Low Back Pain and Degenerative FAQ's

Gerald E. Rodts, M.D. Rick C. Sasso, M.D.

One of the most fascinating areas of SpineUniverse is the community section, where real spinal pain sufferers have the opportunity to speak directly with leading Neurosurgeon, Gerald E. Rodts, M.D. of Emory University, and Orthopaedic Surgeon Rick C. Sasso, M.D. of the Indiana University School of Medicine. We present a series of interesting questions on trauma and injury. SpineUniverse answers appear in red.

Dear Mr. Levinson: Tarlov cysts in general are usually not the cause of symtpoms. There is a paucity of literature regarding this topic. In very select cases, surgeons have advocated surgery when they cyst is causing a single nerve root problem. There is very little data published to support surgery for Tarlov cysts. I recommend speaking further with your physician to determine how much of your current problems is attributable to your spondylolisthesis. Tarlov cysts are often found incidentally in patients that have other, more common causes of pain or neurological deficits. Posted by: Gerald Rodts, M.D.
Date Posted - Mar 18 2000

I recently turner the wrong way and pinched something in my lower back, I went to the doctors said to take 2 asprin for two weeks probably just swelling. It's been 3 weeks and now my top of my spine to half way down my back has alot of pressure and my lower back still has that pinching feeling when i turn the right way and now my back of my legs hurt every night all the way to my ankles. Went to the doctors put me on a muscle relax pill and sent me on my way. I believe it is something more than just tight muscle my spine hurts and is very sore to touch can you let me know what you think
Posted by: Stephanie Date Posted - Mar 15 2000

Stephanie:I can respond to your description of some general symptoms, but we do not specifically treat or evaluate individual patients on this site. Back pain that lingers more than a few weeks despite rest, aspirin, heat, excercises, etc. will likely need re-evaluation. Back pain (alone) can be due to a strained muscle, arthritis, trauma (such as a fracture), infection, malignancy and many other sources. When back pain is associated with leg pains, numbness, and/or weakness, it is possible that an injury to the disc and/or bone may be present that is impinging upon one or more nerve roots. A general recommendation by most spine specialists is to evaluate with further tests is back pain does not resolve with these initial treatments within 6 weeks. If symptoms are progressively worsening, re-evaluation can be considered earlier.
Posted by: Gerald Rodts M.D.

Looking for advice: I had a spinal fusion of the L-5 (through the front as well as a titanium cage in my back) almost two years ago, and I started rehab slowly but aggressively. I'm 36, and I'm in good shape but I want to run a marathon in June-I've been putting on 25+ miles a week, track, beach, grass-my back doesn't hurt but I'm wondering if I'm doing the back damage? Thoughts? Also, if anyone is interested in the surgery, rehab-how I dealt with it-I'll share my experiences.
Posted by: Brett Date Posted - Mar 14 2000

Brett: Patients that have a successful interbody fusion in the lower back (e.g. with "titanium cages") can often return to most recreational activities. If a post-operative fusion patient has x-ray evidence of a solid fusion and does not experience pain after running/training, then one could assume that they are not doing any significant damage to their spine. That type of patient should certainly consult with their own surgeon to get case-specific recommendations about running marathons, etc.
Posted by: Gerald Rodts, M.D. Date Posted - Mar 16 2000

I have had 3 previous back surgeries since I was 15. I am 32 and it has been 2 years since my last surgery. At the age of 15 I had a lamenectomy of L-4. At the age of 21 I had spinal stenosis. At the age of 30 I had Multiple fusion and nerve root decompression. I am now experiencing severe pain and leg numbness and weakness all over again. The doctors have provided pain medication and would like to try an epidural and the usual tests including MRI and Mylogram. What else could be causing my back problems and is surgeryan option after three previous operations? Posted by: Chris Given Date Posted - Mar 13 2000

Chris:Back pain, leg pain, and numbness in the leg are likely due to recurrent or new nerve root impingement in someone who has had multiple previous surgeries. Rarely do we attribute new problems to "scar tissue" alone. If someone started having spine problems at an early age, then it is quite possible that new problems may continue to develop later in life. There are many stories of people who have been reoperated time and again and are no better. In properly selected cases, however, surgery can still be very beneficial if a clear cause for the pain is diagnosed and is amenable to surgery. It is always proper to start off with non-surgical treatments such as therapy, steroid injections, etc., as many patients will indeed improve and not require further surgery.
Posted by: Gerald Rodts, M.D. Date Posted - Mar 14 2000

