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Another study considered the “Structural Injury
Tolerance of the Spine: Stability and Lumbar Lor-
dosis in Lifting.” According to those conclusions
presented to the North American Congress on Bio-
mechanics, “These results confirm our hypotheses
that 1) the stability of the lumbar spine during lift-
ing exertions is influenced by the lordotic shape,”
or the inward curve in the lower back, “of the
spine, and 2) the curvature of the spine necessary
to maintain stability changes,” particularly as the
person bends forward. As author K. P. Granata con-
cluded, “Hence, injuries may occur due to instabil-
ity” of the spinal column, “despite spinal loads well
within recommended safety levels.”
In an article for Ergonomics, Granata and Mar-
ras discussed the “relation between spinal load fac-
tors and the high-risk probability of occupational
low-back disorder.” Studies often apply external
or mechanical forces to compress the spine, since
“spinal compression is traditionally assumed the
principal biomechanical mechanism associated with
occupationally related low-back disorder (LBD).
One of the criteria that the NIOSH lifting guide uses
to discriminate between safe and hazardous tasks is
based . . . on estimates of compressive loads on the
spine. . . . Consequently, research examining the risk
of low-back pain often focuses on axial” or mid-body
“compression loads associated with occupational
tasks.” However, “studies indicate that other factors,
including repetitive twisting or lateral,” sideways,
“bending and lifting, even with relatively light loads,
are significant risk factor for LBD.” With tissue strain
also a factor, the article stated, “No single biome-
chanical factor completely describes the probability
of high-risk classification. . . . Thus, estimates of spi-
nal compression alone cannot fully predict the risk of
LBD, because the injury mechanism is influenced by
multidimensional loading patterns” that affect many
areas. Interestingly, a pattern of job satisfaction may
also affect workers. As researchers noted, “employ-
ees with low approval ratings and who ‘hardly ever’
enjoyed their jobs were at high risk of subsequently
filing a back injury claim.”
Special Aids and Adaptations
Apparently, job satisfaction lifts the load tolerance.
Although disgruntled workers might prefer to reas-
sign their spines to job training for a new position,
the present task may put the person in the position
of straining under a load. If so, an
ORTHOTIC device
or back belt seldom does more than remind a per-
son to lift with the legs and not twist or overdo. A
more productive aid comes in strengthening para-
spinal muscles and lessening the load.
Burgess-Limerick, Robin, UniQuest Pty Ltd. “Issues Asso-
ciated with Force and Weight Limits and Associated
Threshold Limit Values in the Physical Handling Work
Environment,” Issues Paper 2: Commissioned by
NOHSC for the Review of the National Standard and
Code of Practices on Manual Handling and Associated
Documents, February 2003, pages 4 and 7. Available
online. URL: http://ergonomics.uq.edu.au/download/
tlv.pdf. Downloaded January 16, 2006.
Gielo-Perczak, Krystyna. “Differences in Muscular Activa-
tion and Fatigue for Intermittent and Constant Load,”
Occupational Ergonomics 5, no. 1 (2005): 43–56.
Granata, K. P. “Structural Injury Tolerance of the Spine:
Stability and Lumbar Lordosis in Lifting,” North Ameri-
can Congress on Biomechanics. Available online. URL:
http://asb-biomech.org/onlineabs/NACOB98/188/.
Downloaded January 16, 2006.
Granata, Kevin P. and William S. Marras. “Relation
between Spinal Load Factors and the High-risk Prob-
ability of Occupational Low-back Disorder,” Ergonom-
ics 42, no. 9 (1999): 1,187–1,199.
Stokes, Ian A. F. and Mack Gardner-Morse. “Muscle Acti-
vation Strategies and Symmetry of Spinal Loading in
the Lumbar Spine With Scoliosis,” Spine 29, no. 19
(October 1, 2004): 2,103–2,107.
lordosis Also known as swayback, lordosis cre-
ates a vertebral curvature opposite that of
KYPHO-
SIS. While the latter usually presents an outward
bow-curve in the
THORACIC SPINE, lordosis curves
the
LUMBAR SPINE inward, just above the hips.
Whether mild or severe, both of those
POSTURE
problems exaggerate the natural curvature of the
SPINE. Conversely, SCOLIOSIS presents a side to side
abnormality in the spinal column with the
VERTE-
BRAE forming an S or C.
Symptoms and Diagnostic Path
Severe instances of lordosis in a newborn may
indicate a
BIRTH DEFECT OF THE SPINE, especially if
146 lordosis
the normal flexibility of the spinal column seems
rigid or fixed. More commonly, parents may
notice a curve when holding the baby. To check
this at home, the infant can be placed, face up, on
a flat surface. If a gap exists between that surface
and the lower back of the baby, treatment may be
needed.
If lordosis later occurs in
CHILDREN or growing
ADOLESCENTS, a medical history and physical exam-
ination can clarify an underlying cause, such as
DISCITIS, SPONDYLOLISTHESIS, or a previously unde-
tected case of
DWARFISM. To investigate those con-
ditions or rule out other possibilities, X-
RAYS may
be needed.
