How to Avoid Surgery for Back Pain

What are the common causes of Back Pain?

Back pain is typically a result of an injury or trauma, a disorder such as degenerative disc disease (DDD), a tumor, osteoporosis, or arthritis. This can cause:

  • Back, muscle, or ligament strain
  • Spinal instability or scoliosis
  • Bulging or herniated discs
  • Spinal stenosis and bone spurs
  • Spinal nerve impingement

What is Degenerative Disc Disease?

The root cause of back pain may vary from complications during daily activities, a hereditary or congenital abnormality, or anatomical changes that take place during the natural aging process.

Lumbar degenerative disc disease (DDD) is defined simply as the wear and tear of intervertebral discs that act as cushions for the spine. This wear and tear may result from normal aging, or may be due to longstanding trauma. DDD typically begins with a decrease in the water content of the nucleus pulposus and can lead to tears in the annulus fibrosis. Disc degeneration can lead to disc bulging, development of bone spurs or osteophytes, and loss of disc space height and/or alignment. This can cause nerve impingement, which may result in pain.

With advanced DDD, the loss of disc height can lead to segmental instability resulting in disc slippage (degenerative spondylolisthesis) or asymmetric disc height loss, causing a side-to-side curvature of the spine (degenerative scoliosis). These advanced degenerative changes affecting the discs, joints, and surrounding soft tissues can further result in the narrowing of the spinal canal, also known as degenerative stenosis. This can put increased pressure on the spinal cord and spinal nerves that pass through the spinal canal.

What is Muscle Strain?

A major cause of back pain is the straining of muscles around the spine. This can occur in the neck as well as the upper and lower back. When this occurs you may develop muscle spasms, which is when your muscles cramp. During this time you may feel sharp pain in the area. These muscle strains can occur from poor posture, weak muscles around the spine, repetitive motions or not using proper form while lifting things.

What is a Disc Herniation?

In between the bones of the spine are discs which act as shock absorbers as well as allow for motion of the spine. You have discs between the bones of the entire spine, starting from your neck down to your tailbone.
These discs have a thicker outer layer and a softer jelly-like inner layer. When someone refers to having a, “pinched nerve or slipped disc” there usually referring to something that has occured to these discs.

Injury to these discs can occur in many ways. The most common problem we see is actually a result of natural aging process. As we get older, so do our bones, joints, ligaments and discs. As we age the discs lose some of their ability to cushion and as a result are much more prone to damage. This is what we refer to as degenerative disc disease. As the discs age, they can develop cracks and leak out (herniate) the soft jelly like inside. As this inner portion leaks it can irritate nearby structures such as the nerves. This is usually associated with pain which may occur in the neck or back and may even go down your arm or leg and we call this radiating, pain (Radiculopathy).
If this occurs you may feel numbness, tingling, pain and even weakness in your arms or legs, depending on where the injury occurs. Disc herniations may be seen on MRI/CT scans, but not on X-rays.

A majority of disc herniations can be treated without surgery, but there is a subset which requires surgical intervention. The decision to undergo surgery depends on many factors and will be determined by you and your surgeon.

The red arrow points to a disc which has degenerated and herniated.

It is very important that you call your doctor immediately if you experience any of the signs or symptoms listed below:

  • New weakness in your arms or legs
  • Altered sensation or numbness in your “saddle region”, which includes the groin, buttocks, genitals and upper inner thighs
  • Bladder or bowel incontinence

What is Spondylolisthesis?

Degenerative spondylolisthesis is a condition where the intervertebral disc degenerates resulting in a loss of disc height and instability, causing one vertebra to slip forward over another vertebra below it. The word spondylolisthesis is comprised of two parts: spondylo meaning spine, and listhesis meaning slippage. This condition can cause impingement of the spinal nerves and/or fatigue of the back muscles, and may result in lower back and/or leg pain.
Degenerative spondylolisthesis most commonly occurs in the lower back (lumbar spine) and is graded on a numerical scale from 1 to 4, with 1 being the least severe. It is also more common in people over age 50, and women are two times as likely as men to be diagnosed.
Advanced degenerative disc disease (DDD) may lead to degenerative spondylolisthesis when the spinal bones, discs, joints, and ligaments degenerate and become less able to maintain the alignment of the spinal column.
DDD is defined simply as the wear and tear of intervertebral discs.
This wear and tear may result from normal aging or may be due to longstanding trauma. DDD typically begins with a decrease in the water content of the nucleus pulposus and tears in the annulus fibrosus. A progression of DDD may result in spondylolisthesis as well as other conditions (e.g., spinal stenosis and scoliosis).

