to 90% of those who do suffer back pain will get better with little or no treatment. Back pain is the number one reason for visits to the doctor, after the common cold, and is one of the leading causes of lost work days and Workers' Compensation injuries.

Surgery for a herniated disc is a very common procedure. The most standard way is called a microdiscectomy. A small incision is made and your doctor takes just the herniated part of the disc out and any of the loose material - usually done through small open incision with or without a microscope. There are some surgeons that are doing it arthroscopically, that is using a laparoscope and even smaller incisions, and taking the piece of herniated disc out. Ask your own doctor about the pros and cons of either method.

Spinal stenosis of the lower back

Lumbar Spinal Stenosis (LSS) is the medical term for narrowing of the spine. In most cases it is due to arthritis which has developed over a fairly long length of time; in other words, the usual wear and tear of aging. An estimated 400,000 Americans may be afflicted with spinal stenosis.

Think of the spinal canal as a big water pipe in which all the nerves run, and it is clogged up by this arthritic buildup - there's no more room left for the nerves. Because there is no room left for the nerves, they become impinged, inflamed and ultimately very painful, making it difficult to walk. LSS makes walking difficult because of the neurological symptoms in the lower extremities. You may find walking easier when leaning on a shopping carriage or that using an exercise bicycle may be easier than walking. This is because leaning forward relaxes the spinal canal, making it easier to move the lower extremities.

The diagnosis is typically made through the use of magnetic resonance imaging (MRI). The LSS presents as a compromise or narrowing due to this arthritic buildup of the space in the spinal canal usually occupied by the nerves. Treatment begins with nonsteroidal medications and failing that, steroidal medicine by mouth. If that does not work, epidural steroid injections may be tried. In addition, physical therapy may be used to maintain strength and agility where possible. If conservative treatment does not work, and you cannot move without pain, then surgery may be recommended. The surgery consists of removing the arthritic buildup to essentially give the space back to the nerves and open up a canal.

The most common procedures for spinal stenosis are Laminectomy, Laminotomy, Foraminotomy and Spinal Fusion.

Laminectomy

Decompression of the spinal canal by laminectomy means that the lamina or outer part of the vertebra bone over the spinal canal is removed and the facet joints are trimmed to give the spinal cord more room.

Laminotomy

Laminotomy removes only a portion of the lamina; enough to ease tension on the spinal canal, which sometimes is enough to relieve the symptoms of spinal stenosis.

Foramenotomy

Neuroforamen is the space between the vertebra, where the nerve roots pass. In this procedure, the neuroforamen is reduced to ease tension on the nerve root or spinal canal.

Spinal Fusion

If two vertebra slip due to spinal fusion, repair by the above methods may not be possible. Small pieces of bone from elsewhere in the body or donated bone tissue will be used to surgically connect the two vertebra, preventing slippage. A laminectomy may be performed at the same time, if indicated.

Wire, screws, plates or rods may also be used to permanently fasten the vertebra together. Healing of a spinal fusion is a similar process to the healing of a fracture.

Spinal Instability

Each of the vertebral bodies or bones are connected to the next by two small joints in the back and the disc in the front. When those two joints in the back and the disc in the front become degenerative or arthritic, there is a potential for instability, where enough abnormal motion leads to significant pain in the back.

Patients who have abnormal motion of the spine usually present predominantly with back pain, with or without leg pain. Patients with herniated discs or stenosis have primarily leg pain or neurological pain. Those with instability present primarily with back pain versus leg pain, due to the fact that there is significant degenerative disease,occurring both at the joints, as well as the disc that connect up each vertebra.

Over time, the degenerative disease allows abnormal motion to take place between each vertebra, very much like an arthritic hip. It is the abnormal motion that causes mechanical pain or pain due to the degenerative joint or disc disease.

The more pain, the more walking, the more activity, the more it hurts; just like it would if you had a degenerative knee or hip joint (arthritis). Instead of going down the leg, pain typically is present primarily in the back.