An article posted online by the University of
Utah Health Science Center said, “Each child may
experience symptoms differently. The major clinical
feature of lordosis is a prominence of the buttocks.
Symptoms will vary depending if lordosis occurs
with other defects,” such as
MUSCULAR DYSTROPHY,
bone abnormalities, or disorders caused by spinal
nerves. Back pain, while not characteristic of lordo-
sis, can occur, but more commonly, that symptom
indicates the presence of another problem.
Treatment Options and Outlook
As long as the spine remains flexible rather than fixed,
most infants need no treatment. If an older child
develops a lordotic curve, the cause must be medi-
cally investigated to ensure appropriate therapy. For
postural problems with no underlying medical cause,
treatment may include an
ORTHOTIC device, such as a
back brace, to stop progression of the curvature.
Risk Factors and Preventive Measures
Early detection and treatment lessen the risk of spi-
nal deformity, especially if regular physical exami-
nations assess the direction of new bone growth.
Usually, lordosis patients improve with
EXERCISE to
strengthen
PARASPINAL MUSCLES. Physical therapy,
posture training, good
NUTRITION, and other forms
of
BONE BUILDING often prevent the condition from
worsening.
Chen, Andrew L., M.D. “Lordosis,” MedlinePlus, A.D.A.M.
Available online. URL: http://www.nlm.nih.gov/
medlineplus/ency/article/003278.htm. Last updated
December 13, 2005.
University of Utah Health Science Center. “Lordosis,”
University Health Care. Available online. URL: http://
uuhsc.utah.edu/healthinfo/pediatric/orthopaedics/
lordosis.htm. Downloaded January 16, 2006.
low back pain Sometimes called lumbago or,
more commonly, a bad
BACKACHE, nagging back
pains eventually nag most people. According to
an online report from the American Association
of Neurological Surgeons (AANS), “more than 65
million Americans suffer from low back pain every
year. Back aches are the most common reason for
doctor visits, after cold and flu symptoms,” and,
like those pesky health bugs, backaches often come
again. As the AANS reported, “Fifty percent of all
patients who suffer from an episode of low back
pain will have another occurrence within one year.”
While the severity may differ with each episode, the
AANS said, “In the vast majority of cases back pain
is caused by the irritation of a nerve root near the
spine, not by problems with the muscles, ligament or
bone.” For example, pain in the lower
LUMBAR SPINE
may arise from spinal nerve inflammation produced
by
DEGENERATIVE DISC DISEASE, HERNIATED DISC, SCI-
ATICA, SPONDYLOLISTHESIS, or SPINAL STENOSIS.
Despite a multitude of potential causes, medical
professionals generally agree that most low back
pain resolves itself within a few weeks. However,
patients with symptoms of
CAUDA EQUINA SYNDROME,
SPINAL INFECTION, SPINAL TUMOR, or bone FRACTURE
need immediate treatment. So do those who suffer
a trauma or encounter such symptoms as a fever,
rash, bladder problem, or muscle weakness.
An article in American Family Physician advised,
“Imaging studies are generally not recommended in
the first month of acute low back pain.” Although a
BONE SCAN, COMPUTED TOMOGRAPHY SCAN, MAGNETIC
RESONANCE IMAGING, or other imaging device will
seldom be needed, “patients who do not improve
within one month should obtain magnetic reso-
nance imaging if a herniated disc is suspected.
Computed tomographic scanning is useful in dem-
onstrating osseous structures” of bone and their
relations to spinal nerves “and for assessment of
fracture.” Also, “bone scans can be used to deter-
mine the extent of . . . disease throughout the skel-
etal system.” In general, “all imaging results should
low back pain 147
be correlated with the patient’s signs and symptoms
because of the high rate of positive imaging findings
in asymptomatic persons.” Therefore, patients with
no symptoms but a backache could have something
going on, such as an undetected kidney problem
that causes low back pain.
Risks and Complications
E
LDERLY persons and patients with OSTEOPOROSIS or
other bone-weakening condition, such as
CANCER,
may encounter unprovoked episodes of
ACUTE PAIN
in the lower back, which could suggest a sponta-
neous
VERTEBRAL COMPRESSION FRACTURE. Low back
pain that begins after a fall may indicate a fracture
in the
BACK, SPINE, or ribs.
In discussing “Low Back Pain,” The Merck Man-
uals Online Medical Library said, “One of the most
common causes is muscle and ligament strains and
sprains. Strains and sprains may result from lifting,
exercising, or moving in an unexpected way (such
as when falling or when in a car accident).”
Adult workers especially risk back pain that
arises from improperly
LIFTING or exceeding LOAD
TOLERANCE, but CHILDREN and ADOLESCENTS carry
this risk too. For example, young people may not
adhere to
BACKPACK SAFETY, or they might heap
heavy items on a high shelf or participate in con-
tact sports without using safety equipment. Also,
skeletal conditions or
POSTURE problems can cause
low back pain.
