Answers from Dr. Chen

QUESTION: I am considering surgery for my herniated disk. Can you tell me about the procedure? What are the risks and how do I know it's right for me?

DR. ANDREW CHEN: When a disk herniates, part of the disk is pushed into the spinal canal, and may put pressure on the nerves. This may result in symptoms of pain, numbness, tingling, or weakness in the legs, or problems with bowel or urinary function. Surgery for herniated lumbar disks is generally performed after nonoperative treatments, such as anti-inflammatory medicines, physical therapy, and epidural injections (injections of medications into your back performed by a specialist), fail to adequately relieve symptoms.

The traditional surgical treatment for a herniated disc involves removing a portion of the vertebral bone to remove the herniated disk material from the spinal canal. The surgery is performed under general anesthesia, usually with an overnight hospital stay. Newer surgical techniques are less invasive, may be performed under spinal anesthetic, and may be performed on an outpatient basis. The procedure usually takes one to four hours, depending on the exact problem and how many disks are involved, and may require spinal fusion if spinal instability is present.

Most patients experience relief immediately following the procedure, and are able to return to work in 2 - 6 weeks. Although patients are generally able to walk after surgery, they will require assistance for a few days with cooking, cleaning, shopping, laundry, and most household activities that require lifting or bending. The pain from the surgery gradually decreases over the first few days after surgery and is usually well-controlled with oral pain medicines. If a brace is prescribed, it is important that the patient use it as directed by the surgeon.

The risk of complications after low back surgery for herniated disks is low, although the complications themselves may be serious. Possible complications common to all surgical procedures include pain, bleeding, infection, heart attack, stroke, and blood clots. With low back surgery, other possible complications include recurrent disk herniation and rarely, new nerve damage -- which can result in pain, neurological problems, and prolonged recovery time.

As with any surgery, patients should carefully weigh the risks and benefits of the procedure. Surgery should be considered if conservative treatments have failed to adequately address symptoms, particularly if the neurological deficits (numbness, tingling, or weakness in the legs, or problems with bowel or urinary function) are worsening.

QUESTION: I work at a computer all day long. By the end of the day, my lower back is killing me. What can I do?

DR. ANDREW CHEN: As many as four out of five adults experience significant low back pain sometime during their life, with work-related back injuries being the number one occupational hazard. The risk of back pain is higher if your job requires heavy lifting or bending, if you smoke or are overweight, if you do not exercise regularly, and if you bend over for long periods of time, such as over a computer keyboard.

To reduce your risk of low-back pain, you must take care of your back during work and non-work activities:

• When sitting at your desk, keep your back in an upright, slightly arched position.
• Make sure your chair supports your lower back, or place a small pillow in the small of your back as lumbar support.
• Adjust your monitor to keep your head and shoulders erect.
• Adjust your chair or desk to maintain a proper working height to avoid having to lean forward or bend your neck for prolonged periods of time.
• If possible, once an hour stand and stretch by placing your hands on your lower back and gently arching backward (low back extension).
• Ensure proper lifting techniques at all times by being close to the object and bending down at the hips and knees. Do not bend at the waist. This ensures that the lifting is being performed by the powerful leg, thigh, and gluteal muscles rather than the weaker, more easily injured muscles of the low back.

If your back pain worsens or does not improve, your physician may be able to recommend physical therapy or exercises to stretch and strengthen your back, as well as provide medications that may alleviate symptoms of pain and inflammation.

QUESTION: My back pain seems to be much worse at night. Is there anything that I should be concerned about? Do you have any suggestions for getting comfortable so that I can get more sleep?

DR. ANDREW CHEN: Back pain that is worse at night may be divided into two categories: positional and non-positional. Positional back pain is related to the way in which you are lying down. Certain back conditions, such as spinal stenosis, are worsened with lumbar extension ("bending backward") as nerve roots are pinched in this position. Such patients do not tolerate lying prone (on the belly) well, and usually prefer lying on their backs (supine) or sides. Other patients feel that lying supine places excessive stress on the low back and are relieved by sleeping on their sides or with a pillow under the knees to flex the hips and relieve pressure on the low back.

Non-positional back pain that does not improve ("I just can't get comfortable") with time should be further investigated by your physician, as it may be due to an underlying spine condition that requires further evaluation and treatment.

To maximize low-back comfort at night, you should ensure that your mattress is firm and supportive. Your pillow should maintain your neck in a comfortable neck position. If you find that you frequently experience neck aches in the morning, your pillow may be too soft or not maintaining your neck in a supportive position.