While the internet has provided a wealth of information on the specifics of this pending surgery, I have not developed a clear understanding of the anticipated recovery period. I am a 50 year old female.I had L4-5 surgery about ten years ago. I was up and walking within hours, and back to normal housewife routines within several weeks. About one year ago, in treating an arthritic hip, my PCP was showing me how magnets could be used and applied sudden, unexpected pressure to my back and shoulders ( a poor demonstration ! ). My back pain returned. After two attempts at steroid injects I've had no long term relief and will be having an MRI next week as a prerequisite to new surgery. What is anticipated recovery time to get back to my job in as a cleric in the local school ?(Yea I know the doc should have given me all of this but he's a technician not as people person !)
Posted by: vanness Date Posted - Mar 13 2000

Vanness:Though we do not intend to offer medical advice about a patient's specific, individual case, we do offer general advice about neck and back problems on SpineUniverse. If anyone undergoes a second surgery in the lower back, the recovery depends on a few factors. If the surgery is being done at the "old" or previous site only and is similar in goal (remove a hernitated fragment of disc, e.g.), then the recovery should be more or less as it was the first time for that patient with the addition of perhaps an extra day. Reoperative surgery carries a slightly higher risk for spinal fluid leakage, bleeding, infection and other events that may prolong your postoperative stay. If, on the other hand, your "new" surgery will involve a more extensive surgical plan (e.g., a fusion procedure), then you should discuss with your surgeon his/her expectations for hospital stay. In this scenario, your stay may be several days longer and your return to work/recreational activities even longer. In general, muscles and other soft tissues (skin) are never as quick to heal as they are at the first operation so any patient may expect a slightly slower and/or longer recovery following a second operation.
Posted by: Gerald Rodts, M.D. Date Posted - Mar 13 2000

I had and mri and have a thoracic herniated disc that is pressing on the spinal cord. I have alot of pain and numbness all the time even hard to breathe, please i need to see a dr. here in florida but have called around and have not been able to find one in our area(or within 100miles) that will treat my back and worst of all is i got hurt at walmart and i have to see someone they approve of can someone please help me. can't take the pain much longeri live near tampa fl. if that helpsthank you
Posted by: Debbie

Debbie:I am responding to your question about a thoracic disc herniation. Please keep in mind that we can only offer general answers to questions about medical conditions on SpineUniverse. Though thoracic disc herniations may cause pain, they seldomly require surgery. The usual indications to consider surgery would be pressure on the spinal cord resulting in weakness, spasticity or numbness in the legs and trunk and/or bowel or bladder control problems. Another scenario when surgery may be considered is when a specific nerve root is impinged causing a very specific region of pain around the chest wall in the distribution of that nerve root. Even in this latter scenario, surgery can often be avoided as conservative measures are often successful in alleviating the pain. There are many physicians in the Tampa area capable of evaluating thoracic disc problems. Your primary physician or company doctor should be able to help. Our own SpineUniverse site will soon be able to alert you to physicians in your area that have registered on the site and posted some background information. Other sources include the Neurosurgery on-call website (www.neurosurgery.org)or the AAOS (orthopedic) website.
Posted by: Gerald Rodts, M.D. Date Posted - Mar 13 2000

I have had back surgery 5 years ago and still have back pain. I have found that accupunture and yoga and deep muscle massage has helped me. It appears that the muscles keep tighten up. Would moving to AZ (dry heat) help reduce the pain. I seem to flare up more when the weather changes. I currently live in Chicago so it's very volitale. Posted by: Steve Quinn Date Posted - Feb 23 2000

I cannot comment on heat issues very well. I would recommend that you review all sections of the site regarding arthritis which might be of help. If you have not had a check-up by specialist in five years this would be good advice. We will be listing referrals for specialist on site in next couple of weeks.
Posted by: Dr Stewart Eidelson Date Posted - Feb 29 2000