As explained by the National Institute of Neu-
rological Disorders and Stroke (NINDS), “Skeletal
irregularities produce strain on the vertebrae and
supporting muscles, tendons, ligaments, and tissues
supported by the spinal column.” Similarly, strain
on the lumbar spine increases a need for back care
during
PREGNANCY. Also, heavy men, women, and
young people risk the adverse effects
WEIGHT can
have on the lower back.
Statistics and Studies
An article in Health reported, “Northwestern Uni-
versity researchers found that people who experi-
enced lower-back pain for more than a year had up
to 11 percent less brain matter in areas responsible
for learning, higher thought, and reasoning than
those without chronic pain. Our brains do shrink
as we grow older, but only by about ½ percent per
year.” However, “the loss seen in folks with persis-
tent pain is equivalent to what occurs in up to 20
years of normal aging.”
To lessen the discomfort and potential damage
that pain can cause, the National Institute of Neu-
rological Disorders and Stroke (NINDS) said, “Sci-
entists are examining the use of different drugs to
effectively treat back pain, in particular daily pain
that has lasted at least 6 months. Other studies
are comparing different health care approaches to
the management of acute low back pain (standard
care versus chiropractic, acupuncture, or massage
therapy). These studies are measuring symptom
relief, restoration of function, and patient satisfac-
tion. Other research is comparing standard surgical
treatments to the most commonly used standard
nonsurgical treatments to measure changes in
health-related quality of life among patients suffer-
ing from spinal stenosis.”
Measuring pain levels and developing diag-
nostic guidelines continue to provide themes for
RESEARCH of low back pain. For example, an article
in the Southern Medical Journal said, “The goal of
clinical practice guidelines is to provide busy clini-
cians with . . . ‘best practice’ alternatives . . . based
on careful evaluation of the evidence. Ideally, clin-
ical practice guidelines focus on common problems
with significant morbidity or mortality. Back pain
fits this ideal. It is very common, accounting for
200,000 (1.8%) office visits in the United States
per year, and since only one fourth of patients with
physical symptoms seek medical attention, those
presenting for care represent only the tip of the
iceberg.” While most patients return to their regu-
lar daily
ACTIVITY in a month, “others incur seri-
ous disability and consume substantial health care
resources.” For example, “20% of claimants hav-
ing back pain for more than 4 months account for
60% of the back pain health care costs.” Unfortu-
nately, however, the article reported that the gov-
ernmental Agency for Health Research and Quality
“guidelines for the management of acute low back
pain had a modest impact on physician behavior,
increasing the use of acetaminophen and nonste-
roidals and decreasing the use of muscle relaxants
and physical therapy referrals.”
While physicians have reportedly decreased
referrals to physical therapists, that group of medi-
148 low back pain
cal professions has continued to research ways to
assist clinicians in decision-making. As explained
in “Relationship of Physical Examination Findings
and Self-Reported Symptom Severity and Physi-
cal Function in Patients with Degenerative Lumbar
Conditions” in Physical Therapy, “physical therapists
use physical examination (PE) procedures routinely
when making clinical decisions. Yet, limited data are
available to guide the clinical decision-making pro-
cess.” Therefore, “clinicians rely on inductive rea-
soning, intuition, and evidence to formulate clinical
decisions.” However, “by identifying subgroups with
similar PE findings, clinical researchers can deter-
mine which patients are likely to benefit most from
a particular intervention.”
Similarly, an article in the Canadian Medical
Association Journal reported, “So-called red flags to
identify pain that is specific (i.e., pain in the back
originating from tumours, fractures, infections,
cauda equina syndrome, visceral pain and systemic
disease) account for about 3% of all cases of back
pain.” However, “the overwhelming majority of
back-pain problems are nonspecific. One important
feature of nonspecific back pain among workers is
that a small proportion of cases (<10%) accounts
for most of the costs (>70%). This fact has led
investigators to focus on the early identification of
patients who are at higher risk of disability, so that
specialized interventions can be provided earlier,
whereas other patients can be expected to recover
with conservative care.” Usually though, “poten-
tial predictors are often limited to administrative or
clinical data, whereas it is clear that back pain is a
multidimensional health problem.”
Special Aids and Adaptations
Considering the complexity of low back pain, a timely
diagnosis and appropriate treatment can be hard
to find. To complicate the matter, the best form of
therapy depends on the individual person and indi-
vidual set of circumstances surrounding a particular
condition. Although
SURGERY provides the primary
course of treatment for such emergency conditions
as
CAUDA EQUINA SYNDROME, spinal tumors, and
severe bone fractures, most low back pain can be
relieved through
NONSTEROIDAL ANTI-INFLAMMATORY
DRUG (NSAID) THERAPY, doctor-prescribed EXERCISE,
and prescription
PAIN RELIEVERS. Other conservative
treatments involve
COLD THERAPY, HEAT THERAPY,
HYDROTHERAPY, SPINAL MANIPULATION, TRIGGER POINT
THERAPY, MASSAGE THERAPY, and BIOFEEDBACK. While
not clinically proven to help, time-tested
COMPLE-
MENTARY AND ALTERNATIVE MEDICINE approaches to
low back pain, such as
ACUPRESSURE, ACUPUNCTURE,
HERBAL THERAPY, and HOMEOPATHIC MEDICINE, go
back hundreds, sometimes thousands, of years.
