Low back pain can be disabling and erode your quality of life. What are the common causes of low back pain? What is lumbar fusion? Is lumbar fusion effective? Is there a “Do I need back surgery quiz?” to help navigate this issue? Let’s dig in.
Do I Need Back Surgery Quiz
Has the source of my back pain been identified?
Has physical therapy been completed?
Will back surgery eliminate my pain?
Is back surgery risk-free?
Are there regenerative options to treat low back pain?
Common Causes of Low Back Pain – Do I Need Back Surgery Quiz Need-To-Knows
Disc
Between each lumbar vertebrae is a shock absorber called a disc. The disc is identified by the two lumbar vertebrae between which it is sandwiched. For example, the second to lowest lumbar disc is identified as the L4/5 disc as it is between the L4 and L5 vertebral bodies. The disc is compromised of two principal parts, the gelatinous inside called the nucleus and the outer sidewall called the annulus both of which are susceptible to injury and can be a source of pain.
Facet Joint
The facet joint is a joint between two vertebrae in the spine that acts to guide and limit spinal motion. It is compromised of the articular processes (boney projections) of the two adjacent vertebrae. Like all joints, the facet joint is susceptible to trauma, degeneration, and arthritis and can be a real source of pain.
Sacroiliac Joint
The SI joint is the joint between your waist bone (ilium) and sacrum and serves as a shock absorber. Each of us has two SI joints, one on the left and one on the right both of which have strong supporting ligaments. The joint is prone to misalignment, trauma, degeneration, arthritis, and instability due to loose ligaments all of which can create significant low back, buttock and leg pain.
Ligament Instability
Ligaments are thick bands of connective tissue that connect one bone to another. The stability of the lumbar spine is in part dependent upon the strength and integrity of the lumbar ligaments. Common lumbar ligaments include the supra and interspinous ligaments. Trauma, surgery, degeneration, and injury can compromise ligaments creating instability in the lumbar spine with resultant pain.
Multifidus atrophy
The multifidus muscle is a critical stabilizing muscle in the spine. Unfortunately, this muscle is poorly understood and recognized by many physicians and providers. Injury, surgery, trauma and chronic pain can weaken this critical muscle causing instability and pain.
Conditions Which May Warrant Back Surgery
Slippage of the vertebra body – This can occur as a result of a trauma with a possible compromise of the spinal cord and nerves.
Loss of bladder or bowel control – If persistent after trauma may represent a surgical emergency.
Traumatic injury with vertebrae fractures – Typically seen after trauma and may warrant back surgery.
A tumor on the spinal cord.
What is Lumbar Fusion?
A lumbar fusion is a surgical procedure where two or more lumbar vertebrae are fused together by hardware. The hardware can be placed either in the front or back or both. The disc is typically removed and replaced with bone or a spacer. Lumbar fusion is a common surgery designed to treat low back and leg pain. The incidence of lumbar fusion has skyrocketed up 600-700% since 2000(1).
The incidence of infection is 2-5% and increases to 2.4 to 8.5% when implants are used(2). Infection may include muscles, tendons, ligaments, and bone and depending upon severity may warrant additional surgery.
Pseudoarthrosis
Failure of the bones to fuse is called non-union or pseudoarthrosis. This is bad as the intended surgery has failed and now there is instability in the lumbar spine. The incidence of non-union is striking and in one study was found to be 56% (3). The treatment of non-union is terrible as it involves another surgery where the fusion is revised and oftentimes the fusion extended up or down an additional level.
Nerve Injury
Nerves can be damaged during surgery and the incidence varies but was noted to be as high as 20-40% in patients that undergo lateral lumbar interbody fusions(4). Nerve injury may be temporary or permanent and can compromise rehabilitation in addition to being a new source of pain.
CSF Leak
The dura is the outermost membrane that covers the brain and spinal cord. This important membrane can be punctured during surgery causing a leak of spinal fluid. The incidence ranges from 1-17% (5). Severe headache is a common symptom of a dural leak If left untreated may lead to infection, brain abscess and bleeding.
