What is Low Back Pain

What is Low Back Pain?

BACH AND HERNIAIf you have low back pain you are not alone. 240 million people report to have visited a doctor annually for a low back related pain in the U.S. about 80 percent of adults experience low back pain at some point in their lifetimes and it is responsible for 40% of the job-related disability and a leading contributor to missed work days. The number one in job related disability worldwide.

A 2010 a study, ranking the most burdensome conditions in the U.S. in terms of mortality or poor health as a result of disease put low back pain in third place, with only ischemic heart disease and chronic obstructive pulmonary disease ranking higher.

Low back pain is characterized by sensations of pain and discomfort that arise in the lower back, specifically in the area just below the costal margin and above the inferior gluteal folds. Low back pain can sometimes include pain that radiates into the leg (sciatica)

The specific symptoms or sensations of low back pain are widely varied. Some patients will experience the pain as a highly specific sharp stab, while others will describe the pain as more generalized and widespread. Further, the symptoms of low back pain are expected to fluctuate over time. For instance, often dependent on environmental circumstances, a patient may fluctuate in and out of recurring symptoms and exacerbations of pain.

 

What structures make up the back?

SPINE
The lower back where most back pain occurs includes the five vertebrae (referred to as L1-L5) in the lumbar region, which supports much of the weight of the upper body. The spaces between the vertebrae are maintained by round, rubbery pads called intervertebral discs that act like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments hold the vertebrae in place, and tendons attach the muscles to the spinal column. Thirty-one pairs of nerves are rooted to the spinal cord and they control body movements and transmit signals from the body to the brain.
Low back pain can be classified as either acute or chronic. Acute low back pain is characterized as a short-term pain episode, typically lasting between several days to several weeks. Chronic low back pain is characterized as a pain episode whose duration is much longer. A pain episode is considered chronic if it persists for more than three months.

Epidemiology and Impact of Low Back Pain

What causes lower back pain?