Diagnosis is determined by a combination of MRI and x-rays. During the series of x-rays, the patient bends backward and forward, what's called flexion/extension, to demonstrate instability or abnormal motion between the vertebrae.

If the pain does not respond to conservative treatment, first with nonsteroidal medicine, then in certain cases, physical therapy may increase the strength of the muscles adjacent to that area to give some pain relief. If those two conservative measures fail, then the next step is surgery, which in the case of instability would involve a fusion.

Fusion means that the two vertebrae that are unstable are joined, or fused together. This is usually accomplished by putting in a bone graft, which may come from the patient (autograft), cadaver (allograft), or bone substitute (synthetic material). Over about a six-month period, the bone graft solidifies so that any motion that had been taking place between the two vertebrae is eliminated.

Spinal disc problems and stenosis are generally age-specific conditions. Disc pathologies are usually found in the 18 to 50 year old age group.

Bone Stimulation - For Spinal Fusion

High risk patients with the following conditions may be at risk for developing a nonunion or pseudoarthrosis.

Patients with these risk factors may experience decreased chances to successfully fuse. However, electrical bone growth stimulation has been shown to increase these chances.

A direct current stimulator may be implanted during the surgery. An alternative is a noninvasive stimulator, which is not implanted, but uses electrodes placed over the skin. Different types of electrical stimulation are delivered through the skin or with cutaneous electrodes.

Statistically, the number of patients who heal successfully at the end of a six-month period is higher with electrical stimulation than without it. Although other patient factors mentioned above affect healing, the success rate is anywhere between 78%-85%.

Electrical stimulation enhances the healing of the bone. The biologic process by which the bone heals is actually accelerated and turned on by the electric stimulation.

Interbody Spine Fusions

Anterior Lumbar Interbody Fusion (ALIF)

ALIF surgery treats lower spine instability or disc disease. Anterior means "from the front". In other words, the surgeon approaches the spine through the abdomen rather than from the back. The purpose of this approach is to treat the front of the spinal segment being corrected. One advantage of ALIF is avoidance of nerves and back muscles during surgery. However, surgeons need to avoid the aorta and vena cava when approaching the spine from the anterior.

When treating collapsed disc spaces using the ALIF procedure, bone graft materials or titanium cages are inserted into the vertebral space to reinforce the spine and relieve pressure on the nerve roots.

Posterior Lumbar Interbody Fusion (PLIF)

PLIF approaches spinal instability or degenerative disc disease from the back. In this operation bone graft materials or cages are inserted into the disc space while cutting away bone to free up the nerve roots. However, the posterior approach (PLIF) is more difficult than the ALIF, due to difficulty with exposure, available surface area for healing and the fact that a posterior approach is used to treat an anterior part of the spine. PLIF has a greater chance of nonunion than ALIF.

Transforaminal Lumbar Interbody Fusion (TLIF)

Difficulties encountered with PLIF led to the development of TLIF. More of the vertebra is removed to increase the exposure and allow for a larger implant to be used in the vertebral space. TLIF and all lumbar interbody fusions run the risk of nonunion. The chance of a nonunion is affected by cigarette smoking, nutrition, obesity and a history of previous surgery.

Spinal Fracture

Fracture of the vertebra is a much more serious condition. Depending on the type of fracture and the risk of spinal cord injury, the treatment varies from just a couple days of bed rest to extensive surgical procedures.

Fractured vertebrae are often the result of motor vehicle accidents or serious sports injuries, and may be simultaneous with serious injuries to other parts of the body. Patients with these injuries are usually taken to a trauma center. Since paralysis is a serious risk, never attempt to move someone with a suspected spinal injury.

Less severe spinal injuries, such as compression fractures, may not require surgery, but may require 6 to 12 weeks or more in a brace to promote healing. Serious fractures of the spine may require surgery. Screws, rods and bone grafts are used to repair the broken bones of the spine. A spinal fusion may be performed.