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Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge

Eur Spine J. 2012 Sep; 21(9): 1788–1796.

Hiroyuki Yoshihara

Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th St., New York, NY 10003 USA

Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th St., New York, NY 10003 USA

Corresponding author.

Received 2012 Jan 9; Revised 2012 Apr 19; Accepted 2012 Apr 24.

This article has been cited by other articles in PMC.

Abstract

Recently, the sacroiliac joint (SIJ) has gained increased attention as a source of persistent or new pain after lumbar/lumbosacral fusion. The underlying pathophysiology of SIJ pain may be increased mechanical load, iliac crest bone grafting, or a misdiagnosis of SIJ syndrome. Imaging studies show more frequent degeneration of the SIJ in patients with lumbar/lumbosacral fusion than in patients without such fusion. Using injection tests, it has been shown that SIJ pain is the cause of persistent symptoms in a considerable number of patients after fusion surgery. Recent articles reporting on surgical outcomes of SIJ fusion include a high percentage of patients who had lumbar/lumbosacral fusion or surgery before, although well-controlled clinical studies are necessary to assess the efficacy of surgical treatment. Taking these findings into consideration, the possibility that the SIJ is the source of pain should be considered in patients with failed back surgery syndrome after lumbar/lumbosacral fusion.

Keywords: Sacroiliac joint pain, Lumbosacral fusion, Lumbar fusion, Pathophysiology

Introduction

The past decade has seen an increase in the number of lumbar/lumbosacral fusion surgeries [1]. One multicenter study reported that this type of surgery brings about greater relief than classic conservative treatment [2]. However, the failure rate across the different studies ranges between 5 and 30 % [3, 4]. Indeed, some patients continue to complain of persistent or new low back pain after surgery. Cases of recurrent low back pain and/or lower extremity pain after lumbar/lumbosacral surgery are referred to as failed back surgery syndrome [5–11]. Several authors have suggested that the sacroiliac joint (SIJ) may be a possible source of persistent pain [4, 12, 13].

Pathophysiology

Theories of pain generation include ligamentous or capsular tension, extraneous compression or shear forces, hypomobility or hypermobility, aberrant joint mechanics, and imbalances in the myofascial or kinetic chain that result in inflammation and pain [14]. Intra-articular sources of SIJ pain include osteoarthritis; extra-articular sources include enthesis/ligamentous sprain and primary enthesopathy. In addition, ligamentous, tendinous, or fascial attachment and other cumulative soft tissue injuries that may occur posterior to the dorsal aspect of the SIJ may be a source of discomfort.

There are three possible causes of SIJ pain: (1) an increased mechanical load transfer onto the SIJ after fusion; (2) bone graft harvesting in the iliac crest close to the joint; and (3) the misdiagnosis of an SIJ syndrome before fusion (i.e., the lumbar spine is thought, erroneously, to be fused) [4].

Numerous clinical and experimental studies of adjacent segment disease after lumbar fusion procedures have demonstrated increased mobility in the adjacent cephalad and/or caudad segments and increased stress on the facet and/or disc of adjacent mobile segments [15–25]. In the case of lumbosacral fusion, the SIJ is the joint adjacent to the fused segment, and similar biomechanical responses could apply to the SIJ [26]. Ha et al. [27] reported that the incidence of SIJ degeneration is higher in patients in whom fusion is down to S1 than in patients in whom fusion is down to L5. Onsel et al. [28] reported increased SIJ uptake on single photon emission computed tomography (SPECT) after lumbar fusion and/or laminectomy and concluded that increased SIJ uptake is usually caused by changes in spinal mechanics. Although the differences failed to reach statistical significance, Maigne and Planchon [4] reported a trend for more cases of SIJ pain in patients with fusion to the sacrum than in those without. Furthermore, DePalma et al. [29] reported that patients with lumbosacral fusion had an increased frequency of positive SIJ blocks than those without.

A history of bone graft harvesting is a potential risk factor for SIJ pain. After discounting the SIJ as the etiologic source of pain based on a lack of objective findings on physical examination and imaging studies, Frymoyer et al. [12] concluded that sacral sulcus pain encountered in 37 % of patients with low back pain after lumbar fusion was related to the iliac graft donor site. Ebraheim et al. [13] studied patients with donor site pain and found a high frequency of a sacroiliac inner table disruption that resulted in accelerated degeneration of the joint and sacroiliac pain. In addition, Ha et al. [27] reported that the SIJ on the side from which cancellous bone was harvested developed degeneration more often than on the normal side, although damage to the SIJ was not evident on computed tomography (CT) scans. This is in agreement with other studies that have reported that the harvesting of cancellous bone for a bone graft induces pelvic instability and has a negative effect on the SIJ [30–32]. However, Katz et al. [33] failed to find any correlation between the side of low back pain and the side of graft harvest, rendering direct SIJ damage after graft harvesting improbable. In the study of Maigne and Planchon [4], bone graft harvesting is definitely not the only cause of SIJ syndrome, which was present at similar frequencies in patients who had not undergone bone graft harvesting. Recently, Howard et al. [34] reported that 54 % of patients complained of tenderness over the iliac crest, with most having tenderness over both crests rather than just one, regardless of whether a bone graft had been harvested or not. That study found that iliac crest graft site pain can occur even in the absence of iliac crest graft harvesting and is thus a poor marker for graft site morbidity. Furthermore, Liliang et al. [35] have reported that there is no significant association between iliac crest bone graft harvesting on the painful side and positive responses to SIJ blocks.

The presence of a misdiagnosed sacroiliac syndrome as a cause of pre-fusion low back pain is also a possibility. Some patients may have lumbar fusion for misdiagnosed SIJ syndrome or some may have only lumbar fusion for lumbar pathology and SIJ syndrome. Sembrano and Polly [36] reported that up to 14.5 % of patients presenting to a spine surgeon’s clinic for low back pain had SIJ pathology. In another study, Weksler et al. [37] found that patients with low back pain and disc herniation who responded positively to pain provocation tests for SIJ dysfunction exhibited significant improvement in visual analogue scale (VAS) pain scores after SIJ injection. Therefore, a third possible cause of SIJ pain is errors made during the preoperative screening of patients. This cause of SIJ pain can be differentiated from SIJ pain caused by an increased mechanical load when patients are not pain free for even a short period of time after fusion surgery.

In very rare cases, SIJ pain may be caused by hardware. For example, Ahn and Lee [38] reported iatrogenic SIJ syndrome caused by the screw head and rod of percutaneous pedicle screw fixation at the L5–S1 level. The sharp rod tip and the laterally located screw head may irritate the iliac crest and distract the SIJ, leading to intractable SIJ pain.

Biomechanical studies

Frymoyer et al. [12] conducted a clinical study of sacrum motion in patients after lumbar fusion, using flexion–extension lateral radiographs. Although doubts exist as to the validity of using a two-dimensional method to assess SIJ motion, Frymoyer et al. [12] failed to find any significant differences in mobility in the SIJ after spinal procedures.

Ivanov et al. [26] assessed angular motion of the sacrum and stress across the SIJ using a finite element lumbar spine–pelvis model with simulated posterior fusion surgical procedures. The results of that study indicated that posterior fusion of the lumbar spine leads to increased motion at the SIJ and increased stress across SIJ articular surfaces. In addition, the values of the parameters measured were related to the number of spinal segments involved. The authors noted that the differences in angular motion between the intact and instrumented models were not large; however, the ligaments around the sacroiliac articulation are richly innervated and, therefore, even small increases in motion may trigger pain.

Clinical features and pain patterns

Early published referral patterns of SIJ provocation or irritation were based on patients’ complaints and physical examination. Dreyfuss et al. [39] reported that only 4 % of patients with SIJ pain marked any pain above L5 on self-reported pain drawings. Referral of pain into various locations of the lower extremity does not distinguish SIJ pain from other pain states. For example, Schwarzer et al. [40] found that pain below the knee and into the foot was as common in SIJ pain as for other sources of pain. Slipman et al. [41] conducted a retrospective study to determine the pain referral patterns in 50 patients with injection-confirmed SIJ pain. The most common referral patterns for SIJ pain were found to be radiation into the buttock (94 %), lower lumbar region (72 %), lower extremity (50 %), groin area (14 %), upper lumbar lesion (6 %), and abdomen (2 %). Twenty-eight percent of patients experienced pain radiating below their knee, with 12 % reporting foot pain. Based on the existing data, the most consistent factor for identifying patients with SIJ pain is unilateral pain (unless both joints are affected) localized predominantly below the L5 spinous process. Maigne and Planchon [4] reported that the only criterion characterizing patients with SIJ pain following lumbar fusion was postoperative pain that differed from preoperative pain in its distribution. Liliang et al. [35] reported similar results, namely that 67 % of patients diagnosed with SIJ pain after lumbar and lumbosacral fusion had pain with characteristics that differed from their preoperative pain.