TODO HERNIA DISCAL
The vast majority of low back pain is mechanical in nature. In many cases, low back pain is associated with spondylosis, a term that refers to the general degeneration of the spine associated with normal wear and tear that occurs in the joints, discs, and bones of the spine as people get older. Some examples of mechanical causes of low back pain include:
   Sprains and strains account for most acute back pain. Sprains are caused by overstretching or tearing ligaments, and strains are tears in tendon or muscle. Both can occur from twisting or lifting something improperly, lifting something too heavy, or overstretching. Such movements may also trigger spasms in back muscles, which can also be painful.
   Intervertebral disc degeneration is one of the most common mechanical causes of low back pain, and it occurs when the usually rubbery discs lose integrity as a normal process of aging. In a healthy back, intervertebral discs provide height and allow bending, flexion, and torsion of the lower back. As the discs deteriorate, they lose their cushioning ability.
   Herniated or ruptured discs can occur when the intervertebral discs become compressed and bulge outward (herniation) or rupture, causing low back pain.
   Radiculopathy is a condition caused by compression, inflammation and/or injury to a spinal nerve root. Pressure on the nerve root results in pain, numbness, or a tingling sensation that travels or radiates to other areas of the body that are served by that nerve. Radiculopathy may occur when spinal stenosis or a herniated or ruptured disc compresses the nerve root.
   Sciatica is a form of radiculopathy caused by compression of the sciatic nerve, the large nerve that travels through the buttocks and extends down the back of the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and the adjacent bone, the symptoms may involve not only pain, but numbness and muscle weakness in the leg because of interrupted nerve signaling. The condition may also be caused by a tumor or cyst that presses on the sciatic nerve or its roots.
   Spondylolisthesis is a condition in which a vertebra of the lower spine slips out of place, pinching the nerves exiting the spinal column.
   A traumatic injury, such as from playing sports, car accidents, or a fall can injure tendons, ligaments or muscle resulting in low back pain. Traumatic injury may also cause the spine to become overly compressed, which in turn can cause an intervertebral disc to rupture or herniate, exerting pressure on any of the nerves rooted to the spinal cord. When spinal nerves become compressed and irritated, back pain and sciatica may result.
Compression fractures. There is a higher prevalence of this among post-menopausal women with osteoporosis and in those who have had long-term corticosteroid use. One study, examining 7,000 women over the age of 65, found that 5% had sustained a compression fracture of a vertebra over the course of a four-year period. Previous evidence suggests that approximately 4% of adults seen in primary care settings can attribute their symptoms of low back pain to a compression fracture.
   Spinal stenosis is a narrowing of the spinal column that puts pressure on the spinal cord and nerves that can cause pain or numbness with walking and over time leads to leg weakness and sensory loss.
   Skeletal irregularities include scoliosis, a curvature of the spine that does not usually cause pain until middle age; lordosis, an abnormally accentuated arch in the lower back; and other congenital anomalies of the spine.
Low back pain is rarely related to serious underlying conditions, but when these conditions do occur, they require immediate medical attention. Serious underlying conditions include:
   Infections are not a common cause of back pain. However, infections can cause pain when they involve the vertebrae, a condition called osteomyelitis; the intervertebral discs, called discitis; or the sacroiliac joints connecting the lower spine to the pelvis, called sacroiliitis.
   Tumors are a relatively rare cause of back pain. Occasionally, tumors begin in the back, but more often they appear in the back as a result of cancer that has spread from elsewhere in the body.
   Cauda equina syndrome is a serious but rare complication of a ruptured disc. It occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots, causing loss of bladder and bowel control. Permanent neurological damage may result if this syndrome is left untreated.
   Abdominal aortic aneurysms occur when the large blood vessel that supplies blood to the abdomen, pelvis, and legs becomes abnormally enlarged. Back pain can be a sign that the aneurysm is becoming larger and that the risk of rupture should be assessed.
   Kidney stones can cause sharp pain in the lower back, usually on one side.
Other underlying conditions that predispose people to low back pain include:
   Inflammatory diseases of the joints such as arthritis, including osteoarthritis and rheumatoid arthritis as well as spondylitis, an inflammation of the vertebrae, can also cause low back pain. Spondylitis is also called spondyloarthritis or spondyloarthropathy.
   Osteoporosis is a metabolic bone disease marked by a progressive decrease in bone density and strength, which can lead to painful fractures of the vertebrae.
   Endometriosis is the buildup of uterine tissue in places outside the uterus.
   Fibromyalgia, a chronic pain syndrome involving widespread muscle pain and fatigue.


Pathophysiology of Low Back Pain

 Epidemiology and Impact of Low Back Pain


Prevalence estimates suggest that up to 84% of adults will experience some form of lower back pain over the course of their lifetime. Relapse of low back pain is also of concern. Some evidence has suggested that between 44% and 78% of adults who have experienced an episode of low back pain will experience a relapse in pain.

According to the Center for Disease Control (CDC), low back pain has been linked with significant individual disability that is likely to have detrimental impacts on the individual’s functioning both at home and at work. Low back pain is also associated with a negative economic impact. The National Institutes of Health (NIH) have estimated that low back pain costs people in the U.S. approximately $50 billion every year. Indeed, low back pain is considered to be the leading contributor to missed work, as well as the most common cause of employment-related disability. Low back pain is also to blame for decreased productivity at work and increases in health care utilization.

Acute episodes of low back pain can lead to chronic difficulties with low back pain. Not surprisingly, chronic low back pain can cause significant negative impacts to an individual’s daily functioning. Indeed, approximately 12% of the population is disabled by chronic low back pain. Typically, chronic pain episodes progress very slowly over time, from a dull pain to more severe pain. Little evidence is available on the prevalence of chronic, nonspecific low back pain. Chronic and nonspecific low back pain is defined as low back pain where a specific source, such as a tumor, injury, or osteoporosis, cannot be identified. Some have suggested that lifetime prevalence rates of chronic nonspecific low back pain are as high as 23%. This high prevalence may suggest that a large proportion of the adult population is forced to manage a debilitating condition on a day-to-day basis. It is likely that many of these individuals are also unable to work because of their pain condition.