I am sorry to ask so many questions but are there any benefits to external bone growth stimulators for persons who have smoked cigarettes for years and quit before surgery. Are nicotine patches just as detrimental as smoking? Posted by: Larry Date Posted - Feb 21 2000

Larry:The scientific data for external bone stimulators is not as strong as it is for internal bone stimulators (that are placed at the time of fusion surgery). Nicotine patches are helpful in smoking cessation, but they deliver nicotine just like cigarettes. Therefore, many surgeons will wait until a patient has been off of the patches for several weeks or more before proceeding with surgery. Gerald Rodts, M.D., Emory University, Atlanta, GA
Posted by: Gerald Rodts,M.D. Date Posted - Feb 29 2000

What are the advantages and disadvantages in laprascopic fusions assuming an experienced an experienced surgical team? Posted by: Larry Date Posted - Feb 13 2000

Larry:The laparoscopic approach to the lumbar spine has several advantages. Though several incisions are used, they are typically very small (inch or less) and the pain is usually very well-tolerated. These incisions make for a satisfactory cosmetic result on the outside. Your intestinal tract typically recovers from the anesthesia and surgery quickly. The usual hospital stay is 1-3 days, though it could be longer if your intestinal motility takes a little longer to return to normal. One disadvantage is the potential complication of retrograde ejaculation in male patients. Though the rate is quite low, men should discuss this potential problem with their surgeon prior to surgery. In unusual cirmcumstances, your surgeon might elect at surgery to convert your operation from laparoscopic to "open". It is uncommon for this to be necesary.
Posted by: Gerald E. Rodts, Jr., M.D. Date Posted - Feb 14 2000

I have had back surgery 5 years ago and still have back pain. I have found that accupunture and yoga and deep muscle massage has helped me. It appears that the muscles keep tighten up. Would moving to AZ (dry heat) help reduce the pain. I seem to flare up more when the weather changes. I currently live in Chicago so it's very volitale. Posted by: Steve Quinn Date Posted - Feb 23 2000

Steve:I cannot comment on heat issues very well. I would recommend that you review all sections of the site regarding arthritis which might be of help. If you have not had a check-up by specialist in five years this would be good advice. We will be listing referrals for specialist on site in next couple of weeks.
Posted by: Dr Stewart Eidelson Date Posted - Feb 29 2000

I am a 46 year old female,I have been diagnosed as havingSpondylolisthesis L5/S1,also Spondolosis,disc Prolapse L5/S1,and mildScoliosis. I have constant chronic pain,I have been offerd lumbar fusion but haveread good and bad reports on this.My back problems started at the age of24.The last two years I have deteriorated badly.It also seems to beaffecting my bladder.I would be gratefull for any information you couldoffer me. Posted by: Mrs Ann Snalam Lancashire England Date Posted - Feb 3 2000

Mrs. Ann Snalam:Please take a look at our paper this month on lumbar fusion. Perhaps you'll find some useful information here (to start).
Posted by: Gerald Rodts M.D. Date Posted - Feb 6 2000

I am only 33 with DDD in lumbar region w/ bone spurs. Some sciatica down rt. leg (not bad). Very active, healthy. I teach a toning (fitness) class twice a week. Mom of 2 (heavy) little ones. I am scheduled for ant/post fusion next month by Dr. John Roberts. I tried phys. ther. for 9 weeks last year (did nothing for me), have been in pain for 3+ years and sick of it. Another Dr., Dr. Bret Ferree, does a less invasive post. fusion and uses "growth factors" extracted from patients blood pre-operation as a replacement for the pelvic bone graft--somewhat new-resulting in only one incision. He has performed 80 of these newer surgeries with 100% success. Anyone know anything about this? Also, Are there any effective non-surg. treatments for DDD w/ bone spurs? I heard once you had the bone spurs you basically had to get the surgery. Was also thinking about acupuncture. Posted by: Beth B--Cinti, Oh

The question from Beth B. I do believe you should explore the pain section and other non-surgical treatment. If your sciatica is getting worse this would be of concern. In many cases non-surgical control of pain is the real issue. Acupuncture can also be helpful as well as physical therapy.
Posted by: Dr Eidelson Date Posted - Feb 8 2000