Physical examinations

One of the most challenging aspects of treating SIJ pain is the complexity of diagnosis. Literally dozens of physical examination tests have been advocated as diagnostic aids in patients with presumed SIJ pain [42]. Examples of these tests include Patrick’s test, Yeoman’s test, Gaenslen’s test, Gillet’s test, the compression test, sacral sulcus tenderness, the sacral thrust test, and the thigh thrust test. However, when applying pain provocation tests, it is nearly impossible to define which structures are actually stressed [43, 44]. Even structures such as the iliolumbar ligament or piriformis muscle cannot be excluded as potential sources of pain because they are functionally related [45, 46]. Consequently, it is very difficult to determine whether the pain that is provoked is exclusively intra-articular or whether it is related to capsular ligaments.

Previous studies have reported that there is no one single specific physical examination that can accurately identify a painful SIJ [38, 39, 42, 47]. Dreyfuss et al. [39, 48] found that 20 % of asymptomatic adults had positive findings on three commonly performed SIJ provocation tests and that the test with the highest sensitivity was the test of sacral sulcus tenderness (89 %), although this test exhibited poor specificity. Slipman et al. [47] reported a positive-predictive value of 60 % in diagnosing SIJ pain in patients using a positive response to three SIJ provocation tests. Broadhurst and Bond [49] reported a sensitivity of 77–87 % for positive responses to three SIJ provocation tests. Thus, there is evidence of good diagnostic validity of positive responses to a threshold of three SIJ provocation tests to identify SIJ pain [49–53]. However, there are no studies that have specifically examined provocation tests in patients with SIJ pain after lumbar/lumbosacral fusion.

Radiographic studies

No imaging studies consistently provide findings that are helpful in diagnosing primary SIJ pain.

Radiographs are the most cost-effective technique for imaging the SIJ. However, at least 24.5 % of asymptomatic patients >50 years of age have an abnormal SIJ on plain radiographs [54]. In addition, there is currently no consensus in the literature as to the recommended radiographic view or series of views to evaluate the SIJ.

Changes in the bone can be more sensitively detected using CT scans. A diagnosis of SIJ degeneration can be made on the basis of the presence of sclerosis, erosion, osteophytes, narrowing of the joint space, intra-articular bone fragments, or subchondral cysts. In a retrospective study, Elgafy et al. [55] found that abnormal CT findings, such as sclerosis, erosions, and narrowing, had a sensitivity of 58 % and a specificity of 69 % for determining which patients would experience pain relief following injection of an anesthetic into the SIJ. In a prospective cohort study investigating the relationship between fusion and SIJ degeneration after instrumented posterolateral lumbar/lumbosacral fusion, Ha et al. [27] reported that, based on results from CT scans, the incidence of SIJ degeneration in the fusion group was significantly higher than in the control group (75 vs. 38.2 %, respectively). Furthermore, the incidence of SIJ degeneration was greater in patients in whom fusion was down to S1 than in patients in whom fusion was down to L5. Ha et al. [27] concluded that lumbar/lumbosacral fusion can be a cause of SIJ degeneration, which develops more often in patients undergoing lumbosacral fusion regardless of the number of fused segments.

Magnetic resonance imaging (MRI) can detect edema and enhancement before bone changes are visible on CT. In addition, MRI can detect synovitis or extra-articular sources of SIJ pain, such as ligamentous, tendinous, or fascial attachment and other cumulative soft tissue injuries. When performing MRI of the SIJ, most studies report that short tau inversion recovery (STIR) images are preferable to fat-suppressed T2-weighted images because they show early marrow edema better [56, 57]. For patients with SIJ syndrome, MRI is not helpful in determining which patients are likely to benefit from anesthetic injections [58].

Bone scanning is a poor screening test for SIJ pain [59, 60]. In studies of patients with SIJ syndrome, Maigne et al. [59] and Slipman et al. [60] reported sensitivities of 46.1 and 12.9 %, respectively, and specificities of 89.5 and 100 %, respectively, for radionuclide bone scanning in identifying SIJ pain using anesthetic injections into the SIJ.

It has been reported that SPECT is more sensitive in detecting and localizing lesions than planar scintigraphy [61] and, in addition, that SPECT is useful when evaluating patients postoperatively because it is relatively unaffected by metallic fixation devices and can identify specific bony abnormalities in patients with complex problems, such as surgery at multiple levels, repeated surgery, bony fusions, or internal fixation with pedicle screws or metallic plates [62]. Onsel et al. [28] reported increased SIJ uptake demonstrated by SPECT after lumbar fusion and/or laminectomy. They concluded that such spinal surgery can impact on the loading on the SIJ, leading to mechanical overload and sacroiliitis. Note, increased SIJ uptake is usually caused by altered spinal mechanics. Gates and McDonald [62] also reported increased SIJ uptake by SPECT in 18 of 63 patients with back pain and a history of lumbar spinal surgery.

Diagnostic injections and epidemiology

In a retrospective review of patients with low back pain after lumobosacral fusion, Katz et al. [33] reported that 34 patients met their criteria for SIJ injection. Katz et al. [33] concluded that the SIJ was the cause of pain in 11 patients and possibly the cause of pain in a further 10. They did not report the number of patients who had low back pain after lumbosacral fusion, so prevalence is not certain. Maigne and Planchon [4] performed a prospective study of SIJ pain among patients with persistent low back pain after lumbar fusion using diagnostic SIJ blocks. In that study, 61 patients had persistent back pain after fusion surgery and, of these, 45 patients met the criteria for SIJ injection. Fourteen patients responded positively to the injections; on the basis of these reported data, the prevalence of SIJ pain among patients with low back pain after fusion can be calculated as 23 %. DePalma et al. [29] investigated the etiology of chronic low back pain in patients who had undergone lumbar fusion. In 43 % (12/28) of cases, the SIJ were symptomatic. Ten of these 12 cases had fusion to the sacrum and the remaining two cases had fusion to L5. Liliang et al. [35] investigated whether the SIJ is a potential source of pain in patients who have undergone lumbar/lumbosacral fusions. In that study, 130 patients had persistent chronic back pain after fusion surgery and 52 patients in whom positive findings were obtained for at least three of the provocation tests were selected to receive dual diagnostic blocks. Of these patients, 21 (16 %) were considered to have SIJ pain on the basis of two positive responses to diagnostic blocks. Thus, the prevalence of SIJ pain among patients with low back pain after lumbar/lumbosacral fusion appears to be in the range 16–43 % (Table ).

Table 1

Summary of clinical studies of diagnostic injection for sacroiliac joint pain after lumbar/lumbosacral fusion

Reference Study type No. patients Inclusion criteria for injection Fusion levels for injection cases Diagnostic criteria Results
Katz et al. [33] Retrospective 34 pts who had LBP after prior lumbar fusion to the sacrum met the criteria for injection History of pain in the low back below the waist and at or just distal to the posterior iliac crest with or without radiation to the posterior thigh or groin 8 at L5–S1
14 at L4–S1
6 at L3–S1
2 at L2–S1
4 with thoracolumbosacral fusion
Positive when both >75 % pain relief with the local anesthetic and at least 10 days of continued relief with corticosteroids 11 pts were considered positive
10 pts were considered to have possible SIJ dysfunction
Maigne and Planchon [4] Prospective 61 pts had persistent back pain after fusion surgery
45 pts met inclusion criteria for injection
5 pts had unsuccessful block
Unilateral persistent pain for >6 months
Distribution compatible with a sacroiliac origin: not radiating below the knee, tenderness of the sacroiliac sulcus at palpation, and no evidence of a lumbar cause
2 at L2–S1
2 at L2–4
4 at L3–S1
1 at L3–4
3 at L3–5
8 at L4–5
8 at L4–S1
12 at L5–S1
So, 26 at L5–S1 fused and 14 at L5–S1 not fused
Considered positive when the contrast was injected strictly into the joint and when the pain relief was up to 75 % 14 pts (23 %) are positive
11 pts are L5–S1 fused
3 pts are L5–S1 not fused
DePalma et al. [29] Retrospective 28 pts with chronic LBP after fusion surgery undergoing definitive diagnostic procedure
No description for no. pts who had SIJ injection
Paravertebral LBP without midline LBP and three of five positive responses to SIJ provocation tests without centralization during the McKenzie evaluation 2 at L2–5
2 at L3–5
5 at L4–5
2 at L2–S1
4 at L3–S1
5 at L4–S1
6 at L5–S1
2 at T–L4
(Details for 28 pts, not SIJ injection pts)
Deemed positive if the patient’s index pain was relieved by ≥75 % after anesthetic injection 12 pts (43 %) were positive for SIJ
10 of 12 pts had fusion to the sacrum
Liliang et al. [35] Prospective 130 pts had persistent chronic back pain after fusion surgery
52 pts met inclusion criteria for injection
Positive for at least three of the provocation tests for SIJ pain 21 with one level fused
21 with two levels fused
10 with more than two levels fused
(20 with lumbosacral fusion)
A positive response was defined as characteristic pain reduction of 75 % or greater for 1–4 h following the block
Two positive responses are necessary
21 pts (16.2 %) were considered to have SIJ pain on the basis of two positive responses

Treatment

Conservative treatment

No article has been published as yet detailing treatment outcomes for SIJ pain after lumbar/lumbosacral fusion. However, there are several conservative options for the treatment of SIJ pain.

Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain management and to reduce inflammation. Antidepressants may also be useful. However, the use of opiates should be reserved for limited situations only.

Pelvic belts are also a treatment option that work by limiting SIJ motion and improving proprioception. The importance of the correct placement of the belt has been highlighted: the pelvic belts are most effective when worn directly above the greater trochanter, decreasing SIJ motion by approximately 30 % with a 50-N belt [63].

Physical therapy has been an important aspect in the treatment of SIJ pain, along with stabilization. Physical therapy strategies emphasize pelvic stabilization [64] and restoration of postural and dynamic muscle balance, with correction of gait abnormalities [65]. Many studies have described typical muscle imbalance patterns in patients with SIJ pain [66, 67]. Thus, if these imbalances are actually detected, a physical therapy program concentrating on stretching and strengthening the weak muscles is an important aspect in the treatment of SIJ pain [66]. For example, Mooney et al. [68] reported that five women with injection-confirmed SIJ pain had electromyographic (EMG)-documented hyperactivity of the ipsilateral gluteus muscles and contralateral latissimus muscle compared with EMG findings in 15 asymptomatic controls. After an exercise program, all five patients achieved a significant reduction in pain and a return of myoelectric activity to normal patterns.

Intra-articular injections with steroids and local anesthetics are often therapeutic. For example, Liliang et al. [69] reported that 66.7 % (26/39) of patients experienced greater than 50 % pain reduction for more than 6 weeks by SIJ blocks, with an overall mean duration of pain reduction of 36.8 ± 9.9 weeks (range 12–60 weeks). In that study, 12 patients had a history of lumbar/lumbosacral fusion. The block worked in five of the 12 patients (42 %), but not in the remaining seven. Conversely, the block worked in 21 of 27 (78 %) patients without lumbar/lumbosacral fusion and not in six. Furthermore, the duration of the efficacy of the SIJ blocks was shorter in patients with a history of lumbar/lumbosacral fusion.

Prolotherapy and radiofrequency neurotomy have also been used to treat SIJ pain and several studies have reported significant pain relief lasting between 6 months and 1 year [70–72]. However, there are no studies reporting treatment efficacy in patients with SIJ pain after lumbar/lumbosacral fusion.

Although neuroaugmentation has also been reported, it is not a common procedure. Calvillo et al. [73] reported on two cases of severe SIJ pain that had undergone lumbosacral fusion. These patients were treated for 1 week with stimulation following the implantation of a neural prosthesis at the third sacral nerve roots and experienced pain relief of approximately 60 % during the trial. Following permanent implantation, improvements in pain status and in the activities of daily living were reported.

Surgical treatment

Surgical treatment should be considered only in patients with SIJ pain proven by controlled diagnostic anesthetic blocks and without any pain sources in the lumbar spine. It also should be reserved for those who continue to have disabling symptoms that have not responded to aggressive conservative care [14].

Surgical options include open surgery and, recently, minimally invasive surgery. Open surgical access for SIJ arthrodesis can be achieved anteriorly or posteriorly, although the anterior approach has several advantages in that it provides direct exposure of the ventral and cranial synovial portion of the sacroiliac complex without sacrificing any of the primary soft tissue (ligamentous) stabilizers [14]. The incidence of significant complications after open SIJ fusion has been reported to be between 6 and 25 % [74, 75]. Recently, a percutaneous sacroiliac procedure has also been reported [76, 77]. This technique enables arthrodesis by inserting bone material in the cage-type screw and may avoid wound-related complications. However, no comparison studies of successful fusion rates or clinical outcomes exist for the various arthrodesis techniques. Postoperative management includes protected weight bearing for 8–12 weeks.

As yet, no study has reported the surgical outcomes for selected patients with SIJ pain after lumbar/lumbosacral fusion surgery. Regardless of the underlying etiology, based on the existing studies the long-term success rate for SIJ fusion appears to be around 70 % [78–80]. Recent articles reporting surgical outcomes of SIJ fusion include a high percentage of patients after lumbar surgery or lumbar/lumbosacral fusion. For example, Buchowski et al. [74] evaluated the functional and radiological outcome in 20 patients after an open SIJ fusion using the Smith-Petersen approach. In that study, 15 patients (75 %) had at least one previous spinal surgery and eight (40 %) had fusion to the sacrum. Buchowski et al. [74] reported an improvement in both pain and function. Although 85 % (17/20) of patients had solid fusion, two developed deep wound infection. In a retrospective study of bilateral SIJ fusion for degenerative SIJ syndrome with a poor outcome, Schutz and Grob [75] reported that of 17 patients who underwent open bilateral posterior SIJ fusion, eight had had fusion surgery down to the sacrum. The clinical results were not acceptable in 82 % of patients and reoperation was performed in 65 % of patients. Seven patients were found to have symptomatic non-union, with union occurring only in six. Wise and Dall [76] reported on the efficacy and outcomes of minimally invasive SIJ arthrodesis in 13 patients via a percutaneous posterior approach (8 of the 13 patients had a history of a lumbar fusion that extended to the sacrum). Wise and Dall [76] used percutaneous insertion of threaded titanium cages packed with recombinant human bone morphogenetic protein-2 (rhBMP-2) into the SIJ. Significant improvements were seen in low back pain and the overall fusion rate was 89 %. There were no infections or neurovascular complications. In another study, Khurana et al. [77] reported outcomes for 15 patients who underwent percutaneous fusion of the SIJ with hollow modular anchorage screws. In that study, 6 of the 15 patients had undergone previous spinal surgery. Good or excellent results were reported for 87 % of patients. Fusion was obtained in all patients and there were no postoperative neurological or wound complications (Table ).

Table 2

Summary of clinical studies of surgical treatment for sacroiliac joint pain including patients after lumbar/lumbosacral fusion or surgery

References No. patients M/F (n) Median (range) age (years) Median (range) duration of follow-up Surgery Clinical outcome Fusion rate Complications Patients after lumbar/lumbosacral fusion or surgery
Buchowski et al. [74] 20 3:17 45.1 (21.8–66.4) 5.8 years (2.0–9.0) Open SF-36 significantly improved 85 % 3 pseudoarthrosis
2 deep wound infection
15 pts (75 %) had at least one previous spine surgery
1 painful hardware 8 pts (40 %) had fusion to the sacrum
Shutz and Grob [75] 17 (bilateral for all pts) 5:12 43.2 (22–76) 39 months (12–66) Open 18 % of pts were satisfied 35 % (6/17) 11 pts had non-union 8/17 had a history of lumbar fusion down to the sacrum
Wise et al. [76] 13 (bilateral for 6 pts) 1:12 53.1 (45–62) 29.5 months (24–35) Percutaneous Back and leg pain score significantly improved 89 % (17/19) 2 non-union joints 8/13 had a history of lumbar fusion down to the sacrum
Khurana et al. [77] 15 (bilateral for 4 pts) 4:11 48.7 (37.3–62.6) 17 months (9–39) Percutaneous SF-36 and Majeed’s score significantly improved
87 % had good or excellent results
100 % No complications 6/15 had undergone spine surgery previously

Conclusion

The SIJ is a possible source of persistent pain or new pain with failed back surgery syndrome after lumbar/lumbosacral fusion. Thorough examinations, including physical examinations, radiographic studies, and diagnostic injections, are necessary to make a diagnosis. Conservative treatment is the first choice and surgical treatment may be an option for retractable cases. However, well-controlled clinical studies are necessary to assess the efficacy of surgical treatment.

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Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge

Eur Spine J. 2012 Sep; 21(9): 1788–1796.

Hiroyuki Yoshihara

Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th St., New York, NY 10003 USA

Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th St., New York, NY 10003 USA

Corresponding author.

Received 2012 Jan 9; Revised 2012 Apr 19; Accepted 2012 Apr 24.

This article has been cited by other articles in PMC.

Abstract

Recently, the sacroiliac joint (SIJ) has gained increased attention as a source of persistent or new pain after lumbar/lumbosacral fusion. The underlying pathophysiology of SIJ pain may be increased mechanical load, iliac crest bone grafting, or a misdiagnosis of SIJ syndrome. Imaging studies show more frequent degeneration of the SIJ in patients with lumbar/lumbosacral fusion than in patients without such fusion. Using injection tests, it has been shown that SIJ pain is the cause of persistent symptoms in a considerable number of patients after fusion surgery. Recent articles reporting on surgical outcomes of SIJ fusion include a high percentage of patients who had lumbar/lumbosacral fusion or surgery before, although well-controlled clinical studies are necessary to assess the efficacy of surgical treatment. Taking these findings into consideration, the possibility that the SIJ is the source of pain should be considered in patients with failed back surgery syndrome after lumbar/lumbosacral fusion.