Degenerative spondylolisthesis may also be caused by other factors such as stress fractures, birth defects (congenital abnormalities), and in rare cases, a tumor or trauma.

What is Spinal Stenosis?

Your spinal cord and nerves are surrounded and protected by bony structures. These neural elements require a certain amount of room to function normally. When there is not enough room the neural elements may be compressed. Compression can occur anywhere in the spine and be caused by many different factors. A easy way to imagine this is the spinal cord and nerves resembling a waterhose, if the hose is kinked, the water will not flow correctly, as the spinal cord or nerves become compressed they will not operate correctly.

Compression of the spinal cord is much different than compression of the nerves which come off the spinal cord.

Stenosis is usually classified as mild, moderate and severe and is best seen on MRI or CT scan. Symptoms depend on whether there spinal cord or nerves are being compressed, as well as where the compression is occuring.

Symptoms of spinal stenosis include:
Neck (cervical spine):

  • Numbness/tingling in arms or legs
  • Weakness in arms or legs
  • Pain
  • Difficulty with balance (severe)
  • Changes in bowel and bladder function (severe)

Lower back (lumbar spine):

  • Numbness/tingling in legs
  • Weakness in legs
  • Legs feeling tired or heavy during short walks
  • Pain
  • Bending forward may help relieve some symptoms

What causes Stenosis?
Most commonly stenosis is a result of the wear and tear that comes along with aging. This process may cause bone spurs and ligaments of the spine to thicken. These changes will decrease the amount of room that the spinal cord and nerves have. Most stenosis occurs without causing any issues. However, eventually, the spinal cord and nerves are no longer able to tolerate being compressed and this may result in some of the symptoms listed above.

People with a smaller spinal canal diameter (Congenital Stenosis) and are more likely to experience symptoms. However this condition is rare.

What is Scoliosis?

The normal adult spine is balanced with the head directly over pelvis.

Scoliosis is a sideways curvature of the spine and can be caused by many conditions. It can range from mild to severe, and present in children and adults.

You may see the word scoliosis mentioned in your radiology report. In fact most of us have spines that are not completely straight, and usually it’s no cause for concern. Severe scoliosis on the other hand, can be debilitating.

Treatment ranges from observation with serial X-rays, bracing/casting, physical therapy, to surgical correction. It is important to identify the type of scoliosis to understand its potential for worsening and choose the correct treatment.

What is Kyphosis?

Kyphosis is similar to scoliosis, but it occurs in a different plane. Scoliosis causes the spine to deviate from side to side, while kyphosis causes forward rounding of the spine. This is commonly seen in the elderly and can contribute to pain and dysfunction. Kyphosis can occur from many causes including but not limited to: aging, crushed vertebrae (compression fractures), previous spine surgery, and congenital (developmental) conditions.
When severe, it can cause pain and make the activities of daily living difficult. An advanced understanding of the normal position and movement of the spine (sagittal parameters) is imperative as the treatment of kyphosis can be rather difficult.

Advanced clinical imaging tools allow us to better understand the deformity in all of its planes and plan a proper surgical correction.

What is Adjacent Segment Disease?

Adjacent Segment Disease (ASD) is a degenerative disc disease (DDD) that can result from stress on a level adjacent to a former spinal fusion procedure or can be attributed to the natural progression of DDD involving additional levels of the spine. This can lead to, Disc bulging, disc herniation, bone spurs or osteophytes, loss of disc space or alignment or nerve impingement. This can result in pain at the levels adjacent to the previous fusion.

What is Myelopathy?

Myelopathy is a symptom of an underlying spinal condition that compresses or irritates the spinal cord. When the spinal cord is injured, the body and brain cannot communicate with each other properly and this inefficiency can present as myelopathy. Symptoms can present as the feeling of heavy limbs, difficulty balancing, muscle weakness, loss of coordination, and/ or loss of bladder/bowel control.

What are the causes of Cervical Myelopathy?
Cervical Myelopathy is most commonly the result of Degenerative disc disease, Spinal stenosis, Tumor or Trauma.

What is Radiculopathy?

Radiculopathy is a symptom of an underlying spinal condition that compresses or irritates spinal nerves. It can present as pain, numbness, tingling, or weakness along the path of a nerve.
For example, if a spinal nerve in the lumbar region is irritated, radiating pain may be experienced along the associated nerve route that begins in the lower back and travels through the leg.

What are the causes of Radiculopathy?
Radiculopathy is most commonly the result of a condition affecting an intervertebral disc, such as a bulging or herniated disc that presses against the spinal nerves. Other causes may include: Degenerative disc disease (DDD), Spinal stenosis, Bone spurs, Tumor, Trauma or Diabetes.