What is the explanation for the clinical trial that showed no difference in fusion rates with BAK cages between smoker's and non-smokers. Posted by: Larry Lamson Date Posted - Apr 1 2000

Dear Larry Lamson: We don't have a clear answer to your question about smoking and fusion rates in the BAK study. In fact, the literature for both cervical and lumbar interbody fusion shows varying effects of smoking on fusion success rates. What we do know clearly is that smoking does result in a lower fusion rate in cases of posterolateral (on-lay) fusion of the lumbar spine. Interbody fusions, however, may be different. Whether it is a BAK cage, Ray cage, Interfix cage, etc., interbody fusions in general put bone graft material in direct contact with the well-vascularized bone of the vertebral bodies AND is thought to put bone under stress (two key ingredients for a successful fusion). It is unclear just how much stress the bone graft "sees" inside a cage device, but the lack of difference between smokers and non-smokers in the BAK cage study may have to do with the more optimal blood supply to the bone in an interbody fusion in general compared with a posterolateral fusion (bone laid down on the sides and back part of the spine). In general, patients that have surgery or are managed conservatively do better when not smoking.
Posted by: Gerald Rodts, M.D. Date Posted - Apr 2 2000

Date Posted - Mar 30 2000 have been suffering from a pinched nerve(sciatic), pain going down from my butt to my right leg and foot since august/99, I can hardly walk fifty meters. I have been exercising with a trainer for the last five months. My question is how long can this pain persist. Since I am not sure if I can go on much longer. My energy seems to have been drained. Could you please recommend some form of treatment or any thing else. I take some medication, but that only relieves the pain for a while. The pain I experience is very hard to describe, it feels like someone is sitting in the leg & back scraping with a knife. Could you please recommend something so as I can go back to a normal way of life Thanks for your help. Mann Posted by: Mann Work

Dear Mann Work: Pain radiating down the leg from the back or buttock area is commonly referred to as sciatica. A "pinched" nerve is often the cause. Ruptured or bulging discs, bone spurs, slippage of the vertebrae, or inflammation are the common causes of this type of pain. The natural history of sciatica due to disc problems is that most people get better on their own over time. Surgery is usually not necessary. When symptoms persist over several months and/or are associated with neurological signs such as weakness, numbness, or tingling, then a patient may wish to consider more aggressive treatment. The first step is establishing an accurate diagnosis. This is most often accomplished by having a neurological examination and a radiological test such as a MRI scan (most common), myelogram, or CT scan. For people with an identifiable nerve root impingement and who are suffering from chronic pain that is not resolving, then surgery may be the most effective way to get better quicker. Sciatic pain can be very chronic and last months or years. If any patient is continuing to suffer from sciatic pain many months after its onset, then it is recommended they consult with their physician for further recommendations.
Posted by: Gerald Rodts, M.D. Date Posted - Mar 30 2000

Dear Dr. Rodts: Thank you for your response to my question regarding any increased short/long term risk for adjacent vertabrae in a post fusion patient. Could you cite 4-5 papers in which these studies have been published. Posted by: R. Wynne Date Posted - Mar 31 2000

Dear R. Wynne: I know of a few to start with (not a complete list): Hilbrand et al., J Bone Joint Surg 1999 April 81(4):519-28 Hubach et al., Eur Spine 1994 3(4):209-13 Sato T., Nippon Seik. Gak. Zas. 1992 July 66(7):607-620 Hilbrand et al., Spine 1997 July 15:22(14): 1574-79 Yamamoto et al., Spine 1991 March 16(3):272-9
Posted by: Gerald Rodts, M.D. Date Posted - Mar 31 2000

Are there any studies that indicate short or long term increased risk to adjacent vertibrae for post fusion patients? Posted by: R. Wynne Date Posted - Mar 22 2000RATIVE

Dear R. Wynne: There are approximately 10-12 well-written papers published in peer-reviewed literature regarding the development of new problems adjacent to a fused segment of the spine. The percentages vary tremendously, so each individual study must be scrutinized carefully. In general, in the lumbar spine, there is anywhere between 3 and 18% chance of adjacent level problems arising. These problems could include back pain, new leg pain, etc. They often take several months or years to develop and often are tolerable)
Posted by: Gerald Rodts, M.D., Emory University Date Posted - Mar 23 2000