Keywords: Sacroiliac joint pain, Lumbosacral fusion, Lumbar fusion, Pathophysiology

Introduction

The past decade has seen an increase in the number of lumbar/lumbosacral fusion surgeries [1]. One multicenter study reported that this type of surgery brings about greater relief than classic conservative treatment [2]. However, the failure rate across the different studies ranges between 5 and 30 % [3, 4]. Indeed, some patients continue to complain of persistent or new low back pain after surgery. Cases of recurrent low back pain and/or lower extremity pain after lumbar/lumbosacral surgery are referred to as failed back surgery syndrome [5–11]. Several authors have suggested that the sacroiliac joint (SIJ) may be a possible source of persistent pain [4, 12, 13].

Pathophysiology

Theories of pain generation include ligamentous or capsular tension, extraneous compression or shear forces, hypomobility or hypermobility, aberrant joint mechanics, and imbalances in the myofascial or kinetic chain that result in inflammation and pain [14]. Intra-articular sources of SIJ pain include osteoarthritis; extra-articular sources include enthesis/ligamentous sprain and primary enthesopathy. In addition, ligamentous, tendinous, or fascial attachment and other cumulative soft tissue injuries that may occur posterior to the dorsal aspect of the SIJ may be a source of discomfort.

There are three possible causes of SIJ pain: (1) an increased mechanical load transfer onto the SIJ after fusion; (2) bone graft harvesting in the iliac crest close to the joint; and (3) the misdiagnosis of an SIJ syndrome before fusion (i.e., the lumbar spine is thought, erroneously, to be fused) [4].

Numerous clinical and experimental studies of adjacent segment disease after lumbar fusion procedures have demonstrated increased mobility in the adjacent cephalad and/or caudad segments and increased stress on the facet and/or disc of adjacent mobile segments [15–25]. In the case of lumbosacral fusion, the SIJ is the joint adjacent to the fused segment, and similar biomechanical responses could apply to the SIJ [26]. Ha et al. [27] reported that the incidence of SIJ degeneration is higher in patients in whom fusion is down to S1 than in patients in whom fusion is down to L5. Onsel et al. [28] reported increased SIJ uptake on single photon emission computed tomography (SPECT) after lumbar fusion and/or laminectomy and concluded that increased SIJ uptake is usually caused by changes in spinal mechanics. Although the differences failed to reach statistical significance, Maigne and Planchon [4] reported a trend for more cases of SIJ pain in patients with fusion to the sacrum than in those without. Furthermore, DePalma et al. [29] reported that patients with lumbosacral fusion had an increased frequency of positive SIJ blocks than those without.

A history of bone graft harvesting is a potential risk factor for SIJ pain. After discounting the SIJ as the etiologic source of pain based on a lack of objective findings on physical examination and imaging studies, Frymoyer et al. [12] concluded that sacral sulcus pain encountered in 37 % of patients with low back pain after lumbar fusion was related to the iliac graft donor site. Ebraheim et al. [13] studied patients with donor site pain and found a high frequency of a sacroiliac inner table disruption that resulted in accelerated degeneration of the joint and sacroiliac pain. In addition, Ha et al. [27] reported that the SIJ on the side from which cancellous bone was harvested developed degeneration more often than on the normal side, although damage to the SIJ was not evident on computed tomography (CT) scans. This is in agreement with other studies that have reported that the harvesting of cancellous bone for a bone graft induces pelvic instability and has a negative effect on the SIJ [30–32]. However, Katz et al. [33] failed to find any correlation between the side of low back pain and the side of graft harvest, rendering direct SIJ damage after graft harvesting improbable. In the study of Maigne and Planchon [4], bone graft harvesting is definitely not the only cause of SIJ syndrome, which was present at similar frequencies in patients who had not undergone bone graft harvesting. Recently, Howard et al. [34] reported that 54 % of patients complained of tenderness over the iliac crest, with most having tenderness over both crests rather than just one, regardless of whether a bone graft had been harvested or not. That study found that iliac crest graft site pain can occur even in the absence of iliac crest graft harvesting and is thus a poor marker for graft site morbidity. Furthermore, Liliang et al. [35] have reported that there is no significant association between iliac crest bone graft harvesting on the painful side and positive responses to SIJ blocks.

The presence of a misdiagnosed sacroiliac syndrome as a cause of pre-fusion low back pain is also a possibility. Some patients may have lumbar fusion for misdiagnosed SIJ syndrome or some may have only lumbar fusion for lumbar pathology and SIJ syndrome. Sembrano and Polly [36] reported that up to 14.5 % of patients presenting to a spine surgeon’s clinic for low back pain had SIJ pathology. In another study, Weksler et al. [37] found that patients with low back pain and disc herniation who responded positively to pain provocation tests for SIJ dysfunction exhibited significant improvement in visual analogue scale (VAS) pain scores after SIJ injection. Therefore, a third possible cause of SIJ pain is errors made during the preoperative screening of patients. This cause of SIJ pain can be differentiated from SIJ pain caused by an increased mechanical load when patients are not pain free for even a short period of time after fusion surgery.

In very rare cases, SIJ pain may be caused by hardware. For example, Ahn and Lee [38] reported iatrogenic SIJ syndrome caused by the screw head and rod of percutaneous pedicle screw fixation at the L5–S1 level. The sharp rod tip and the laterally located screw head may irritate the iliac crest and distract the SIJ, leading to intractable SIJ pain.

Biomechanical studies

Frymoyer et al. [12] conducted a clinical study of sacrum motion in patients after lumbar fusion, using flexion–extension lateral radiographs. Although doubts exist as to the validity of using a two-dimensional method to assess SIJ motion, Frymoyer et al. [12] failed to find any significant differences in mobility in the SIJ after spinal procedures.

Ivanov et al. [26] assessed angular motion of the sacrum and stress across the SIJ using a finite element lumbar spine–pelvis model with simulated posterior fusion surgical procedures. The results of that study indicated that posterior fusion of the lumbar spine leads to increased motion at the SIJ and increased stress across SIJ articular surfaces. In addition, the values of the parameters measured were related to the number of spinal segments involved. The authors noted that the differences in angular motion between the intact and instrumented models were not large; however, the ligaments around the sacroiliac articulation are richly innervated and, therefore, even small increases in motion may trigger pain.

Clinical features and pain patterns

Early published referral patterns of SIJ provocation or irritation were based on patients’ complaints and physical examination. Dreyfuss et al. [39] reported that only 4 % of patients with SIJ pain marked any pain above L5 on self-reported pain drawings. Referral of pain into various locations of the lower extremity does not distinguish SIJ pain from other pain states. For example, Schwarzer et al. [40] found that pain below the knee and into the foot was as common in SIJ pain as for other sources of pain. Slipman et al. [41] conducted a retrospective study to determine the pain referral patterns in 50 patients with injection-confirmed SIJ pain. The most common referral patterns for SIJ pain were found to be radiation into the buttock (94 %), lower lumbar region (72 %), lower extremity (50 %), groin area (14 %), upper lumbar lesion (6 %), and abdomen (2 %). Twenty-eight percent of patients experienced pain radiating below their knee, with 12 % reporting foot pain. Based on the existing data, the most consistent factor for identifying patients with SIJ pain is unilateral pain (unless both joints are affected) localized predominantly below the L5 spinous process. Maigne and Planchon [4] reported that the only criterion characterizing patients with SIJ pain following lumbar fusion was postoperative pain that differed from preoperative pain in its distribution. Liliang et al. [35] reported similar results, namely that 67 % of patients diagnosed with SIJ pain after lumbar and lumbosacral fusion had pain with characteristics that differed from their preoperative pain.

Physical examinations

One of the most challenging aspects of treating SIJ pain is the complexity of diagnosis. Literally dozens of physical examination tests have been advocated as diagnostic aids in patients with presumed SIJ pain [42]. Examples of these tests include Patrick’s test, Yeoman’s test, Gaenslen’s test, Gillet’s test, the compression test, sacral sulcus tenderness, the sacral thrust test, and the thigh thrust test. However, when applying pain provocation tests, it is nearly impossible to define which structures are actually stressed [43, 44]. Even structures such as the iliolumbar ligament or piriformis muscle cannot be excluded as potential sources of pain because they are functionally related [45, 46]. Consequently, it is very difficult to determine whether the pain that is provoked is exclusively intra-articular or whether it is related to capsular ligaments.

Previous studies have reported that there is no one single specific physical examination that can accurately identify a painful SIJ [38, 39, 42, 47]. Dreyfuss et al. [39, 48] found that 20 % of asymptomatic adults had positive findings on three commonly performed SIJ provocation tests and that the test with the highest sensitivity was the test of sacral sulcus tenderness (89 %), although this test exhibited poor specificity. Slipman et al. [47] reported a positive-predictive value of 60 % in diagnosing SIJ pain in patients using a positive response to three SIJ provocation tests. Broadhurst and Bond [49] reported a sensitivity of 77–87 % for positive responses to three SIJ provocation tests. Thus, there is evidence of good diagnostic validity of positive responses to a threshold of three SIJ provocation tests to identify SIJ pain [49–53]. However, there are no studies that have specifically examined provocation tests in patients with SIJ pain after lumbar/lumbosacral fusion.

Radiographic studies

No imaging studies consistently provide findings that are helpful in diagnosing primary SIJ pain.