It is for these reasons that low back pain has received such extensive empirical attention. Over the course of the last ten years there has been a significant increase in studies exploring prognostic factors of low back pain, as well as randomized control trials testing the effectiveness of the varying treatment options available.


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Symptoms and Diagnosis of Low Back Pain

 Mechanism of Low Back Pain
Prior to considering treatment options for low back pain, it is imperative that the patient and physician accurately identify the cause of the pain.

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The back is comprised of a complex network of bones, muscles, and other tissues that span from the neck to the pelvic bone. The spinal column is a bony structure that acts as the body’s support and protects the delicate spinal cord. The spinal column is positioned such that the individual bones of the spine, or the vertebrae, link together creating a flexible support.

Inside of this column, the spinal cord descends down from the brain. In a typical adult, the spinal cord reaches to just below the rib cage. The spaces between the individual vertebrae making up the spinal column are cushioned with pads of cartilage, also known as intervertebral discs. The intervertebral discs not only act as shock absorbers, but they contribute to the overall flexibility within the lower back. Attached to each invertebrate are also ligaments and muscles that provide strength and mobility. Each of these individual components of the back are susceptible to typical every day wear and tear damage, as well as more acute trauma, all of which can lead to a pain condition in the lower back.


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Treatment for Low Back Pain

 Symptoms and Diagnosis of Low Back Pain

While the specific symptom clusters generally depend on the underlying cause, some common complaints associated with low back pain include:

  •    Cramping 
  •    Stiffness 
  •    Muscle spasms 
  •    Radiating pain 
  •    Tingling, numbness, or weakness 
  •    Sensitivity to touch or pressure

How is low back pain diagnosed?

The assessment of low back pain will likely include a brief yet detailed history gathered by your physician. The goal of the assessment is to ensure an accurate diagnosis of the source of the pain. In many cases, the precise cause is not identified. In these instances, however, the physician will ensure that certain diagnoses are ruled out. Specifically, in terms of low back pain, the physician will be sure to rule out any specific spinal pathology and nerve root pain.

Your physician will also generally assess for your degree of risk for persistent difficulties with low back pain, by asking about prognostic indicators. These factors, also known as “yellow flags” will provide the physician with the information necessary to determine the most appropriate treatment and follow-up plan. The prognostic indicators identified in relation to low back pain include work-related factors, psychosocial distress, depressed mood, severity of pain, degree of functional impact, prior episodes of low back pain, extreme report of symptoms, and patient perceptions.

Signs that there may be a serious problem, or “red flags,” include extreme patient age (i.e., less than 20 years of age or older than 55 years of age), non-mechanical pain, thoracic pain, history of cancer, steroid use, structural changes, general unwellness, weight loss, or diffuse neurological deficits. These may be indicators of a more serious condition, such as neoplasm, underlying infection, tumor, fracture, inflammatory disorder, or cauda equine syndrome. While a patient exhibiting one of these signs does not necessarily guarantee the presence of an underlying condition, it is suggestive of an increased risk. It is recommended that a patient receive further evaluation should they present with more than one red flag.

Imaging tests are not warranted in most cases. Under certain circumstances, however, imaging may be ordered to rule out specific causes of pain, including tumors and spinal stenosis. Imaging and other types of tests include:

X-ray is often the first imaging technique used to look for broken bones or an injured vertebra. X-rays show the bony structures and any vertebral misalignment or fractures. Soft tissues such as muscles, ligaments, or bulging discs are not visible on conventional x-rays.