To aid healing and protect the back from future
problems, the International Association of Fire
Fighters adapted these rules: “Stand smart—Main-
tain a neutral pelvic position. If you must stand for
long periods of time, alternate placing your feet on
a low footstool to take some of the load off your
lower back.” Also, “Sit smart—Choose a seat with
good lower back support or place a pillow or rolled
towel in the small of your back to maintain its nor-
mal curve. Keep your knees and hips level.” Besides
those aids to the joints, “Lift smart—Let your legs
do the work. Move straight up and down. Keep
your back straight and bend only at the knees. Hold
the load close to your body. Avoid lifting and twist-
ing simultaneously.” Finally, “Sleep smart—Lie on
a firm mattress. Use pillows for support, but don’t
use a pillow that forces your neck up at a severe
angle.”
Regarding
SLEEP, the article, “Bed Rest or Nor-
mal Activity for Patients with Acute Low Back
Pain,” in Spine reported, “For patients with acute
low back pain, normal activity is at least equivalent
to bed rest. The findings of this study indicate that
prescriptions for bed rest, and thus for sick leaves,
should be limited when the physical demands of
the job are similar to those for daily life activities.”
For those who want to stay home or change
occupations, an occupational therapist (OT) may
help. No, an OT is not in the job-placement busi-
ness, but the therapist will be apt to notice
TENSION
held in the lower back because of job dissatisfaction.
Also, an OT will investigate
ERGONOMIC FACTORS at
work then show the patient how to support the
spine, keep joints in a neutral position, and utilize
time, equipment, and talent well. As information
from The American Occupational Therapy Associa-
tion Web site explained, “Occupational therapists
are trained in recognizing both psychological and
physical issues that may influence the treatment
of back pain. By looking at all factors that could
low back pain 149
contribute to low back pain, occupational therapists
can provide the tools to help people accomplish
their daily tasks at work and at leisure activities.”
American Association of Neurological Surgeons. “Low
Back Pain,” AANS. Available online. URL: http://
www.neurosurgerytoday.org/what/patient_e/low.asp.
Downloaded January 12, 2006.
American Occupational Therapy Association, The. “Tack-
ling Low Back Pain,” AOTA. Available online. URL:
http://www.aota.org/featured/area6/links/link02bc.
asp. Downloaded January 12, 2006.
Dionne, Clermont E., Renee Bourbonnais, Pierre Fremont,
Michel Rossignol, Susan R. Stock, Isabelle Larocque.
“A Clinical Return-to-work Rule for Patients with
Back Pain,” Canadian Medical Association Journal, CMAJ
172, no. 12 (June 7, 2005): 1,559–1,567.
Humphreys, S. C., J. C. Eck, and S. D. Hodges. “Neuroim-
aging in Low Back Pain,” American Family Physician 65,
no. 11 (June 2002): 299–306.
International Association of Fire Fighters. “Back Injuries
and the Fire Fighter,” IAFF. Available online. URL:
http://www.iaff.org/safe/content/BackPain/BackPain.
htm. Downloaded January 12, 2006.
Jackson, Jeffrey L., M.D. and Robert Browning, M.D.
“Impact of National Low Back Pain Guidelines on Clin-
ical Practice,” Southern Medical Journal 98, no. 2 (Feb-
ruary 2005): 139–143.
Lyle, Mark A., Sarah Manes, Michael McGuinness, Sarah
Ziaei, and Maura D. Iversen. “Relationship of Physi-
cal Examination Findings and Self-Reported Symp-
tom Severity and Physical Function in Patients with
Degenerative Lumbar Conditions,” Physical Therapy
85, no. 2 (February 2005): 120–133.
Merck.com. “Low Back Pain,” The Merck Manuals Online
Medical Library. Available online. URL: http://www.
merck.com/mmhe/sec06/ch094/ch094a.html. Down-
loaded January 12, 2006.
National Institute of Neurological Disorders and Stroke.
“Low Back Pain Fact Sheet,” National Institutes of
Health. Available online. URL: http://www.ninds.nih.
gov/disorders/backpain/detail_backpain.htm. Last up-
dated November 23, 2005.
Patel, Atul T., M.D. and Abna A. Ogle, M.D. “Diagnosis
and Management of Acute Low Back Pain,” American
Family Physician (March 15, 2000). Available online.
URL: http://www.aafp.org/afp/20000315/1779.html.
Downloaded January 12, 2006.
Rozenberg, Sylvie, M.D., Cecile Delval, M.D., Yvonne Rez-
vani, M.D., Nicole Olivieri-Apicella, M.D., Jean-Louis
Kuntz, M.D., Eric Legrand, M.D., Jean-Pierre Valat,
M.D., Francis Blotman, M.D., Jean Meadeb, Denis
Rolland, M.D., Stephanie Hary, M.D., Bernard Duplan,
M.D., Jean-Louis Feldmann, M.D., Pierre Bourgeois,
M.D. “Bed Rest or Normal Activity for Patients with
Acute Low Back Pain: A Randomized Controlled Trial,”
Spine 27, no. 14 (July 15, 2002): 1,487–1,493.