Radiographs are the most cost-effective technique for imaging the SIJ. However, at least 24.5 % of asymptomatic patients >50 years of age have an abnormal SIJ on plain radiographs [54]. In addition, there is currently no consensus in the literature as to the recommended radiographic view or series of views to evaluate the SIJ.

Changes in the bone can be more sensitively detected using CT scans. A diagnosis of SIJ degeneration can be made on the basis of the presence of sclerosis, erosion, osteophytes, narrowing of the joint space, intra-articular bone fragments, or subchondral cysts. In a retrospective study, Elgafy et al. [55] found that abnormal CT findings, such as sclerosis, erosions, and narrowing, had a sensitivity of 58 % and a specificity of 69 % for determining which patients would experience pain relief following injection of an anesthetic into the SIJ. In a prospective cohort study investigating the relationship between fusion and SIJ degeneration after instrumented posterolateral lumbar/lumbosacral fusion, Ha et al. [27] reported that, based on results from CT scans, the incidence of SIJ degeneration in the fusion group was significantly higher than in the control group (75 vs. 38.2 %, respectively). Furthermore, the incidence of SIJ degeneration was greater in patients in whom fusion was down to S1 than in patients in whom fusion was down to L5. Ha et al. [27] concluded that lumbar/lumbosacral fusion can be a cause of SIJ degeneration, which develops more often in patients undergoing lumbosacral fusion regardless of the number of fused segments.

Magnetic resonance imaging (MRI) can detect edema and enhancement before bone changes are visible on CT. In addition, MRI can detect synovitis or extra-articular sources of SIJ pain, such as ligamentous, tendinous, or fascial attachment and other cumulative soft tissue injuries. When performing MRI of the SIJ, most studies report that short tau inversion recovery (STIR) images are preferable to fat-suppressed T2-weighted images because they show early marrow edema better [56, 57]. For patients with SIJ syndrome, MRI is not helpful in determining which patients are likely to benefit from anesthetic injections [58].

Bone scanning is a poor screening test for SIJ pain [59, 60]. In studies of patients with SIJ syndrome, Maigne et al. [59] and Slipman et al. [60] reported sensitivities of 46.1 and 12.9 %, respectively, and specificities of 89.5 and 100 %, respectively, for radionuclide bone scanning in identifying SIJ pain using anesthetic injections into the SIJ.

It has been reported that SPECT is more sensitive in detecting and localizing lesions than planar scintigraphy [61] and, in addition, that SPECT is useful when evaluating patients postoperatively because it is relatively unaffected by metallic fixation devices and can identify specific bony abnormalities in patients with complex problems, such as surgery at multiple levels, repeated surgery, bony fusions, or internal fixation with pedicle screws or metallic plates [62]. Onsel et al. [28] reported increased SIJ uptake demonstrated by SPECT after lumbar fusion and/or laminectomy. They concluded that such spinal surgery can impact on the loading on the SIJ, leading to mechanical overload and sacroiliitis. Note, increased SIJ uptake is usually caused by altered spinal mechanics. Gates and McDonald [62] also reported increased SIJ uptake by SPECT in 18 of 63 patients with back pain and a history of lumbar spinal surgery.

Diagnostic injections and epidemiology

In a retrospective review of patients with low back pain after lumobosacral fusion, Katz et al. [33] reported that 34 patients met their criteria for SIJ injection. Katz et al. [33] concluded that the SIJ was the cause of pain in 11 patients and possibly the cause of pain in a further 10. They did not report the number of patients who had low back pain after lumbosacral fusion, so prevalence is not certain. Maigne and Planchon [4] performed a prospective study of SIJ pain among patients with persistent low back pain after lumbar fusion using diagnostic SIJ blocks. In that study, 61 patients had persistent back pain after fusion surgery and, of these, 45 patients met the criteria for SIJ injection. Fourteen patients responded positively to the injections; on the basis of these reported data, the prevalence of SIJ pain among patients with low back pain after fusion can be calculated as 23 %. DePalma et al. [29] investigated the etiology of chronic low back pain in patients who had undergone lumbar fusion. In 43 % (12/28) of cases, the SIJ were symptomatic. Ten of these 12 cases had fusion to the sacrum and the remaining two cases had fusion to L5. Liliang et al. [35] investigated whether the SIJ is a potential source of pain in patients who have undergone lumbar/lumbosacral fusions. In that study, 130 patients had persistent chronic back pain after fusion surgery and 52 patients in whom positive findings were obtained for at least three of the provocation tests were selected to receive dual diagnostic blocks. Of these patients, 21 (16 %) were considered to have SIJ pain on the basis of two positive responses to diagnostic blocks. Thus, the prevalence of SIJ pain among patients with low back pain after lumbar/lumbosacral fusion appears to be in the range 16–43 % (Table ).

Table 1

Summary of clinical studies of diagnostic injection for sacroiliac joint pain after lumbar/lumbosacral fusion

Reference Study type No. patients Inclusion criteria for injection Fusion levels for injection cases Diagnostic criteria Results
Katz et al. [33] Retrospective 34 pts who had LBP after prior lumbar fusion to the sacrum met the criteria for injection History of pain in the low back below the waist and at or just distal to the posterior iliac crest with or without radiation to the posterior thigh or groin 8 at L5–S1
14 at L4–S1
6 at L3–S1
2 at L2–S1
4 with thoracolumbosacral fusion
Positive when both >75 % pain relief with the local anesthetic and at least 10 days of continued relief with corticosteroids 11 pts were considered positive
10 pts were considered to have possible SIJ dysfunction
Maigne and Planchon [4] Prospective 61 pts had persistent back pain after fusion surgery
45 pts met inclusion criteria for injection
5 pts had unsuccessful block
Unilateral persistent pain for >6 months
Distribution compatible with a sacroiliac origin: not radiating below the knee, tenderness of the sacroiliac sulcus at palpation, and no evidence of a lumbar cause
2 at L2–S1
2 at L2–4
4 at L3–S1
1 at L3–4
3 at L3–5
8 at L4–5
8 at L4–S1
12 at L5–S1
So, 26 at L5–S1 fused and 14 at L5–S1 not fused
Considered positive when the contrast was injected strictly into the joint and when the pain relief was up to 75 % 14 pts (23 %) are positive
11 pts are L5–S1 fused
3 pts are L5–S1 not fused
DePalma et al. [29] Retrospective 28 pts with chronic LBP after fusion surgery undergoing definitive diagnostic procedure
No description for no. pts who had SIJ injection
Paravertebral LBP without midline LBP and three of five positive responses to SIJ provocation tests without centralization during the McKenzie evaluation 2 at L2–5
2 at L3–5
5 at L4–5
2 at L2–S1
4 at L3–S1
5 at L4–S1
6 at L5–S1
2 at T–L4
(Details for 28 pts, not SIJ injection pts)
Deemed positive if the patient’s index pain was relieved by ≥75 % after anesthetic injection 12 pts (43 %) were positive for SIJ
10 of 12 pts had fusion to the sacrum
Liliang et al. [35] Prospective 130 pts had persistent chronic back pain after fusion surgery
52 pts met inclusion criteria for injection
Positive for at least three of the provocation tests for SIJ pain 21 with one level fused
21 with two levels fused
10 with more than two levels fused
(20 with lumbosacral fusion)
A positive response was defined as characteristic pain reduction of 75 % or greater for 1–4 h following the block
Two positive responses are necessary
21 pts (16.2 %) were considered to have SIJ pain on the basis of two positive responses

Treatment

Conservative treatment

No article has been published as yet detailing treatment outcomes for SIJ pain after lumbar/lumbosacral fusion. However, there are several conservative options for the treatment of SIJ pain.

Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain management and to reduce inflammation. Antidepressants may also be useful. However, the use of opiates should be reserved for limited situations only.

Pelvic belts are also a treatment option that work by limiting SIJ motion and improving proprioception. The importance of the correct placement of the belt has been highlighted: the pelvic belts are most effective when worn directly above the greater trochanter, decreasing SIJ motion by approximately 30 % with a 50-N belt [63].

Physical therapy has been an important aspect in the treatment of SIJ pain, along with stabilization. Physical therapy strategies emphasize pelvic stabilization [64] and restoration of postural and dynamic muscle balance, with correction of gait abnormalities [65]. Many studies have described typical muscle imbalance patterns in patients with SIJ pain [66, 67]. Thus, if these imbalances are actually detected, a physical therapy program concentrating on stretching and strengthening the weak muscles is an important aspect in the treatment of SIJ pain [66]. For example, Mooney et al. [68] reported that five women with injection-confirmed SIJ pain had electromyographic (EMG)-documented hyperactivity of the ipsilateral gluteus muscles and contralateral latissimus muscle compared with EMG findings in 15 asymptomatic controls. After an exercise program, all five patients achieved a significant reduction in pain and a return of myoelectric activity to normal patterns.