Computerized tomography (CT) is used to see spinal structures that cannot be seen on conventional x-rays, such as disc rupture, spinal stenosis, or tumors. Using a computer, the CT scan creates a three-dimensional image from a series of two dimensional pictures.

Myelograms enhance the diagnostic imaging of x-rays and CT scans. In this procedure, a contrast dye is injected into the spinal canal, allowing spinal cord and nerve compression caused by herniated discs or fractures to be seen on an x-ray or CT scans.

Discography may be used when other diagnostic procedures fail to identify the cause of pain. This procedure involves the injection of a contrast dye into a spinal disc thought to be causing low back pain. The fluid’s pressure in the disc will reproduce the person’s symptoms if the disc is the cause. The dye helps to show the damaged areas on CT scans taken following the injection. Discography may provide useful information in cases where people are considering lumbar surgery or when their pain has not responded to conventional treatments.

Magnetic resonance imaging (MRI) uses a magnetic force instead of radiation to create a computer-generated image. Unlike x-ray, which shows only bony structures, MRI scans also produce images of soft tissues such as muscles, ligaments, tendons, and blood vessels. An MRI may be ordered if a problem such as infection, tumor, inflammation, disc herniation or rupture, or pressure on a nerve is suspected. MRI is a noninvasive way to identify a condition requiring prompt surgical treatment. However, in most instances, unless there are “red flags” in the history or physical exam, an MRI scan is not necessary during the early phases of low back pain.

Electrodiagnostics are procedures that, in the setting of low back pain, are primarily used to confirm whether a person has lumbar radiculopathy. The procedures include electromyography (EMG), nerve conduction studies (NCS), and evoked potential (EP) studies. EMG assesses the electrical activity in a muscle and can detect if muscle weakness results from a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body. NCSs are often performed along with EMG to exclude conditions that can mimic radiculopathy. In NCSs, two sets of electrodes are placed on the skin over the muscles. The first set provides a mild shock to stimulate the nerve that runs to a particular muscle. The second set records the nerve’s electrical signals, and from this information nerve damage that slows conduction of the nerve signal can be detected. EP tests also involve two sets of electrodes—one set to stimulate a sensory nerve, and the other placed on the scalp to record the speed of nerve signal transmissions to the brain.

Bone scans are used to detect and monitor infection, fracture, or disorders in the bone. A small amount of radioactive material is injected into the bloodstream and will collect in the bones, particularly in areas with some abnormality. Scanner-generated images can be used to identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.

Ultrasound imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the back.

Blood tests are not routinely used to diagnose the cause of back pain; however in some cases they may be ordered to look for indications of inflammation, infection, and/or the presence of arthritis. Potential tests include complete blood count, erythrocyte sedimentation rate, and C-reactive protein. Blood tests may also detect HLA-B27, a genetic marker in the blood that is more common in people with ankylosing spondylitis or reactive arthritis (a form of arthritis that occurs following infection in another part of the body, usually the genitourinary tract).


Treatment for Low Back Pain

Low back pain has received extensive attention within the literature, and many of the currently available interventions for managing low back pain have undergone rigorous investigation before ultimately receiving empirical support. Given the diversity in the underlying causes of low back pain, it is best to discuss your condition with your physician so as to determine the best available pain management treatment plan.

If you are experiencing problematic symptoms of low back pain, it is recommended that you discuss your worries and concerns with a physician. Your physician will be able to answer your questions about low back pain and the treatment options available. In addition, your physician will likely provide you with lots of information and educational resources about the condition. If your low back pain is not severe and is not causing you any significant impairment, it is likely that your physician will encourage you to make a gradual return to the typical levels of activity maintained prior to the onset of low back pain. Previous work in the field of back pain has suggested that up to 90% of all low back pain patients will see significant improvements in their symptoms of pain by engaging in conservative treatments, such as physical therapy.