Woodbury, M. A. “Beware the Aching Back,” Health 19,
no. 4 (May 2005): 142.
lumbago See LOW BACK PAIN.
lumbar disc replacement See DISC REPLACEMENT.
lumbar epidural steroid injection See EPIDURAL
INJECTION.
lumbar laminectomy See LAMINECTOMY.
lumbar microdiscectomy See MICRODISCECTOMY.
lumbar puncture Commonly known as a spinal
tap, a lumbar puncture (LP) provides a diagnostic
tool to assess various neurological conditions, such
as spinal meningitis or
MENINGOCOCCAL DISEASE,
that affect the
SPINE.
Procedure
An article in RN referred to this procedure as a
means of, “injecting contrast agents or administer-
ing spinal anesthesia. . . . An LP is usually done at
the bedside, and involves inserting a needle into the
subarachnoid space of the spinal column.” Since
that space occurs beneath the delicate arachnoid
membrane that covers the spinal cord, vital signs
must be “monitored continuously for 24 hours,”
which necessitates a hospital stay.
Risks and Complications
Because a lumbar puncture invades the sensitive
arachnoid membrane, patients encounter a very
150 lumbago
small but, nevertheless, dangerous risk of develop-
ing
ARACHNOIDITIS. A more likely development after
an LP is a headache, which an article in European
Neurology called “trivial and usually self-limited.
However, there are other less common but seri-
ous complications that physicians should bear in
mind whenever they perform this procedure.”
For instance, the article mentioned potential leak-
age of spinal fluids and also a risk of blood clots,
the latter of which “should not be considered a
benign condition, since up to 44% of them may
become complicated with progressive deteriora-
tion of consciousness and life-threatening symp-
toms,” requiring surgical removal. Regarding the
LP itself, the article concluded, “Although it is not
usually a dangerous procedure, clinicians should
keep in mind that it should be performed only
when necessary.”
Outlook and Lifestyle Modifi cations
An article from MedicineNet.com said, “Headaches
occur less frequently when the patient remains
lying flat 1–3 hours after the procedure.” More
importantly, “LP can provide lifesaving informa-
tion.” For example, “spinal fluid obtained from the
lumbar puncture can be used to diagnose many
important diseases such as bleeding around the
brain; increased pressure from hydrocephalus;
inflammation of the brain, spinal cord, or adjacent
tissues (encephalitis, meningitis); tumors of brain
or spinal cord, etc. Sometimes spinal fluid can indi-
cate diseases of the immune system, such as mul-
tiple sclerosis.”
Beanie Dulak, Sally. “Lumbar Puncture,” RN 68, no. 6
(June 2005): 36–39.
Martin-Millan, M., J. L. Hernandez, P. Matorras, A.
Oterino, and J. Gonzalez-Macias. “Multiple Subdural
Haematomas following Lumbar Puncture,” European
Neurology 53, no. 3 (2005): 159–160.
MedicineNet.com. “Lumbar Puncture (LP).” Available
online. URL: http://www.medicinenet.com/lumbar_
puncture/article.htm. Downloaded January 18, 2006.
lumbar radiculopathy This type of LOW BACK PAIN
radiates with
SCIATICA and often causes numbness
or weakness in the lower part of the body.
Symptoms and Diagnostic Path
To assess
RANGE OF MOTION and strength, a physi-
cal examination focuses on the
LUMBAR SPINE and
legs. As an article for SpineUniverse said, “You may
be asked to stand, walk or lie down on the exam
table during the physical examination. In a lying
position, your physician will raise each of your legs
to demonstrate flexibility and strength in your low
back and legs.” The specific symptoms and location
of pain also aid a diagnosis. For example, nerve
involvement of the second
VERTEBRA in the lumbar
region (L2) may lessen the strength in the hip. Spi-
nal nerve involvement at L3 may lessen reflexes in
the knee, whereas L4 will be more likely to cause
a sensory loss in the foot. L5 may have that effect,
too, but that level can also affect the large toe with
pain felt down the side of the leg. Conversely, the
S1
SACRAL VERTEBRA may affect the little toe with
“pain down the back of the leg into the bottom or
side of the foot.”
Besides a medical history, the doctor may request
X-
RAYS to evaluate the condition of the vertebrae
and
MAGNETIC RESONANCE IMAGING to assess the
DISCS and other soft tissue.
Treatment Options and Outlook
An article posted by the Spine Center of the Uni-
versity of Rochester Medical Center said, “In most
cases, surgery is offered after physical therapy, rest,
and medications have failed to adequately relieve
the symptoms of pain, numbness and weakness
over a period of time.” More commonly, treatment
requires “bed rest for 48 hours, occasionally up to 7
days.” Other conservative treatments include phys-
ical therapy and
NONSTEROIDAL ANTI-INFLAMMATORY
DRUG (NSAID) THERAPY. Occasionally, steroids, an
EPIDURAL INJECTION or SPINAL INJECTION may be used
to relieve inflammation or pain. Depending on the
causal factor, an
ORTHOTIC back brace or lumbar
support may be prescribed, but only for temporary
support.
