Prosthetic disc replacement ....is it for you ?

There is a lot of talk nowadays about prosthetic disc replacement (PDR) for low back pain. Should all patients with back pain get their discs replaced ? Is it the new ultimate therapy for back pain ?

PDR is another wonderful advance in the treatment of low back pain. Here the patient's diseased disc is replaced by a prosthetic one, much like a total knee replacement. Chronic low back pain is a big and difficult problem, frustrating for both, the doctor and the patient. In this depressing scenario, the results of PDR look promising. Unfortunately only a few patients would qualify for disc replacement. This is because there are multiple causes for low back pain. Pain could arise from the discs, the facet joints, the ligamentum flavum, etc. Obviously a disc replacement is useless for pain arising from facet arthropathy.

What, then are the indications for disc replacement ?
Disc replacement is advocated in ...

1. Patients with severe & disabling pain with degenerative disc disease who have failed at least 6 months of non operative treatment. (anti-inflammatory and analgesic medication, physiotherapy, injections, acupuncture, bed-rest, back school training) with

2. Objective evidence of disc disease in the form of x rays and MRI with

3. A positive provocative discography as confirmation (preferable)

4. In patients between 18 to 60 years of age.
   

Disc replacement is not for ...

1. Patients with facet arthropathy.

2. Patients with osteoporosis.

3. Patients with spinal deformities and instabilities (spondylolisthesis, post op instability)

4. Patients with morbid obesity.

5. Patients with disc bulges that significantly compress the spinal cord & nerve roots causing leg pain and weakness.

6. Patients with infection.

7. Patients with failed back syndrome and epidural fibrosis.
   

As is obvious, PDR is useful for a limited population of patients. In fact only 5% of of patients qualifying for lumbar spine surgery meet the criteria for disc replacement.

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Exercising for back pain

Chronic low back pain is common. However, finding an effective treatment is not. Doctors today are still in search of the elusive lumbar spine pain generator

Not wanting to complicate matters further, the real question I wanted to ask was - Is exercising useful for back pain?
Literature reveals the Cochrane review
A summary of their review says

"Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in populations visiting a healthcare provider. In adults with subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. For patients with acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments."

So there is evidence that exercise for low back pain works ! but which exercises ?

Here is a list of a few of them

First the basics

1. Avoid exercising if you have acute back pain, consult your doctor first
2. Don't expect miracles. Exercise is helpful, not curative
3. Always do a few warm up stretches first
4. Start with sets of 5 repititions, 4 times a week and work upto 10 repititions

here goes.....

1. Pelvic Tilt - Lie on your back with knees bent. Put your hands on the abdomen. Then pull your abdomen towards the floor. Use your stomach muscles. Hold for ten seconds. Repeat.

2. Back Lift - Lie on your stomach with your arms overhead. Lift your head and shoulders, without looking up. Hold for ten seconds. Repeat.

3. Abdominal Curl - Lie on your back with your knees bent. Curl up to raise your head and shoulders. Hold for ten seconds. Repeat.

4. Wall slides - Stand with your back against the wall with your knees bent at 90 degrees. The knees should be slightly apart. Hold for ten seconds. Repeat.

5. Leg raises - Lie on your stomach. Raise the leg from the floor. Hold for ten seconds. Repeat. Then lie on your back. Again raise the the leg as much as you can. Hold for ten seconds. Repeat.

6. Knee to chest stretch - Lie on your back with both knees bent. Hold one thigh and bring knee upto chest. Hold for 10 seconds. Repeat.

7. Hamstring Stretch - Lie on your back with knees bent. Hold one thigh behind knee. Now straighten the knee as much as you can. Hold for 10 seconds. Repeat.

8. Heel raises - Stand on both feet. Raise heels. Hold for ten seconds. Repeat.

9. Hip flexor stretch - Lie on your back near edge of bed, holding knees to chest. Slowly lower one leg down, keeping knee bent, until a stretch is feltacross top of the hip/thigh. Hold for ten seconds. Repeat.

10. Aerobic exercise - Low impact aerobic exercise is an essential component of any back training program.

These exercises are a good starting point. A swiss ball could also be used.

For the more enthusiastic, I would recommend the core spinal fitness systems from MedX

the myth of the lumbar corset

If you have suffered from chronic low back pain, the idea of a lumbar belt must have seemed appealing. The fact is many people use one and even get habituated to it.
The myth is if you have back pain, use a belt, it will help.
This unfortunately is far from true.

If worn for the wrong reasons, a belt can cause muscle atrophy. This further weakens your back and aggravates the pain. So you wear the belt more often. A self propagating cycle starts which ends in habituation to belt wear.

The web of the back says that belts may be used for

1. Patients with back pain when performing heavy work such as weightlifting. This is obvious to understand.

2. When acute back pain limits activity significantly. Here the belt is used to allow the patient to walk. Because walking around is a better idea than being bed ridden, a belt in such a scenario is useful.

3. For older patients, again only to allow them to return to normal daily activities.

4. For adolescents or children with scoliosis.

Most patients do not fall into any of the above categories.

The bottom line is use a belt if your incapacitated by pain, only if it allows you to move around and get rid of it as soon as you can.