In addition to providing patients with relief from the distressing symptoms of pain, treatment interventions are focused on reducing the level of impairment low back pain has on the patient’s life, as well as any accompanying disability. For instance, for patients who have had to take a leave of absence from their job owing to low back pain, it is likely that a goal of treatment will be to have the patient return to work. Reaching the status of disability can be an exacerbating factor in terms of low back pain by acting like a feedback loop. If an individual, debilitated by severe and chronic low back pain, does not make efforts to maintain some mobility they are at risk for maintaining their own symptoms of pain.

Indeed, the pain and disability associated with low back pain does not solely emerge by way of a somatic pathology. It is widely accepted that many factors are involved in accounting for a patient’s degree of pain severity and disability. For instance, attitudes that patients have regarding pain and beliefs that they possess about disability have been shown to have a significant impact on the severity of their low back pain and degree of impairment. Further, psychological distress and responses to the onset of the condition also have been found to be influential. As such, these factors can become targets of treatment.

Patients suffering from chronic low back pain have been shown to benefit from using positive reinforcement to reward healthy behaviors and to implement consequences for pain behaviors. Patients may also be challenged to identify the thoughts that they have about their condition and disability, as they may be helping to maintain the pain condition. For instance, patients may be asked to explore their own personal beliefs about the meaning of their chronic low back pain, or even their own expectations with regard to their ability to manage and control pain. While it is unknown whether changing an individual’s perceptions of pain can have a significant impact on their own trajectory, there is some data to suggest that these changed perceptions can have other beneficial effects on the patient. For instance, a changed perception of the unremitting nature of their chronic pain is likely to encourage a patient in their efforts in physical therapy.

Treatment for low back pain generally depends on whether the pain is acute or chronic. In general, surgery is recommended only if there is evidence of worsening nerve damage and when diagnostic tests indicate structural changes for which corrective surgical procedures have been developed.

Conventionally used treatments and their level of supportive evidence include:

Hot or cold packs have never been proven to quickly resolve low back injury; however, they may help ease pain and reduce inflammation for people with acute, subacute, or chronic pain, allowing for greater mobility among some individuals.

Activity: Bed rest should be limited. Individuals should begin stretching exercises and resume normal daily activities as soon as possible, while avoiding movements that aggravate pain. Strong evidence shows that persons who continue their activities without bed rest following onset of low back pain appeared to have better back flexibility than those who rested in bed for a week. Other studies suggest that bed rest alone may make back pain worse and can lead to secondary complications such as depression, decreased muscle tone, and blood clots in the legs.

Strengthening exercises, beyond general daily activities, are not advised for acute low back pain, but may be an effective way to speed recovery from chronic or subacute low back pain. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Health care providers can provide a list of beneficial exercises that will help improve coordination and develop proper posture and muscle balance. Evidence supports short- and long-term benefits of yoga to ease chronic low back pain.

Physical therapy programs to strengthen core muscle groups that support the low back, improve mobility and flexibility, and promote proper positioning and posture are often used in combinations with other interventions.

Medications: A wide range of medications are used to treat acute and chronic low back pain. Some are available over the counter (OTC); others require a physician’s prescription. Certain drugs, even those available OTC, may be unsafe during pregnancy, may interact with other medications, cause side effects, or lead to serious adverse effects such as liver damage or gastrointestinal ulcers and bleeding. Consultation with a health care provider is advised before use. The following are the main types of medications used for low back pain:

   Analgesic medications are those specifically designed to relieve pain. They include OTC acetaminophen and aspirin, as well as prescription opioids such as codeine, oxycodone, hydrocodone, and morphine. Opioids should be used only for a short period of time and under a physician’s supervision. People can develop a tolerance to opioids and require increasingly higher dosages to achieve the same effect. Opioids can also be addictive. Their side effects can include drowsiness, constipation, decreased reaction time, and impaired judgment. Some specialists are concerned that chronic use of opioids is detrimental to people with back pain because they can aggravate depression, leading to a worsening of the pain.