Intra-articular injections with steroids and local anesthetics are often therapeutic. For example, Liliang et al. [69] reported that 66.7 % (26/39) of patients experienced greater than 50 % pain reduction for more than 6 weeks by SIJ blocks, with an overall mean duration of pain reduction of 36.8 ± 9.9 weeks (range 12–60 weeks). In that study, 12 patients had a history of lumbar/lumbosacral fusion. The block worked in five of the 12 patients (42 %), but not in the remaining seven. Conversely, the block worked in 21 of 27 (78 %) patients without lumbar/lumbosacral fusion and not in six. Furthermore, the duration of the efficacy of the SIJ blocks was shorter in patients with a history of lumbar/lumbosacral fusion.

Prolotherapy and radiofrequency neurotomy have also been used to treat SIJ pain and several studies have reported significant pain relief lasting between 6 months and 1 year [70–72]. However, there are no studies reporting treatment efficacy in patients with SIJ pain after lumbar/lumbosacral fusion.

Although neuroaugmentation has also been reported, it is not a common procedure. Calvillo et al. [73] reported on two cases of severe SIJ pain that had undergone lumbosacral fusion. These patients were treated for 1 week with stimulation following the implantation of a neural prosthesis at the third sacral nerve roots and experienced pain relief of approximately 60 % during the trial. Following permanent implantation, improvements in pain status and in the activities of daily living were reported.

Surgical treatment

Surgical treatment should be considered only in patients with SIJ pain proven by controlled diagnostic anesthetic blocks and without any pain sources in the lumbar spine. It also should be reserved for those who continue to have disabling symptoms that have not responded to aggressive conservative care [14].

Surgical options include open surgery and, recently, minimally invasive surgery. Open surgical access for SIJ arthrodesis can be achieved anteriorly or posteriorly, although the anterior approach has several advantages in that it provides direct exposure of the ventral and cranial synovial portion of the sacroiliac complex without sacrificing any of the primary soft tissue (ligamentous) stabilizers [14]. The incidence of significant complications after open SIJ fusion has been reported to be between 6 and 25 % [74, 75]. Recently, a percutaneous sacroiliac procedure has also been reported [76, 77]. This technique enables arthrodesis by inserting bone material in the cage-type screw and may avoid wound-related complications. However, no comparison studies of successful fusion rates or clinical outcomes exist for the various arthrodesis techniques. Postoperative management includes protected weight bearing for 8–12 weeks.

As yet, no study has reported the surgical outcomes for selected patients with SIJ pain after lumbar/lumbosacral fusion surgery. Regardless of the underlying etiology, based on the existing studies the long-term success rate for SIJ fusion appears to be around 70 % [78–80]. Recent articles reporting surgical outcomes of SIJ fusion include a high percentage of patients after lumbar surgery or lumbar/lumbosacral fusion. For example, Buchowski et al. [74] evaluated the functional and radiological outcome in 20 patients after an open SIJ fusion using the Smith-Petersen approach. In that study, 15 patients (75 %) had at least one previous spinal surgery and eight (40 %) had fusion to the sacrum. Buchowski et al. [74] reported an improvement in both pain and function. Although 85 % (17/20) of patients had solid fusion, two developed deep wound infection. In a retrospective study of bilateral SIJ fusion for degenerative SIJ syndrome with a poor outcome, Schutz and Grob [75] reported that of 17 patients who underwent open bilateral posterior SIJ fusion, eight had had fusion surgery down to the sacrum. The clinical results were not acceptable in 82 % of patients and reoperation was performed in 65 % of patients. Seven patients were found to have symptomatic non-union, with union occurring only in six. Wise and Dall [76] reported on the efficacy and outcomes of minimally invasive SIJ arthrodesis in 13 patients via a percutaneous posterior approach (8 of the 13 patients had a history of a lumbar fusion that extended to the sacrum). Wise and Dall [76] used percutaneous insertion of threaded titanium cages packed with recombinant human bone morphogenetic protein-2 (rhBMP-2) into the SIJ. Significant improvements were seen in low back pain and the overall fusion rate was 89 %. There were no infections or neurovascular complications. In another study, Khurana et al. [77] reported outcomes for 15 patients who underwent percutaneous fusion of the SIJ with hollow modular anchorage screws. In that study, 6 of the 15 patients had undergone previous spinal surgery. Good or excellent results were reported for 87 % of patients. Fusion was obtained in all patients and there were no postoperative neurological or wound complications (Table ).

Table 2

Summary of clinical studies of surgical treatment for sacroiliac joint pain including patients after lumbar/lumbosacral fusion or surgery

References No. patients M/F (n) Median (range) age (years) Median (range) duration of follow-up Surgery Clinical outcome Fusion rate Complications Patients after lumbar/lumbosacral fusion or surgery
Buchowski et al. [74] 20 3:17 45.1 (21.8–66.4) 5.8 years (2.0–9.0) Open SF-36 significantly improved 85 % 3 pseudoarthrosis
2 deep wound infection
15 pts (75 %) had at least one previous spine surgery
1 painful hardware 8 pts (40 %) had fusion to the sacrum
Shutz and Grob [75] 17 (bilateral for all pts) 5:12 43.2 (22–76) 39 months (12–66) Open 18 % of pts were satisfied 35 % (6/17) 11 pts had non-union 8/17 had a history of lumbar fusion down to the sacrum
Wise et al. [76] 13 (bilateral for 6 pts) 1:12 53.1 (45–62) 29.5 months (24–35) Percutaneous Back and leg pain score significantly improved 89 % (17/19) 2 non-union joints 8/13 had a history of lumbar fusion down to the sacrum
Khurana et al. [77] 15 (bilateral for 4 pts) 4:11 48.7 (37.3–62.6) 17 months (9–39) Percutaneous SF-36 and Majeed’s score significantly improved
87 % had good or excellent results
100 % No complications 6/15 had undergone spine surgery previously

Conclusion

The SIJ is a possible source of persistent pain or new pain with failed back surgery syndrome after lumbar/lumbosacral fusion. Thorough examinations, including physical examinations, radiographic studies, and diagnostic injections, are necessary to make a diagnosis. Conservative treatment is the first choice and surgical treatment may be an option for retractable cases. However, well-controlled clinical studies are necessary to assess the efficacy of surgical treatment.

References

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If You’re Experiencing Pain after Neck or Back Surgery, It Might be Post Laminectomy Pain Syndrome: SamWell Institute for Pain Management: Interventional Pain Management Specialists

You may have had neck and back surgery in hopes of getting rid of your pain. After your recovery from the surgery, you probably expected to feel better. But sometimes, surgery yields unexpected results. Because back surgery involves such delicate nerves and small spaces, it is an inherently risky process.

While the surgery is complete, you still have pain—maybe even more pain than you were in before. This is called post-laminectomy pain syndrome, also known as failed back surgery.

Fortunately, you don’t have to live with the pain forever. Let Dr. Jay M. Shah of the Samwell Institute for Pain Management help you get your life back. For patients in Colonia and West Orange, New Jersey, our expert team is here to help you understand your symptoms and manage your pain.

How does post-laminectomy pain syndrome develop?

There’s no exact way to predict which patients will go on to develop post-laminectomy pain syndrome. But certain factors do make the syndrome more likely to occur after surgery.

The spinal nerve is often decompressed during surgery. When the surgery is over, many people recover to find that their spine returns to normal. In some patients, however, the spinal nerve remains decompressed and the initial trauma remains.

Scars can also develop around the root of the nerves, including the sciatic nerve, which can cause further pain. Some patients also develop new or recurrent disc herniation, unstable ligaments, or an unstable spine.

Post-laminectomy pain syndrome can occur after many different types of surgeries on the neck or back, including lumbar laminectomy, fusions, and discectomy to treat sciatica.

What are the symptoms of post-laminectomy pain syndrome?

Post-laminectomy pain syndrome is a significant cause of pain and disability. Common symptoms of post-laminectomy pain syndrome include the following:

  • Dull, aching pain in the neck, shoulders, arms, fingers, back, buttocks, or hips
  • Pain levels similar to what you felt before surgery
  • Pain in your arms or legs, which may be either constant or radiating
  • Pain that runs down your arms to your fingers or legs to your toes, which may be throbbing or associated with numbness, tingling, or burning
  • Joint problems
  • Depression and anxiety

Who is at greater risk of getting post-laminectomy pain syndrome?

Anyone who has had surgery on their back or neck is potentially at risk of developing this syndrome. However, certain patients are much more likely than others to develop post-laminectomy pain syndrome, including the following:

  • Smokers
  • Those who fail to take their post-surgery rehabilitation exercises seriously
  • Uncontrolled diabetes
  • Having open rather than minimally invasive surgery
  • Patients whose pain has an unknown cause
  • Procedures performed by less experienced surgeons
  • Patients who have had more than one neck or back surgery

How is post-laminectomy pain syndrome diagnosed?

Doctors diagnose post-laminectomy pain syndrome by the use of imaging tests such as X-rays, magnetic resonance imaging (MRI), electromyography, and computed tomography (CT) tests. They look for visual confirmation of the patient’s self-described pain and coincide these findings with a physical exam and possibly a nerve test or EMG/NCV.

How can post-laminectomy pain syndrome be treated?