Multifidus Atrophy
The multifidus is a critical muscle in the lumbar spine that provides support. In a recent study, the multifidus muscle was evaluated prior to and after lumbar fusion surgery (6). In the study, 6 patients underwent lumbar fusion and ten healthy patients were used as controls, Both groups underwent pre and post cross-section MRIs of their lumbar spine muscles which included the multifidus. The multifidus muscle was not functioning in the patients that had fusion surgery. This creates instability and these patients are prone to additional degeneration, injury and pain.
Adjacent segment disease
The lumbar disc functions as a shock absorber. Removal of the disc or discs in lumbar surgery compromises the body’s ability to absorb the forces of daily living. These forces are then redirected to the discs and facets above and below the fusion which then precipitates tear and tear, injury and degeneration. This phenomenon is called Adjacent Segment Disease ( ASD) and occurs in 9 %patients (7). Treatment oftentimes includes additional surgery with one or more additional lumbar discs fused. To learn more about adjacent segment disease please click on the video below.
Does Lumbar Fusion work?
As a practicing interventional orthopedic and pain physician, I have witnessed first hand the frustration and disappointment of patients who have under lumbar fusion. This was the case both in the United States Army as well as private practice. The effectiveness of lumbar fusion has recently been questioned. Why?
Fusion surgery for spinal stenosis was no more effective for pain or function than physical therapy. (8)
A long-term study for spinal stenosis demonstrated no difference in low back pain scores in patients who underwent lumbar fusion vs those who underwent physical therapy at the 10-year mark. (9)
Is There An Alternative to Surgery?
Yes!
Platelet-rich plasma and bone marrow stem cells injections are effective non-surgical options in the treatment of low back pain. At the Centeno-Schultz Clinic, we pioneered orthopedic stem cell injections. We have also published our results. In 2016 we demonstrated the effectiveness of culture-expanded stem cells injected into lumbar discs(10). All patients reported overall improvement as well as improvement in strength. In 2017 we demonstrated that PRP epidural injections were effective in reducing pain and increasing function in the 470 patients studied (11). At 24 months after PRP epidural injection, pain on average was improved by approximately 50%.
Low back pain can be miserable with debilitating pain and impaired function. Common causes of low back pain include injury or degeneration of the disc, facet joints, SI joints, ligaments, and muscles. Lumbar fusion is a common surgery for low back pain. Unfortunately, it has been demonstrated to be no more effective than physical therapy and has significant complications which include infection, non-union, nerve injury, CSF leak, multifidus atrophy, and adjacent segment disease. Platelet-rich plasma and bone marrow-derived stem cells are effective non-surgical options for the treatment of low back pain, making it a viable alternative to spinal fusion.
Ghiasi MS, Arjmand N, Shirazi-Adl A, et al. Cross-sectional area of human trunk paraspinal muscles before and after posterior lumbar surgery using magnetic resonance imaging. Eur Spine J. 2016;25(3):774-8.DOI: 10.1007/s00586-015-4014-y
Okuda S, Yamashita T, Matsumoto T, et al. Adjacent Segment Disease After Posterior Lumbar Interbody Fusion: A Case Series of 1000 Patients. Global Spine J. 2018;8(7):722-7. doi: 10.1177/2192568218766488
Delitto A, Piva SR, Moore CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Ann Intern Med. 2015;162(7):465-73.DOI: 10.7326/M14-1420 -Do I Need Back Surgery Quiz
Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study. Spine. 2005;30(8):936-43.
Elabd C, Centeno CJ, Schultz JR, Lutz G, Ichim T, Silva FJ. Intra-discal injection of autologous, hypoxic cultured bone marrow-derived mesenchymal stem cells in five patients with chronic lower back pain: a long-term safety and feasibility study. J Transl Med. 2016;14:253.DOI: 10.1186/s12967-016-1015-5
Centeno C, Markle J, Dodson E, et al. The use of lumbar epidural injection of platelet lysate for treatment of radicular pain. J Exp Orthop. 2017;4(1):38.DOI: 10.1186/s40634-017-0113-5
Do I Need Back Surgery Quiz
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