   Nonsteroidal anti-inflammatory drugs (NSAIDS) relieve pain and inflammation and include OTC formulations (ibuprofen, ketoprofen, and naproxen sodium). Several others, including a type of NSAID called COX-2 inhibitors, are available only by prescription. Long-term use of NSAIDs has been associated with stomach irritation, ulcers, heartburn, diarrhea, fluid retention, and in rare cases, kidney dysfunction and cardiovascular disease. The longer a person uses NSAIDs the more likely they are to develop side effects. Many other drugs cannot be taken at the same time a person is treated with NSAIDs because they alter the way the body processes or eliminates other medications.

   Anticonvulsants—drugs primarily used to treat seizures—may be useful in treating people with radiculopathy and radicular pain.

   Antidepressants such as tricyclics and serotonin and norepinephrine reuptake inhibitors have been commonly prescribed for chronic low back pain, but their benefit for nonspecific low back pain is unproven, according to a review of studies assessing their benefit.

   Counter-irritants such as creams or sprays applied topically stimulate the nerves in the skin to provide feelings of warmth or cold in order to dull the sensation of pain. Topical analgesics reduce inflammation and stimulate blood flow.

Spinal manipulation and spinal mobilization are approaches in which professionally licensed specialists (doctors of chiropractic care) use their hands to mobilize, adjust, massage, or stimulate the spine and the surrounding tissues. Manipulation involves a rapid movement over which the individual has no control; mobilization involves slower adjustment movements. The techniques have been shown to provide small to moderate short-term benefits in people with chronic low back pain. Evidence supporting their use for acute or subacute low back pain is generally of low quality. Neither technique is appropriate when a person has an underlying medical cause for the back pain such as osteoporosis, spinal cord compression, or arthritis.

Traction involves the use of weights and pulleys to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Some people experience pain relief while in traction, but that relief is usually temporary. Once traction is released the back pain tends to return. There is no evidence that traction provides any longterm benefits for people with low back pain.

Acupuncture is moderately effective for chronic low back pain. It involves the insertion of thin needles into precise points throughout the body. Some practitioners believe this process helps clear away blockages in the body’s life force known as Qi (pronounced chee). Others who may not believe in the concept of Qi theorize that when the needles are inserted and then stimulated (by twisting or passing a low-voltage electrical current through them) naturally occurring painkilling chemicals such as endorphins, serotonin, and acetylcholine are released. Evidence of acupuncture’s benefit for acute low back pain is conflicting and clinical studies continue to investigate its benefits.

Biofeedback is used to treat many acute pain problems, most notably back pain and headache. The therapy involves the attachment of electrodes to the skin and the use of an electromyography machine that allows people to become aware of and selfregulate their breathing, muscle tension, heart rate, and skin temperature. People regulate their response to pain by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects. Evidence is lacking that biofeedback provides a clear benefit for low back pain.

Nerve block therapies aim to relieve chronic pain by blocking nerve conduction from specific areas of the body. Nerve block approaches range from injections of local anesthetics, botulinum toxin, or steroids into affected soft tissues or joints to more complex nerve root blocks and spinal cord stimulation. When extreme pain is involved, low doses of drugs may be administered by catheter directly into the spinal cord. The success of a nerve block approach depends on the ability of a practitioner to locate and inject precisely the correct nerve. Chronic use of steroid injections may lead to increased functional impairment.

Epidural steroid injections are a commonly used short-term option for treating low back pain and sciatica associated with inflammation. Pain relief associated with the injections, however, tends to be temporary and the injections are not advised for long-term use. An NIH-funded randomized controlled trial assessing the benefit of epidural steroid injections for the treatment of chronic low back pain associated with spinal stenosis showed that long-term outcomes were worse among those people who received the injections compared with those who did not.