There are several ways that post-laminectomy pain syndrome can be treated. Among the types of treatment include the following:

  • Epidural steroid injections
  • Nerve root block
  • Facet joint or nerve injections
  • Radiofrequency Rhizotomy
  • Dorsal root ganglion stimulation
  • Spinal cord stimulation
  • Physical therapy
  • Anti-inflammatory medications
  • Nerve pain medication

 

 

If you’ve had surgery on your spine or neck and are still experiencing pain, you don’t have to live with it forever. Talk to our expert team at the Samwell Institute for Pain Management today by calling or booking an appointment online.

Is the Pain Coming From Your Hip or Back?

Often people go to the doctor seeking help for hip pain. Sometimes, people try to treat it themselves. They are convinced there is something wrong with their hip and the treatments begin. However, one thing is for sure, hip pain is not always as it appears. Hip pain can be a result of a problem in the hip joint itself. However, it can also be a result of a back problem or a soft tissue problem around the hip region.

Obtaining an accurate diagnosis is the first step to resuming activities and living an active lifestyle. Let’s discuss the reasons for confusion and see if we can realize the causes and treatments for both hip and back pain. Some of a patient’s misunderstanding about the origin of the pain is due to not understanding hip and back anatomy. Sounds odd but it’s true. The hip joint lies just behind the groin area on each side of the body. At the same time, the spine runs from the base of the skull to the tip of the tailbone. The lumbar spine contains specific nerves that can influence the feelings in the region around the hip area.

Pain Originating in the Hip

If the problem originates in the hip joint itself, common symptoms include groin pain on the affected side, and sometimes down the inner aspect of the thigh in the front of the leg. This pain can move to the knee and sometimes feels like a knee problem instead of a hip problem. Walking worsens the pain and with continued activity, the pain increases. Rest relieves it; however, when hip arthritis becomes severe, you may have pain most of the time. Minimal activity such as slight movements while in bed can worsen the pain. Other conditions such as advanced congenital hip dysplasia or avascular necrosis of the hip can cause these symptoms as well.

When the pain originates in the hip from arthritis, motion of the hip is often limited. This limitation is often realized when attempting to get out of a chair or bed and standing up. Contrary to hip pain, pain coming from the back may worsen when sitting or lying down, depending on the origin of the back pain itself.

Sometimes pain on the side of the hip is a result of bursitis. A weak abductor muscle, a leg length discrepancy, overuse, and an underlying early degenerating hip joint can cause bursitis. At times, the origin cannot be determined. Symptoms include pain on the side of the hip with prolonged walking, side lying in bed or when rising from a chair or similar types of movement.

Pain Originating in the Back

Low back pain commonly is experienced in the back itself. However, due to the complexity of the spinal cord and associated nerves being an intricate part of the low back, pain may and frequently can radiate or travel further down the course of the nerves. This is similar to striking your “funny bone” in the elbow and feeling the sensation in the hand below the elbow.

Although some of us are familiar with a pinched nerve, which is associated with sciatic-like pain in the leg, irritation or inflammation of nerves in the low back region can also cause a sensation in the upper leg or hip region. It is important to realize there are many things that can go wrong in the spine. Remember, sciatica is not a diagnosis but, instead, a symptom of an underlying problem. It is possible to feel back-related pain in the hip region and upper leg as well. It depends on the nerves involved and ultimately the actual diagnosis. Back pain or hip pain is not a diagnosis but simply an explanation of the area of pain. Symptoms are correlated with physical examination and confirmed through x-rays and similar tests.

Some back pain is caused from a “ruptured disc”. This pain is often experienced in the gluteal region of the body. Many people call this the “hip” region although it is not usually indicative of a hip joint problem. This is actually behind the hip, an important anatomic thought when considering hip pain, rather than in the hip itself. A condition related to degeneration of the lower back creating narrowing of the spinal canal or adjacent areas is called spinal stenosis and frequently causes pain in the hip region. The history of stenosis has to be compared with hip joint pain. Spinal stenosis can cause leg pain while walking as well as fatigue in the legs even when rising from a chair. Stenosis pain is relieved with sitting and will re-occur when walking is resumed.

There are differences in symptoms between spinal stenosis pain and herniated or ruptured disc pain. A herniated disc often is more painful when sitting and relieved by standing or walking (opposite of stenosis). A herniated disc can cause sciatica (so can stenosis) and can be a result of degenerative changes in the disc. Sciatica will commonly radiate or travel down the backside of the thigh, into the calf and sometimes the foot itself.>

Getting an Accurate Diagnosis

A thorough history and physical examination is a good start when sorting out symptoms. X-rays will attest to specific bony/cartilage changes but x-rays don’t always correlate with the pain. It is possible to have little pain and much damage on the x-rays or visa versa. It is important to treat the patient, not the x-rays alone. Secondly, x-rays of the back can reveal degeneration of the discs or small joints in the spine but the person does well. Contrary, the back may look degenerative and because of the subsequent bone spurring and symptoms as arthritis progresses, it is important to obtain an MRI to confirm nerve impingements that are suspected. X-rays alone will not show nerve impingement. As you can see, it is important to undergo the history and physical examination and tests that can confirm your diagnosis before treatment begins.

Treatment

Both types of problems are frequently helped by anti-inflammatory medications particularly in mild to moderate situations. Some types of analgesics can be used intermittently as well. It’s important to realize that both problems can be helped significantly by weight loss, proper forms of exercise and conditioning. In fact, back pain can become chronic without a commitment to the appropriate exercises necessary to stabilize and strengthen the spine. Epidural blocks (corticosteroids are injected into the canal of the low back to reduce inflammation and pain) can help several types of back disorders. Using a cane when walking can help both hip and back pain.

Surgery, whether a hip replacement for hip arthritis or back surgery due to a herniated disc, vertebral disorders or spinal stenosis, is a last resort for the treatment of the pain. Both surgery of the hip and the back are quite successful. Full evaluation is necessary and conservative measures are always tried first.

The question of pain in the hip region is not always a simple one and frequently involves specialized evaluation. Once the diagnosis is determined, options are many and should be discussed with you prior to instituting a treatment plan. The purpose of this article is to help to better assess pain, whether it’s coming from the back or the hip itself. Remember, there are many options for treatment. Diagnosis is the first step to successful treatment.

Post Laminectomy Syndrome – Birmingham, AL

Post-laminectomy Syndrome

What is Post-laminectomy Syndrome?

Post-laminectomy syndrome is a condition where the patient suffers from persistent pain in the back following surgery to the back. This article reviews this condition in a bit more detail.

A laminectomy is a procedure where a part of the vertebra that protects the spinal-cord is removed. It is usually performed to relieve pressure on the spinal-cord from a protruding disc. Very often, following a laminectomy, patients recover without any complications. However in a small group of people, back pain and sometimes leg pain may persist following laminectomy. This persistent pain is called post laminectomy syndrome. Post-laminectomy syndrome is also called Failed Back Surgery Syndrome, or FBSS.

What causes Post-laminectomy Syndrome?

There are a number of reasons why patients can develop back pain following a laminectomy. These could include the fact that the surgery itself was probably not necessary or that the surgery did not have the outcome that was expected. In some cases, despite performing a laminectomy, patients experience pain because the spinal column itself is narrowed in a condition called spinal stenosis. Sometimes, there may be a small fragment of the disc still remaining following the laminectomy which can irritate the spinal-cord causing pain. In other words, the term “post laminectomy syndrome” encompasses any cause that results in back pain following back surgery.

There is also evidence to suggest that patients who are smokers are more likely to develop post-laminectomy syndrome following surgery to the back. In addition to this, patients who have previously had a failed surgery in the back are at a higher risk of developing this syndrome.

Symptoms and Diagnosis

The most common symptom that patients experience is back pain at the site of surgery along with leg pain. As a result of the pain, patients have difficulty performing their activities of daily living and may have difficulty sleeping as well. The longer the pain lasts, the more of an impact it can have on the patient’s lives resulting in depression and anxiety.

When examined, patients will still complain of tenderness at the site of surgery. Doctors may notice altered postures and varied positions when walking.

In most cases, a history and clinical examination is sufficient to make a preliminary diagnosis. However, sometimes x-rays of the site of pain may reveal the cause for the pain. More advanced scan such as a CT scan or MRI will show whether there is residual compression on the spinal nerves following surgery. Any infections or abscess formation around the spinal cord may also be diagnosed this way though additional blood tests may be required.

How is Post-laminectomy Syndrome treated?

Treatment options may vary. Below are some of the options your doctor may consider.

  • Pain killers:these may be the first-line treatment that is prescribed by the doctors. In cases of post-laminectomy syndrome, the doctors may prescribe morphine-based painkillers in high doses. However, if this is done, the patient will be monitored closely to avoid the development of dependence on opioids.
  • Physical therapy:this may be recommended by the treating physician as physical therapists can prescribe exercises and treatments such as electrical stimulation which can help relieve pain and improve overall movement.
  • Specialist therapies: in some cases, doctors may consider referring patients for more advanced treatments such as epidural nerve blocks, radiofrequency denervation and platelet rich plasma therapy. Research is always being conducted with newer techniques being looked into all the time.

