In the lumbar spine, the lumbar discs are larger but also carry more weight on them every day and with every step. Lumbar disc symptoms can come about due to a gradual loss of water in the disc space and a loss of the elastic qualitiy of the disc outer ring or annulus. Lifting and twisting can put shear stress on the disc and cause the outer ring to fail and a portion of the soft gel-like center of the disc to push out near the adjacent nerve roots. This can cause back pain, buttock pain or pain shooting down the leg to the foot along with numbness or weakness. Many conditions like this can be treated with non-surgical measures like physical therapy, diet, exercise, traction or steroids. Only about 50% of the symptomatic lumbar disc patients ever end up needing surgery to relieve their symptoms. Dr. Brennan will always try non-surgical measures first unless there is evidence of progressive muscle weakness or the pain is severe, disabling and not improving with other treatments. Most commonly, Dr. Brennan performs the minimally invasive micro-endoscopic discetomy which is a very small incision and uses a microscope to remove the portion of the disc putting pressure on the nerve roots.
The procedure is done in the hospital, is occasionally same day surgery and patients are generally back at work in 2-4 weeks depending on many factors. It’s not unusual for patients to be back at the gym going easy in 3-4 weeks after surgery.
As the lumbar spine holds up a greater portion of our body weight, the stress factors on these larger vertebrae are also larger and, as a result, the bone responds to stress by making bone spurs to protect itself. These bone spurs, or osteophytes, can grow in such a way as to narrow the tunnel that the nerve roots use to exit the spine and can even progress to the point where they block the entire spinal canal. When these conditions occur, symptoms become noticed as a reduced ability to walk long distances due to cramping in the legs. Many patients find this relieved somewhat by tilting their body forward at the waist giving rise to the “forward lean” of these patients. The forward bending helps open the canal slightly. Many patients get relief with epidural steroid injections for several months and Dr. Brennan will use this treatment plan depending on how severe the symptoms.
Surgery for this condition usually involves taking off the shingle-like portion of the vertebrae covering the back of the canal called the lamina. The procedure is called a lumbar laminectomy and Dr. Brennan often uses minimally invasive surgery to remove this blockage and patients can expect a surgery for 1-2 hours and to return to work or recreation in 2-4 weeks.
A relatively common condition caused by an undiagnosed lumbar fracture during adolescence, this fracture line never heals in some people and can become the source for “slippage” of a lumbar vertebra. This slippage is in the forward direction over a long period of time and the forward motion causes the nerve tunnels to narrow and puts pressure on the involved nerve roots causing lumbar nerve root symptoms of pain in the back, buttock and leg as wells as numbness and weakness in the involved leg(s). Dr. Brennan has helped many patients with this condition by using a lumbar fusion done using bone graft and titanium screws that are placed through the minimally invasive surgery methods. The patients can expect surgery for 1-3 hours in a hospital setting and many go home the next day or day two. Generally a brace is worn under the clothing for 2-4 weeks and patients return to work or recreation in gradual fashion over the next 2-4 weeks. Follow up appointments involve x-rays to show the fusion solidifying over time.
For many patients the relief of symptoms is immediate from the surgery. Over time, this area fuses so no further slippage occurs.
Much more common as patients’ age is this slippage of the vertebrae of the lumbar region but not due to a fracture as described above but just due to the structure of the lumbar spine changing as the elements responsible for holding the alignment get soft and loosen with aging. This progressive slippage forward over many years can progress until symptoms occur or can go a certain distance and stop and never produce symptoms. Dr. Brennan will try all non-surgical measures to help his patients relieve symptoms before considering surgery. If surgery is needed, Dr. Brennan performs the minimally invasive lumbar fusion described above and in the photos shown here. The recovery is 2-4 weeks and a brace is worn under the clothing during that time. Return to work or recreation is 2-4 weeks but varies between patients.
Dr. Brennan is a big believer in non-surgical treatment of spinal problems and although traction is an inexpensive, low risk method of treating problems in the neck, the lumbar region is much more challenging to get good traction therapy or results due to the mechanics of the low back. Some facilities around Louisiana are set up to provide lumbar traction but the equipment is expensive and the treatments reflect that. In the old days, patients would be placed in the hospital at bed rest and the lower part of the body put in a girdle-like harness attached to a pulley and weights on the end of the bed. It was difficult to keep the patients from sliding down the bed and bed rest has been shown to be detrimental to a recovery. As a result, that process was abandoned.