Transcutaneous electrical nerve stimulation (TENS) involves wearing a battery-powered device consisting of electrodes placed on the skin over the painful area that generate electrical impulses designed to block incoming pain signals from the peripheral nerves. The theory is that stimulating the nervous system can modify the perception of pain. Early studies of TENS suggested that it elevated levels of endorphins, the body’s natural pain-numbing chemicals. More recent studies, however, have produced mixed results on its effectiveness for providing relief from low back pain.

 

 



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Surgery

When other therapies fail, surgery may be considered an option to relieve pain caused by serious musculoskeletal injuries or nerve compression. It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility.   Patients considering surgical approaches should be fully informed of all related risks. Surgical options include:
 
  

 

 

 

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Vertebroplasty and kyphoplasty are minimally invasive treatments to repair compression fractures of the vertebrae caused by osteoporosis. Vertebroplasty uses three-dimensional imaging to assist in guiding a fine needle through the skin into the vertebral body, the largest part of the vertebrae. A glue-like bone cement is then injected into the vertebral body space, which quickly hardens to stabilize and strengthen the bone and provide pain relief. In kyphoplasty, prior to injecting the bone cement, a special balloon is inserted and gently inflated to restore height to the vertebral structure and reduce spinal deformity.

   Spinal laminectomy (also known as spinal decompression) is performed when spinal stenosis causes a narrowing of the spinal canal that causes pain, numbness, or weakness. During the procedure, the lamina or bony walls of the vertebrae, along with any bone spurs, are removed. The aim of the procedure is to open up the spinal column to remove pressure on the nerves.

   Discectomy or microdiscectomy may be recommended to remove a disc, in cases where it has herniated and presses on a nerve root or the spinal cord, which may cause intense and enduring pain. Microdiscectomy is similar to a conventional discectomy; however, this procedure involves removing the herniated disc through a much smaller incision in the back and a more rapid recovery. Laminectomy and discectomy are frequently performed together and the combination is one of the more common ways to remove pressure on a nerve root from a herniated disc or bone spur.

   Foraminotomy is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve pressure on the nerve.

   Intradiscal electrothermal therapy (IDET) is a treatment for discs that are cracked or bulging as a result of degenerative disc disease. The procedure involves inserting a catheter through a small incision at the site of the disc in the back. A special wire is passed through the catheter and an electrical current is applied to heat the disc, which helps strengthen the collagen fibers of the disc wall, reducing the bulging and the related irritation of the spinal nerve. IDET is of questionable benefit.

   Nucleoplasty, also called plasma disc decompression (PDD), is a type of laser surgery that uses radiofrequency energy to treat people with low back pain associated with mildly herniated discs. Under x-ray guidance, a needle is inserted into the disc. A plasma laser device is then inserted into the needle and the tip is heated to 40-70 degrees Celsius, creating a field that vaporizes the tissue in the disc, reducing its size and relieving pressure on the nerves. Several channels may be made depending on how tissue needs to be removed to decompress the disc and nerve root.

   Radiofrequency denervation is a procedure using electrical impulses to interrupt nerve conduction (including the conduction of pain signals). Using x-ray guidance, a needle is inserted into a target area of nerves and a local anesthetic is introduced as a way of confirming the involvement of the nerves in the person’s back pain. Next, the region is heated, resulting in localized destruction of the target nerves. Pain relief associated with the technique is temporary and the evidence supporting this technique is limited.


   Spinal fusion is used to strengthen the spine and prevent painful movements in people with degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. The fusion can be performed through the abdomen, a procedure known as an anterior lumbar interbody fusion, or through the back, called posterior fusion. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together. Spinal fusion has been associated with an acceleration of disc degeneration at adjacent levels of the spine.

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Artificial disc replacement is considered an alternative to spinal fusion for the treatment of people with severely damaged discs. The procedure involves removal of the disc and its replacement by a synthetic disc that helps restore height and movement between the vertebrae.

 

 

 

 

 

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