I recieved a 2-level fussion, 360 degree with spinal cage, bone graph, and bone plugs. Lower back L 4/5 and L 5/S1. Its been almost 3 years and I am on more medication than ever, and continue to get worse. Pain Management has pretty much run its course, and my Dr. has now suggested a Dorsal Column Stimulator as a close to last resort. Currently, I am taking Fentenyl patches, Elavil, Neurontin,Flexril, clonzapam, vioxx, forgive the spelling but you can see my problem. Is their any better treatment of drug combination or injections. My pain levels are cripleing and run my life. I want my life back, and so does my wife and children. My surgeon told me I would have a brand new back, instead I have a failed fussion. I went from epidural injections to a 360 degree fussion, 3 very large scars and traded old problems which seemed huge before my surgery to a living nightmare, depression, thoughts of suicide,I dont know what to do, and would love to find a Dr. who really cared about his patient, not his wallet. Can you tell me about MS Contin and Morphine pumps? I see a new Dr. in about a week in regards to a Dorsal Column Stimulator and unfortunately dont know alot about them. I NEED SERIOUS HELP, QUICKLY!!!!! Posted by: Greg Albee Date Posted - Mar 28 2000

Dear Mr. Albee: Any patient who is suffering from very severe back pain following a lumbar fusion several years ago and requiring high dose narcotic medication may benefit from a fresh look. Spinal cord stimulation is considered a reasonable alternative when all other sources of post-operative pain have been confidently ruled out. Keep in mind that the scientific literature suggests that spinal cord stimulation works primarily for limb pain and has a lesser effect on back pain. Some causes of long-term postoperative pain are indeed not treatable except by medication and possibly spinal cord stimulation. One such example is arachnoiditis, an irreversible scarring together of nerves within the sac of spinal fluid. Possibly treatable sources of long-term post-operative pain include failed fusion or pseudoarthrosis. It is well known that sometimes it is difficult to determine the presence of fusion when titanium "cages" are used as they can obscure the usual means of x-ray evaluation. Before considering placement of a spinal cord stimulator, I would discuss with your surgeon whether any further diagnostic tests are recommended to search for reversible or repairable sources of pain. Most surgeons are also quite open to patients who wish to obtain a second opinion. If a patient does indeed have a solid fusion and no demonstrable signs of nerve root impingement or narrowing of the spinal canal or instability, then spinal cord stimulation may be useful in reducing limb pain and (to a lesser extent)back pain and in reducing the need for narcotic (pain medicine) use.
Posted by: Gerald Rodts, M.D. Date Posted - Mar 29 2000

I am a 21 year old elite cyclist and recently had a L4-5 microdiscetomy for a disc that I herniated while weight lifting. Does anyone know of any sources that have information on athletes that have had similar problems? I am also interested in what kind of recovery I can expect. My doctor told me that I need to wait 3 weeks before I can begin physical therapy and it will be 2 months before I will be able ride my bike. Is this a typical recovery time for someone in very good physical condition? Also what can I expect long term? Weight lifting is a very important part of my training, how much can I expect to be able to do? I know I have to be careful because it can happen again. What would I be faced with if it happened again? I also have buldging disc's at L3-4 and L5-S1, so my doctor said a fusion would not be possible because it would put too much pressure on those two disc's. This injury has already put me out of the running for the olympics this year and I am hoping that it will not further hamper my cycling career. Any help would be greatly appreciated. Thanks. Posted by: M. Thompson

Dear Mr. M. Thompson: Your question is a good one as the demands of a competitive athlete are quite different from the more recreational athlete. Furthermore, cyclists in general generate higher intradiscal pressures because of the flexed position of the lower spine when riding. Common, sound advice for the competitive athlete is to wait several weeks to allow the acute situation (pain, inflammation, muscle spasm) to calm down before beginning physical therapy. Cyclists, runners, professional football player, baseball players, etc. will have very different demands than the recreational athlete when trying to return to activity. To protect one's athletic potential long-term, a slow, careful recovery is safer than pushing for a quick return to competition. If your condition worsens and you develop intractable leg symptoms, minimally invasive surgery may be an option to consider.
Posted by: Gerald Rodts, M.D.