Risk Factors and Preventive Measures
Again, the underlying condition must be addressed
to assess both the risks and the means of preven-
tion. For most patients, doctor-recommended
EXER-
CISE will help. Whether those exercises provide
RESISTANCE TRAINING, STRENGTH TRAINING, or a means
lumbar radiculopathy 151
of improving flexibility depends on the cause and
severity of the condition.
Skelton, Alta. “Lumbar Radiculopathy,” SpineUniverse.
Available online. URL: http://www.spineuniverse.
com/displayarticle.php/article1469.html. Last updated
June 20, 2005.
Strong Health. “Lumbar Radiculopathy,” Orthopaedics,
Spine Center, University of Rochester Medical Center.
Available online. URL: http://www.stronghealth.com/
services/orthopaedics/spinecenter/backcare/lumbar.
cfm. Downloaded January 10, 2006.
lumbar spinal fusion A type of ARTHRODESIS, lum-
bar fusion surgery may be needed if conventional
medicine and
COMPLEMENTARY AND ALTERNATIVE
MEDICINE fail to alleviate LOW BACK PAIN or weakness
and numbness in the lower limbs.
SCIATICA may be
the most common reason for spinal fusion, but the
procedure can also be used to treat
SPONDYLOLISTHE-
SIS, DEGENERATIVE DISC DISEASE, and less frequently,
ARTHRITIS. A lumbar spinal fusion can also address
FAILED BACK SURGERY SYNDROME and other causes
of instability in the
LUMBAR SPINE. With the use of
an autologous
BONE GRAFT from the patient’s own
body and
BONE MORPHOGENETIC PROTEIN (BMP) to
encourage new bone growth, spinal fusion eventu-
ally stops movement in painful segments of
VERTE-
BRAE, thus making the spine more stable but less
flexible.
An online article posted by the North American
Spine Society (NASS) explained, “The ultimate goal
of fusion is to obtain a solid union between two
or more vertebrae. Fusion may or may not involve
use of supplemental hardware (instrumentation)
such as plates, screws and cages. Instrumentation is
sometimes used to correct a deformity, but usually
is just used as an internal splint to hold the verte-
brae together while the bone grafts heal.”
After referring to autologous bone grafts as the
“gold-standard material for achieving successful
spinal fusions,” an international group of research-
ers reported in the Journal of Neurosurgery: Spine,
“Nevertheless, attempts at arthrodesis of the lum-
bar spine, even when performed using an autolo-
gous bone graft, result in a failure of fusion . . . in
5 to 35% of patients.” Also, the use of devices that
aid “spinal fusion by applying rigid internal fixa-
tion thus far has failed to eradicate the incidence of
nonunion.” Since the whole point of the procedure
is to get the vertebrae to unite, fuse, and hold, BMP
helps to enhance the process by speeding up forma-
tion of new bone tissue.
Procedure
In writing for Spine-health, Dr. Peter F. Ullrich Jr.
described four types of lumbar spinal fusion, each
of which involves a slightly different method or
approach. For example, one “surgical approach to
the spine is from the back through a midline inci-
sion that is approximately three inches to six inches
long. . . . This type of spinal fusion, which involves
placing bone graft in . . . a region just outside the
spine . . . , has a long history and is considered by
many surgeons to be the ‘tried and true’ method of
spinal fusion.” However, “the principal risk of this
type of low back surgery is that a solid fusion will
not be obtained (nonunion) and further surgery to
re-fuse the spine may be necessary. Nonunion rates
of between 10% and 40% have been quoted in the
medical literature.”
Another option involves a similar incision in the
back but “achieves spinal fusion in the low back by
inserting a bone graft and/or spinal implant (e.g.
cage) directly into the disc space.” This procedure
involves a
LAMINECTOMY, but “not as much of the
disc space can be removed with a posterior approach
(from the back.)” In a frontal or anterior approach
to lumbar fusion, the procedure “is similar to the
posterior lumbar interbody fusion . . . , except
that . . . the disc space is fused by approaching the
spine through the abdomen instead of through the
lower back.” With a three- to five-inch incision
made on the left side of the abdomen, the nearness
of large blood vessels in the legs adds to the surgi-
cal risks. Therefore, some procedures add endos-
copy for
MINIMALLY INVASIVE SURGERY that reduces
the size of surgical incision. However, Dr. Ullrich
cautioned, “The endoscopic approach has more
limited visualization, and it usually leads to larger
surgical times and carries with it a much higher
technical learning curve for the surgeon.” Despite
the increased risks, an advantage is that “both
the back muscles and nerves remain undisturbed.
Another advantage is that placing the bone graft in
152 lumbar spinal fusion
the front of the spine places it in compression, and
bone in compression tends to fuse better.”
Finally, lumbar fusion can combine front and
back approaches. As Dr. Ullrich explained, “This
anterior/posterior lumbar fusion procedure is usu-
ally done for patients with a high degree of spinal
instability (e.g. fractures), or in revision surgery (if
the initial fusion did not set up), although some
spine surgeons do prefer the anterior/posterior
fusion surgery as a primary spinal fusion tech-
nique.” Fusing the front and the back of the verte-
brae produces the greatest stability with about a 95
percent success rate. However, “a drawback of the
procedure is that both an anterior incision in the
abdomen and a posterior incision in the low back
need to be done.”