Back pain at night may be minimized by reducing causes of back pain during the day, including the use of proper lifting techniques, avoidance of smoking, maintenance of proper posture when standing and sitting, ensuring a reasonable body weight, and exercising regularly to maintain flexibility and strength.

QUESTION: Are lumbar support belts any good for preventing back pain?

DR. ANDREW CHEN: The use of lumbar support belts, corsets, and binders is controversial. Such belts may help prevent injury in some patients, particularly in activities that require heavy lifting. However, proper lifting technique and posture is necessary to reduce the risk of injury.

Lumbar support may be of value with a flare-up of low back pain. However, some physicians are concerned that over-reliance on such supports may actually decondition your back muscles.

QUESTION: My neighbor suggested that I try one of those large exercise balls to help my back. Is this a good idea? What exactly can it do to help my back?

DR. ANDREW CHEN: A large exercise ball, or Swiss ball, may be very helpful for the physical rehabilitation of the low back. It is not intended for use with a flare-up of back pain, but rather, AFTER you have obtained reasonable pain relief and mobility and can safely participate in the use of the ball.

For improving strength and flexibility of the low back, the ideal ball height is such that when you sit on the ball, a right angle (90 degrees) is made between your trunk and your thighs, the knees are bent 90 degrees, and the feet are flat on the ground. Many exercises have been described to improve the strength and flexibility of the lumbar (low-back), abdominal, hip flexor, and gluteal muscles. This can greatly assist recovery from a low back injury, diminish low back pain, and enhance functional return to activities. Maximal benefit from the use of these balls is achieved with the help of a physical therapist to ensure that proper technique is employed to decrease potential for injury.

QUESTION: Six weeks after giving birth to my son, I was given the go-ahead to exercise by my doctor. I started running again and now I have terrible low back pain. I never had this before or during my pregnancy. Why now?

DR. ANDREW CHEN: Complaints of back pain are common during and after pregnancy. Changes in weight distribution with pregnancy place around an additional 20 - 30 pounds in front of the low back, causing significant increases in stress. After pregnancy, low back pain is common as you begin lifting and carrying the infant regularly. Initially, you may be lifting a 5 - 10 pound baby over 50 times per day. As the baby grows, the weight load increases, thus placing further strain on your back. When the child is 2 years of age, you may be lifting and carrying a 25 - 35 pound child regularly!

Running places repetitive impact stresses to the low back. After having a baby, your back is under increased stresses from the weight gain and redistribution from pregnancy, the decrease in muscle tone and relative deconditioning of the lumbar (low back) and abdominal muscles, and the repetitive lifting and carrying of the growing infant.

To reduce low back pain after having a baby, try these suggestions:

• Ensure proper lifting technique when picking up the baby. This means bending at the knees-not at the waist-to lift the infant.
• When possible, avoid lifting the baby with extended, outstretched arms. This may mean removing the high chair tray, letting down the side of the crib, or kneeling on the back seat to lift the baby out of a car seat.
• Soon after delivery, begin an active exercise program. Stretching and strengthening exercises should be performed to restore abdominal and lumbar muscle tone and reduce back pain. Cardiovascular conditioning helps with general health and weight loss.
• Avoid carrying the child on your hip. This results in uneven stress distribution to the low back and overloads the muscles (this can also occur from carrying the infant on the same side all the time).
• When nursing, ensure upright posture with the infant well supported to minimize stress on the low back.

QUESTION: I can go for months without having back pain. Then suddenly, something minor, like bending in the shower, will make it hurt again. Why is that?

DR. ANDREW CHEN: The low back is an intricate system that provides for strength and mobility. Movements such as bending, twisting, and turning must be coupled with functional stability and strength to allow for almost all activities of daily living. Injuries to the low back are common, with 4 out of 5 adults experiencing significant back pain some time during their lives.

Most commonly, back pain arises from strain of muscles that are poorly conditioned or overworked, or from a sprain of ligaments due to sudden forceful movements. Aging may worsen back pain through deconditioning and decreased flexibility of muscles, as well as decreased strength and elasticity of ligaments.

The natural history of low back pain is such that the majority of patients never require surgery and improve with conservative measures alone. However, unless proper conditioning (strength and flexibility) of the back is maintained and proper back "hygiene" (i.e., proper lifting techniques, posture, etc.) is practiced, many patients experience recurrence of their back pain even after pain-free periods and often after trivial movements or injuries.

Andrew L. Chen, M.D., M.S., Department of Orthopaedic Surgery, Hospital for Joint Diseases, New York, NY. Dr. Chen's answers are provided by VeriMed Healthcare Network.

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