I've had spinal fusion, as well as metal implant surgery done approximately 6 months ago. As a result of a fall, and due to the fact that I have inherited degenertive disc disease, I dislocated L5 (rupturing the disc between L5 and S1). In addition, a myleogram reflected that I had major nerve damage to my sciatic nerve. I thought the surgery would "cure" my problems, and my doctor felt prognosis was good. I felt some improvement, I no longer hurt 24 hrs a day, seven days a week, however, I am still experiencing a lot of pain. I still cannot sit comfortably for more than a couple of hours, and walking is very painful. Is this normal? Can I expect to remain in this much pain? I am an accountant. My job requires extensive sitting, and just getting to my desk from my car is murder. I have been seriously considering disability retirement. Please advise if you have any suggestions. Don't think that I'm knocking my doctor or anything, I just want to know if I'm crazy or what?? Hurt, Confused, Desperate, Debbie M. Posted by: Debbie Mitchell Date Posted - Mar 27 2000

Dear Debbie Mitchell: Anyone that has had a lumbar fusion performed needs to keep in mind that most physicians measure the outcome results of that procedure much further along in time. In other words, patients that continue to have back and leg pain within (e.g. 6) months of surgery may still continue to improve over time. After one year or more, the maximal benefit of surgery may be more realistically measured. Fusions themselves are not biologically healed until well beyond a year.
Posted by: Gerald Rodts, M.D. Date Posted - Mar 28 2000

I had anterior BAK fusion for DDD on 12/29/99. This was after 2 discectomy/laminectomy at the same site which is L5/S1, in March and August. All in all I feel really good and have very little pain or discomfort. The last couple of weeks I have been experiencing some pain/discomfort in my back as well as in the buttocks. I also have trouble when I flex backwards even the slightest. I thought initially that this was muscular, but it has not gotten better, instead it is getting worse. I find I can not stand for very long without discomfort hitting me. I also experience this pain in the left side of my back and buttocks when I sit down after standing for a while. I am allowed to walk as much as I want and am also riding a bike about 8 miles about 3 times a week. I am concerned that the cages have become loose or have moved. I know you can not "diagnose" this problem, but was wondering if my symptoms are just something that is a part of the healing or if perhaps I need to notify my neurosurgeon. Thank you for your opinion. Posted by: Lynn H Date Posted - Mar 25 2000

Lynn your situation could reprsent several concerns. I very much recommend that you get in contact with your surgeon as he is the best person to review your situation. Hopefully, this is related to your increased activity rather than non-union of the fusion. The concern has been a topic of much discussion in the professioI recently had surgery to remove a ruptured disc (entire disc in nerve canal due to auto accident). I also have several discs that have deteriorated due to rhuematoid arthritis. Are there trials on going doing disc replacement. I know there is joint replacement. I don't want to fuse my spine and although I feel much better now, the missing discs are causing me discomfort and I'm shrinking away. I would be very interested in participating in such a trial because I'd like to have the discs replaced if there is such a thing. Thank you.

I recently had surgery to remove a ruptured disc (entire disc in nerve canal due to auto accident). I also have several discs that have deteriorated due to rhuematoid arthritis. Are there trials on going doing disc replacement. I know there is joint replacement. I don't want to fuse my spine and although I feel much better now, the missing discs are causing me discomfort and I'm shrinking away. I would be very interested in participating in such a trial because I'd like to have the discs replaced if there is such a thing. Thank you. Posted by: Liz Levy Date Posted - Mar 22 2000

nal arena about whether stand alone cages will fuse. The answer has not been fully obtained and much research is needed. What I mean is that you had two sururies prior to the cage and in some cases the cage has micromotion over time and does not fuse. If this is your case a decision by your surgeon regarding other fixation might be a necessary topic of discussion. I would certainly slow some of your activity down in the short run to see the result and contact your physician. DrEidelson 3/28/00
Posted by: Dr Stewart Eidelson Date Posted - Mar 27 2000