Risks and Complications
In an article for SpineUniverse, Dr. Todd Albert
said, “As with any operation, there are risks
involved with spine fusion surgery. Some patients
may develop a distended abdomen and may not be
able to eat. If this happens, a special tube may be
inserted to relieve the distension.” Although rare,
some patients may not respond well to an antibiotic
given to avoid infection, while others may develop
urinary tract problems or a potentially dangerous
blood clot. Also, “some patients may continue to
have pain at the bone graft donor site. If the fusion
does not heal, (a condition known as pseudoar-
throsis) the instrumentation, such as rods, screws,
hooks, may break, and further surgery may be
required. People who smoke are at a higher risk for
pseudoarthrosis complications.”
The risk of a failed fusion increases for patients
who previously had
SURGERY in the same area. As Dr.
Albert explained, “Revision surgery often involves
correcting a deformity caused by a previously failed
back surgery, breakage of instrumentation or pseu-
doarthrosis. The type of revision depends on the
problem. The procedure may include operating on
both the front and back of the spine. The incidence
of complications from revision lumbar spine fusion
surgery is higher than in first-time procedures. It is
also more difficult to relieve pain and restore nerve
function in revision surgery. Patients should be
aware that the chance of having long-term spinal
pain is increased.”
Outlook and Lifestyle Modifi cations
After surgery, deep-breathing exercises will be
encouraged, but smoking assuredly will not. Since
motion must remain limited for three months,
patients will be instructed on ways to move without
straining the lower back. Short walks in the hospi-
tal hallway begin regular
ACTIVITY that can gradu-
ally increase each day. For about a month though,
patients should not drive a car nor lift heavy
objects. During the postoperative visit four to six
weeks after lumbar fusion, the doctor may recom-
mend
EXERCISE and physical therapy to strengthen
PARASPINAL MUSCLES and keep the spine flexible.
As the NASS cautioned, “Recovery following
fusion surgery is generally longer than for other
types of spinal surgery. . . . It also takes longer to
return to a normal active lifestyle after spinal fusion
than many other types of surgery. This is because
you must wait until your surgeon sees evidence
of bone healing. The fusion process varies in each
patient as the body heals and incorporates the bone
graft to solidly fuse the vertebrae together. The
healing process after fusion surgery is very similar
to that after a bone fracture. In general, the ear-
liest evidence of bone healing is not apparent on
X-ray until at least six weeks following surgery.
During this time, the patient’s activity is gener-
ally restricted. Substantial bone healing does not
usually take place until three or four months after
surgery. At that time activities may be increased,
although continued evidence of bone healing and
remodeling may continue for up to a year after sur-
gery.” Since lumbar fusion decreases the RANGE OF
MOTION, this “can put added strain on the vertebrae
above and below the fusion. Fortunately, once a
fusion has healed it rarely, if ever, breaks down.”
Albert, Todd, M.D. “Understanding Lumbar Fusion Sur-
gery,” SpineUniverse. Available online. URL: http://
www.spineuniverse.com/displayarticle.php/article
1562.html. Last updated December 12, 2005.
Hasharoni, Amir, M.D., Yoram Zilberman, M.D., Gadi
Turgeman, M.D., Gregory A. Helm, M.D., Meir Lie-
bergall, M.D., and Dan Gazit, M.D. “Murine Spinal
Fusion Induced by Engineered Mesenchymal Stem
Cells that Conditionally Express Bone Morphogenetic
Protein-2,” Journal of Neurosurgery: Spine 3, no. 1 (July
2005): 47–52.
lumbar spinal fusion 153
North American Spine Society. “Spinal Fusion Surgery,”
NASS. Available online. URL: http://www.spine.org/
articles/spinalfusion.cfm. Downloaded January 18,
2006.
Ullrich, Peter F. Jr., M.D. “Lumbar Spinal Fusion Sur-
gery,” Spine-health.com. Available online. URL:
http://www.spine-health.com/topics/surg/overview/
lumbar/lumb05.html. Updated January 20, 2004.
lumbar spinal stenosis See SPINAL STENOSIS.
lumbar spine Better known as the lower back, the
lumbar spine offers a familiar site for
BACKACHE and
LOW BACK PAIN. Anatomically speaking, this portion
of the spinal column consists of five
VERTEBRAE num-
bered L1 through L5. Some individuals may have a
sixth lumbar bone labeled L6, which may actually
be part of the
SACRAL VERTEBRAE. Regardless of the
number, vertebrae come well-padded with
DISCS. In
addition to that cushy effect, strengthening occurs
through knobby aspects that protrude on either side
of each vertebra then connect to create facet joints.
In describing the lumbar spine, Dr. Stewart G.
