Low Back and Leg Pain

Causes of Lower Back and Leg Pain

Treatment of Lower Back and Leg Pain

• Fortunately, there are a wide variety of treatments available for lower back (lumbar spine) conditions. Before any treatment can be considered, we must first determine the cause of the back and leg pain. This includes ordering tests such as x-rays, MRI, and CT scans and performing a detailed examination of the person so that a correct diagnosis and assessment of the condition can be made.
• Once the correct diagnosis is made, a treatment plan can be custom-tailored for each patient based on the current technology available and the lifestyle goals of the individual. Oftentimes spine surgery for back and leg pain will not be necessary. The condition can be treated with physical therapy, steroid injections, and adjustment of activity level. This treatment is called conservative therapy.
• Spinal tumors can be removed surgically or followed depending on the type of problems that are being caused by the tumor. In most cases, weakness should be treated with surgery to remove the spinal tumor.
• Problems which do not directly involve a lower back (lumbar spine) condition would need to be treated by another specialist.
• Hip disease would require referral to an orthopedic surgeon or physical medicine specialist.
• Inflammatory joint disease would be best treated by either a rheumatologist who specializes in treating arthritic conditions.
• Problems with nerve nutrition should be evaluated and treated by a neurologist.
• All the conditions noted above do not require any spine surgery.
• If conservative therapy fails and the person continues to have back and leg pain, a number of options are available if the patient wishes to consider surgery. Most of the spinal surgery options are minimally invasive and often can be performed as an outpatient (same day surgery). The surgery results vary according to procedure, but overall is about 80-85% successful in relieving leg and back pain. During surgery, special monitoring is used to check the status of the nerves and muscles in the legs using small needle electrodes placed into the legs to record nerve and muscle activity. This helps to reduce the risk of nerve damage during the surgery. Magnification of the surgical site is during the procedure is also performed to help the surgeon to see the spinal nerves so that they can be preserved.
• Microdiscectomy-A minimally invasive surgery performed through a 3/4inch incision which removes a piece of disc material pinching a nerve to relieve back and leg pain. A microscope is used to perform the procedure through a tube-shaped retractor. This procedure is often performed as a same-day surgery. There are activity restrictions such as avoiding lifting for about 6 weeks. The patient is encouraged to resume walking as soon as possible up to 1 hour per day and after about 2 weeks will be reassessed in the office and referred for physical therapy for another month. Following physical therapy, a decision will be made regarding changes in activity restrictions. This procedure works very well for relieving leg pain and some back pain associated with a herniated disc.
• Micro-decompression (laminotomy/medial facetectomy)-also a minimally invasive surgery using the same size of incision as a microdiscectomy, involves opening the narrow canal or tube that the nerves must pass through to reach the legs. Usually excess arthritic bone is removed from around the nerves to enlarge the spinal canal and relieve the nerve compression. Disc material may or may not be removed. Depending on your insurance, this procedure may also be performed as same day surgery or overnight hospital stay. After surgery care is similar to those patients who undergo microdiscectomy. This procedure helps relieve the back and leg pain associated with walking and allows the person to walk farther and at a faster pace.
• Lumbar interbody fusion-there are 3 types of this procedure which are related to the direction of approach to the spine. An interbody fusion involves placing either a hollow plastic or metallic device, called a cage, which is filled with ground-up bone, into the disc space between 2 or more vertebrae. Most of the ground-up bone is obtained from donors which have been carefully screened for diseases. Some of the bone is also obtained from the patient in the case of a TLIF listed below. Either a portion or the entire the disc is removed and replaced by the cage. The cage then serves as a conduit to allow bone to grow through it and connect the vertebrae together (fusion). The shape and placement of the cage can also be utilized to help correct spinal deformity and relieve pressure around the nerves that pass near the disc space. For successful fusion to occur, the vertebrae on either side of the cage must be held together using screws and rods. Minimally invasive surgical technique is utilized to place cages and stabilization device through small incisions. All of these fusion procedures require the patient to wear a lumbar brace for about 6 weeks during activities such as sitting standing or walking. After returning home, a 1-month walking program at home is then followed by 1 month of physical therapy in the water (aqua therapy) followed by another month of physical therapy on land. During the recovery phase activity levels are changed according to the patient’s progress. Complete healing (fusion) usually takes 9 months to a year. Most patients can resume most of their normal activities by 6 months.
• Extreme lateral interbody fusion (XLIF)-in this procedure a cage is placed into the disc space from the side of the spine. Screws and rods are then placed through small incisions in the back to secure the cage and allow for successful fusion. This type of fusion can often be performed as same day surgery. Cages can also be placed into multiple disks and used to correct deformity and abnormal motion in the spine (instability). Conditions which are treated using this technique include narrowing of the spinal canal due to collapse of disc, abnormal spine curvature called scoliosis, slipping of 1 vertebra over the other causing an unstable spine. Usually some ground-up bone is also placed to the side of the screws through the same incision which also results in a fusion (posterior fusion). If 2 or more cages are placed, the hospital stay is usually about 3-5 days.
• Transforaminal lumbar interbody fusion (TLIF)-in this procedure to incisions are placed in the lower back region and one of the joints supporting the back of the spine called a facet joint is removed. The bone which made up the facet joint is saved and used later in the procedure for placement within the cage. After the facet is removed the surgeon can see the disc space, preserve the nerves, and remove the disc. Then a cage is placed into the back of the disc at a diagonal and the cage is expanded within the disc space. Ground-up bone from the patient and bone bank is placed into the center of the cage. Screws and rods are also placed into the vertebrae on both sides to secure the cage while fusion is occurring. This type of procedure usually requires a 2-day hospital stay.
• Anterior lumbar interbody fusion (ALIF)-in this procedure an approach surgeon works with the neurosurgeon to expose the front of the spine through an abdominal incision. Once the spine has been successfully exposed, the neurosurgeon removes a portion of the disc and replaces it with a plastic or titanium cage filled with bone from the bone bank. The cage is usually held in place by one or 2 screws into the vertebrae and the abdominal incision is closed by the approach surgeon. The patient is then turned over onto a special table while still asleep under anesthesia and 2 incisions are made into the back to allow placement of rods and screws to hold the cage in position during fusion. More bone is also placed between the screws (posterior fusion). This type of procedure also requires a 2-3-day hospital stay.