Helpful Tips

Helpful tips for:
Proper Posture
Lifting Techniques
Seating Positions
Sleeping Positions,
Getting Out Of Bed

Proper posture is very important and can help reduce back pain as well as improve your appearance.

Some basic tips on proper posture:

  1. Point the center of your chest forward and your chin straight with the floor
  2. Roll your shoulders back
  3. Tighten your your core muscles while walking
  4. Avoid heavy backpacks, purses and bags
  5. Avoid high heeled or improper footwear as much as possible
  6. Stand as close as you can to the task you are performing: ie. if you are doing the dishes, stand as close as you can to the sink, when preparing food, be as close as safely possible to the counter.
  7. Stand up straight while brushing your teeth and bend at the hips when rinsing your mouth

Many of us are able to keep good posture until eventually our muscles become tired. If these muscles are becoming tired throughout your day they would likely benefit from strengthening.

Some tips on lifting technique:

  1. When you bend down, bend at the hips and not in the back
  2. Bend your hips, knees and squat down and slowly straighten your legs to lift
  3. Keep weights as close to your body as possible. Never lift with your arms extended, this puts considerable stress on your spine.
  4. Avoid twisting or turning your spine while holding anything. If you have to hand something off, turn your entire body instead
  5. Avoid lifting anything over 30 lbs, if you have had recent spine surgery you will have weight restrictions of 10 lbs for 4-6 months, depending on the surgery

Many of us spend a lot of time at our desks or driving, both of which can cause back pain. Many businesses allow for ergonomic evaluations where someone can inspect your work station and optimize your arrangement.

Many companies will try to sell you fancy chairs and desks at a high price. The truth is if the muscles around your spine are strong and you practice good posture, you do not need any fancy chair or desk.

Some basic tips on proper seating positions:

  1. Pick a chair that is comfortable but not too soft
  2. Make adjustments so your feet are flat on the floor and your knees are bent about 90 degrees
  3. Make adjustments so that the back of the chair is reclined about 100 degrees. Avoid being too forward or reclined in your chair
  4. Sit as far back as possible in your chair
  5. If possible make adjustments to the arm rests until your shoulders can rest comfortably
  6. Avoid crossing your feet
  7. It is important to keep all three curves of your spine when you are seated and therefore you may need to use a small pad in the lower back to maintain the normal bend in your lower back
  8. Avoid being seated for longer than 45 minutes at a time (even when driving). Every so often you need to get up and move around

Many patients complain that they are unable to find a comfortable position when sleeping. Many companies advertise special mattresses and accessories to help those of us with discomfort, but most important is proper sleep hygiene and following some basic principles discussed below.

Tips on proper sleeping positions:

  1. Pick a mattress that is firm and does not sag. Many of people believe they should sleep on the floor when they have back pain, this is not necessary.
  2. When changing your mattress you may experience some discomfort until your body adjusts
  3. Change your mattress or box spring if you notice any sag or as the manufacturer recommends
  4. You may sleep in any position (ie: on your back, stomach or side). After surgery most patients prefer to sleep on their backs but you will not cause harm in other positions
  5. If you sleep on your back, try placing pillows under your knees. If you sleep on your side, place a pillow in between your legs.
  6. Use a pillow that allows your neck to be in a natural position, as if you were standing with good posture. Avoid large or multiple pillows under your neck.

Many people complain of back pain first thing in the morning. This may be due to several reasons including improper sleeping positions, as well as stiffness that occurs in the muscles and joints after being still for long periods of time.
Your physical therapist should work with you on the proper way of getting out of bed but below are some helpful tips.

Proper way of getting out of bed:

  1. Avoid sudden changes in position, our bodies need time to adjust. As we get older this process becomes even more important. Changing position suddenly can cause dizziness and even cause fainting.
  2. Lay flat on your back, turn to your side, bring your knees up towards your chest and slowly swing your legs to the side of the bed. You will use your arms to push your upper body upwards. Now sit on the side of the bed for 15-30 seconds.
  3. When you feel stable, stand up using your legs and arms. Stand for a few seconds before beginning to walk. If at any time your feel unstable or dizzy, please sit back down and try again in a few minutes.
  4. Avoid obstacles on the floor that may cause a fall

Physical therapy can help teach you proper form, technique as well as help strengthen the muscles around your entire spine. Strengthening these muscles can be harder than you may think. Many of these muscles are not used while working out at the gym and it can take a good therapist to really explain and show you how to strengthen these muscles.