Eidelson said, “The vertebrae and discs are held
together by groups of ligaments. Ligaments connect
bone to bone, whereas tendons connect muscle to
bone. In the spine, tendons connect muscles to the
vertebrae. The ligaments and tendons help to stabi-
lize the spine and guard against excessive movement
in any one direction.” That stability not only keeps
a person upright and mobile, but protects the spinal
cord that runs through vertebrae in the spinal col-
umn. Whether the vertebrae are located in the
CER-
VICAL SPINE, THORACIC SPINE, or lumbar, “small nerve
roots branch off from the spinal cord through spaces
between each vertebra and extend out into the entire
body. The spinal cord and the nerves are part of the
central nervous system that includes the brain. The
nerves are the body’s neural message system.”
As a Back.com article explained, “The true spi-
nal cord ends at approximately the L1 level, where
it divides into many different nerve roots that
travel to the lower body and legs. This collection
of nerve roots is called the ‘cauda equina,’ which
means horse’s tail and describes the continuation
of the nerve roots at the end of the spinal cord.”
Besides providing this avenue for
CAUDA EQUINA
SYNDROME, Back.com said, “The lumbar vertebrae,
L1–L5, are most frequently involved in back pain
because these vertebrae carry the most amount of
body weight and are subject to the largest forces
and stresses along the spine.”
Risks and Complications
In discussing the anatomy of the lumbar spine, The
Mount Sinai Medical Center reviewed these risks:
“Low back pain is a very common complaint for a
simple reason. Since the lumbar spine is connected
to your pelvis, this is where most of your weight
bearing and body movement takes place. Typically,
this is where people tend to place too much pressure,
such as: lifting up a heavy box, twisting to move a
heavy load, or carrying a heavy object. Such repeti-
tive injuries can lead to damage to the parts of the
lumbar spine.” This damage may include
HERNIATED
DISC, FACET JOINT DISORDER, and even a FRACTURE.
Complications in the lumbar spine begin prior to
birth with
GENETIC FACTORS, such as DWARFISM, that
can affect the lower back. At delivery,
INFANTS may
exhibit
BIRTH DEFECTS OF THE SPINE, such as LORDO-
SIS or SCOLIOSIS. Although problems with POSTURE
usually arise later, newborns may have frail or
weakened bones, such as occurs with
OSTEOGENESIS
IMPERFECTA. If the mother had insufficient FOLIC
ACID prior to pregnancy, a newborn may have SPINA
BIFIDA. Later, other factors related to NUTRITION,
such as
CALCIUM intake or VITAMIN D, can increas-
ingly affect bone strength.
Even with healthy vertebrae, injuries cause spi-
nal concerns for
ATHLETES, CHILDREN, and ADOLES-
CENTS. During periods of growth, young spines can
be particularly vulnerable in exceeding
LOAD TOLER-
ANCE or forgetting BACKPACK SAFETY. Teenaged and
adult workers untrained in proper methods of
LIFT-
ING may be especially prone to injury. In addition,
ELDERLY persons or OSTEOPOROSIS patients can sus-
tain
VERTEBRAL COMPRESSION FRACTURES simply by
bearing the weight of their own bodies.
Statistics and Studies
R
ESEARCH often tests the outer limits of load toler-
ance by loading the lumbar spine with mechanical
devices or external force. As an article in the Jour-
nal of Rehabilitation Research & Development said, “For
154 lumbar spinal stenosis
a full understanding of the mechanical response of
the spine . . . , measuring the forces and the move-
ments produced simultaneously is essential.” Also,
medical staff may measure the movements or rota-
tion in the hips to indicate spinal stiffness, but “in
future studies, researchers may employ the present
method to study various factors that may affect the
bending stiffness of the spine—for instance, breath-
ing and muscular contraction.”
Special Aids and Adaptations
To aid the lumbar spine, adequate nutrition, ade-
quate daily
ACTIVITY, adequate fresh water intake,
adequate
EXERCISE, and adequate SLEEP are needed.
Throughout life, though, the lower back must con-
stantly adapt to changing conditions, inside the
body and out. For most people, ongoing aid comes
by adapting a lifestyle to a simple adage: be kind to
the spine.
Eidelson, Stewart G., M.D. “Lumbar Spine,” SpineUniverse.
Available online. URL: http://www.spineuniverse.com/
displayarticle.php/article1394.html. Last updated June
30, 2005.
Lee, Raymond Y. W., Bonnie Y. S. Tsung, Pin Tong, and
John Evans. “Bending Stiffness of the Lumbar Spine
Subjected to Posteroanterior Manipulative Force,”
Journal of Rehabilitation Research & Development 42, no.
2 (March/April 2005): 167–174.
Medtronic Sofamor Danek. “Lumbar Spine,” Back.com.
Available online. URL: http://www.back.com/anatomy-
lumbar.html. Last updated March 17, 2005.
Mount Sinai Medical Center, The. “Anatomy: The Parts
of Your Spine and How They Work,” Orthopaedic
Spine Surgery at Mount Sinai. Available online. URL:
http://www.mountsinai.org/msh/msh_frame.jsp?
url=clinical_services/orthospine_lbp.htm#Anatomy.
Downloaded January 12, 2006.
lumbar spine 155
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