Today, there are no good home lumbar traction devices with the exception of the “inversion tables” advertised on TV. The cost of these has come down a little and for someone with back problems they need to judge if the expense is worth it. Also, medical clearance should be performed before engaging in inversion therapy. The other tables out there are the VAX-D and its competitors. They are usually purchased by chiropractors, physical therapy or back clinics and patients are charged each time for their use. Dr. Brennan will be happy to write a prescription for these methods but insurance coverage varies. Fees for use also vary. In general, they do accomplish lumbar traction and many patients find relief after a few treatments. Dr. Brennan’s biggest concern about these facilities is that the length of time for a treatment may not be long enough to do some good. Any treatment should be 20-30 minutes and less may be a waste of time and money.
Lumbar Epidural Steroid Injection
Dr. Brennan perscribes epidural steroid injections initially in the management of many spinal problems in the patients he sees. The procedure is very similar to the epidural used in childbirth but the medicine injected is different. Instead of numbing medicine, they use a steroid mixture that reduces inflammation in the soft tissue and nerve roots. These medicines are referred to in everyday language as “cortisone shots” but the actual medicine is slightly different. Many practitioners use Depo-Medrol. This is a similar medicine to Cortisone but lingers in the tissue much longer and provides longer lasting relief of symptoms. Dr. Brennan cautions his patients that doctors sometimes disagree about how many injections may be required for each patient. Dr. Brennan believes that each patient should assess the effectiveness of each injection each time and if there is only relief that lasts a little while, then more injections may not be worthwhile.
“I’d say that approximately half of all the patients that I have seen for nerve root symptoms, who underwent epidural steroids, made a recovery that did not involve surgery” states Dr. Brennan
Probably the most commonly performed surgery on the lower spine. Dr. Brennan has performed thousands of these procedures since 1995 and feels that today’s minimally invasive surgery methods make the old days of a week in the hospital and weeks of recovery a thing of the past. If non-surgical treatments are not providing sufficient relief of the patient’s symptoms or there is progressive weakness developing in the leg muscles, Dr. Brennan may recommend a minimally invasive lumbar discectomy. This procedure is done in the hospital and either same day surgery or one night stay depending on how early the case can be started. The surgery involves going in and taking out as much of the center of the disc as possible and relieving the pressure on the affected nerve root. Patients are all the way asleep and the surgery takes a little under an hour in most cases. Patients are up that night walking around and are instructed to do a daily walking program.
Lumbar Artificial Disc Replacement
Over the past few years much research has been done on the Lumbar Artificial Disc Replacement or “Lumbar ADR”.. In Europe, the procedure has been done for 10 years but the FDA is slowly adopting these devices here in the United States. The idea is to completely remove the disc from the disc space from the front and replace it with a device which takes up the same amount of room and continues to provide the shock absorber effect of the disc and allowing range of motion preservation. The ideal candidate for this procedure is someone whose back pain can be narrowed down to being due to the disc material itself. Dr. Brennan will always be looking for these patients and will discuss this as a possibility if the MRI shoes no herniations to treat but simply a dried out painful disc. He will also recommend diagnostic tests to firm up the disc as the cause of the patients’ pain. “If you find the right patient, they are very happy with the result” says Dr. Brennan. “The trick is that not all back pain patients have only the disc to blame for their pain”.
When Dr. Brennan determines that a patient is a good candidate for a lumbar fusion, he may use minimally invasive surgery to perform the fusion. A fusion is the placement of bone graft across a motion segment of the spine in hopes that motion will be eliminated along with motion induced pain. In the 1960’s, surgeons were just using bone graft to perform the fusions and the success rate was 50%. With the development of the pedicle screw in the 1980’s the success rate of fusion was up into the 90% range because the screws held the bone motionless which is a good environment for the healing bone to grow into position. The growth of the bone up until 2002 was usually about 6-12 months before it was complete. In 2002, a product that speeds the healing of bone was developed and called BMP for “Bone Morphogenic Protein”. This protein, when applied to the surgical area on an absorbable matrix, causes bone to complete the fusion process in a matter of weeks not months and the fusion rates in some studies was 100% !.
This was good news in the spine world and the FDA has approved the use of this product for some types of fusions. Lumbar fusions can be done from either the front of the spine or the back of the spine. Incisions for the front of the spine are from the belly button down about 4-5 inches. From the back there are generally two incisions on the side of the midline of the spine, occasionally in the midline.
Patients who have fusions have about a 2-3 hour surgery and spend 1 or 2 days in the hospital. They are up and walking around the next morning after their surgery and begin a daily walking program and wear a brace under their clothing for 2-4 weeks. Return to work or recreation varies from 2-4 weeks.