Hip Replacement May Also Ease Back Pain

By Serena McNiff
HealthDay Reporter

THURSDAY, July 9, 2020 (HealthDay News) — If you have a bad hip and lower back pain, a new study suggests that hip replacement surgery may solve both issues at once.

Researchers at the Hospital for Special Surgery in New York City focused on 500 patients who underwent hip replacement surgery and followed up with them one year after the operation.

Over 40% reported pain in their lower back prior to hip surgery. Of that group, 82% saw their back pain vanish after surgery.

It was “completely gone,” said study author Dr. Jonathan Vigdorchik, a hip and knee surgeon at the hospital.

He said that experts in his field have studied the connection between the hip and back for years.

A hip replacement is a surgical procedure to replace a worn-out or damaged hip joint with an artificial one. On average, it is a highly successful operation, with 95% of patients experiencing pain relief, according to the Hospital for Special Surgery.

“It’s an outstanding procedure,” said Dr. Craig Della Valle, a professor of orthopedic surgery at Rush University Medical Center in Chicago. “There are very few things in medicine that are close to hip replacement in terms of how good of a medical procedure it is.” He wasn’t part of the study.

But Vigdorchik added that patients who have undergone some types of spinal surgery before a hip replacement face five times the rate of complications compared to the general population — for which the complication rate is less than 1%.

This knowledge prompted him to dive deeper into the hip-back interplay.

“We noticed that there are certain conditions where a hip condition can actually put undue stress on the back,” Vigdorchik explained.

He and his fellow researchers wanted to find out how effective a hip replacement can be in eliminating low back pain, and determine which patients are more likely to benefit.

The patients whose low back pain resolved after the surgery were those with “flexible spines,” according to Vigdorchik. When a person’s spine is flexible, a stiff or poorly functioning hip can drive the spine to move more than usual, causing pain.

Those with normal flexibility in their spine were also highly likely to have their pain resolved.

“Those are the patients whose back pain went away completely after their hip replacement, because their back pain was probably caused by their hip not functioning properly to begin with,” said Vigdorchik.

But the back pain in patients with stiff spines did not go away. Patients with stiff spines already have serious arthritis of the spine, and replacing the hip is unlikely to relieve their pain.

But how can you know if your back pain could be resolved with a hip replacement?

It’s not easy to figure that out on your own, according to Vigdorchik. “It really relies on a good physical exam, and then good X-rays,” he said.

Before a patient undergoes a hip replacement, surgeons will typically take an X-ray of the patient lying down.

In this study, researchers took X-rays of their patients standing up and sitting down, both before and after the surgery.

These X-rays allowed them to see how the hip and spine moved in relation to each other, and assessed the flexibility of their spine, as the patient switched from a standing position to a seated position.

Vigdorchik encouraged other surgeons to utilize these X-rays to identify patients whose ailing backs may be relieved by a hip replacement.

He also advised surgeons in the field to “look beyond just the hip.”

“Anytime they’re looking at the hip, they should also look at the back, and anytime they’re looking at the knee, they should also look at the hip,” Vigdorchik said.

The existence of an interplay between the hip and back is well known to experts, but Della Valle said that this study showed how consistent it is.

He said the study gives surgeons in the field “some tools to try to predict which patients you can tell, ‘Yeah, your back pain will get better,’ and others, well, maybe it won’t.”

The study was published online recently during a virtual meeting of the American Academy of Orthopaedic Surgeons.

Oh, My Aching Back — Or Is It My Hip? – Cleveland Clinic

Back problems can masquerade as hip problems. “There is a lot of overlap,” says hip specialist Trevor Murray, MD. Most pain from hip and back problems is due to ordinary wear and tear on the body.

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When the hip is the usual suspect

Surprisingly, hip problems
usually produce groin pain on the affected side. That’s because the actual
joint of the hip is near the spine.

“Groin pain is a hip issue until proven otherwise,” says back pain specialist Russell DeMicco, DO. “Pain above the belt line is not a hip issue.”

The most common cause of
hip pain is osteoarthritis of the hip joint. You may have hip arthritis if:

  • Pain is in your groin.
  • Discomfort comes and goes, becoming more frequent over time.
  • Pain worsens with standing, walking and activity, and is relieved by rest.
  • You feel stiff.
  • You walk with a limp.

Avascular necrosis, or AVN,
is a serious condition marked by death of hip bone at the joint. The pain is
usually worse and far more constant than in osteoarthritis. “People come to me
saying, ‘My hip is killing me,’” says Dr. Murray.

When the spine is the likely culprit

Most lower spine problems are caused by a herniated disk that presses on nerves in the spinal column. This produces the pain known as sciatica, which can be felt in the hip. You may have a herniated disk if pain:

  • Is limited to your back, buttocks or hip.
  • Shoots down your leg.
  • Worsens with sitting or bending.
  • Improves when standing or walking.

If you have night sweats, a
history of cancer, or pain that is not relieved by lying down (“night pain”),
see your doctor — the problem may be more serious.

Some people develop what
Dr. DeMicco calls a “double whammy” — problems in both the hip and lower back.
“It’s not surprising, since both osteoarthritis and spinal changes are more
common with each passing decade,” he explains.

To relieve hip pain, try these
first:

  • See your primary care doctor. He or she will likely prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to see if hip pain improves.
  • Lose weight. Shedding extra pounds is critical in relieving hip pain. “Losing weight often reduces symptoms to the point where surgery is not necessary,” says Dr. Murray. “It also increases your chances of a successful outcome if surgery is one day warranted.”

For back pain problems, try these
first:

  • See your care primary doctor, and stay active. He or she will likely prescribe NSAIDs for two weeks. Meanwhile, stay active. “Activity can and should be continued. Prolonged bed rest (more than 24 to 48 hours) is bad advice,” says Dr. DeMicco.
  • Schedule physical therapy if needed after two weeks. If you’re still in pain after two weeks, a physical therapist can show you exercises that can strengthen the muscles supporting your spine as well as back-friendly maneuvers.
  • Lose weight, and quit tobacco. Maintaining your ideal weight will take the pressure off your spine. It’s important to avoid tobacco products too. “Nicotine impedes microcirculation, so your spine will degenerate at a faster rate,” says Dr. DeMicco.

If the source of your pain is difficult to pinpoint, seek help from a hip or spine specialist. The specialist may order an injection of lidocaine, or they may perform diagnostic/therapeutic hip injection under fluoroscopy or ultrasound.

If the problem is the hip,
this will numb the hip joint and relieve symptoms immediately. “If the pain
does not improve, we know we’re barking up the wrong tree,” says Dr. Murray.
The same technique can rule out or confirm back pain.

SPINE SURGERY | orto.lv

Fusion of the vertebrae of the spine The purpose of the operation is to block the movement of individual vertebrae by fusing them together. As a result, the vertebrae do not irritate or pinch the spinal cord and nerve roots, which limits the cause of the pain. In the case of fixation of the vertebrae, an implant is placed in the spine, which promotes the growth of the bone of individual vertebrae (facilitates the fusion of these vertebrae).

Fusion of the vertebrae is used to treat various diseases and injuries of the spine, for example, spinal stenosis, spondylolisthesis, scoliosis, fractures, to reduce pain in the back and legs associated with degenerative processes in the discs of the spine.After the operation, the fusion of the vertebrae occurs within three to six months. In some cases, the process takes a year.

Decompression. The term refers to any surgical procedure that aims to make room in the spinal canal for a pinched spinal cord and nerves. Depending on what tissue is operated on to make room for the nerves in the back, this operation is called laminectomy (removal of parts of the bone located in the back of the spinal canal and forming a kind of roof over the spinal cord), foraminectomy (removal of parts of the bone through which the vertebral nerve – in the place where the root of the vertebral nerve leaves the vertebra) or discectomy (removal of the vertebral disc, thereby relieving pressure on the nerves of the spine).

Laminectomy is done to relieve pressure on the spinal canal. This operation is used to treat spinal canal stenosis and spondylolisthesis. During the operation, implants are usually used, which allows for greater stability in a specific area of ​​the spine. During a laminectomy, a small portion of the bone is removed, which is located at the back of the spinal canal. The operation gives an immediate feeling of relief, pain is reduced. However, leg pain, numbness, or weakness may persist for several weeks after surgery.

Foraminectomy is done to relieve pressure on the nerves of the spine. During a foraminectomy, a small amount of bone and other tissue is removed that pinch the nerves in the spine near where they exit from the vertebra. Most patients experience immediate relief after surgery, and their troubling symptoms disappear completely. In some cases, pain persists for several days after surgery.

Microdiscectomy or removal of disc herniation.Microdiscectomy can be done in any part of the spine – cervical, thoracic, or lumbar. The surgeon gains access to the disc from behind through the muscles and bones. The surgeon gains access to the disc by making fenestration – the opening of the spinal canal. There are various surgical instruments and techniques for performing a discectomy. The “open” technique uses a large skin incision and muscle exfoliation so that the surgeon can directly view the anatomy. In a minimally invasive technique called microdiscectomy, a small incision is made in the skin and the discectomy is performed under microscope guidance.Microdiscectomy is done to treat a herniated disc and relieve the associated leg pain. Minimally invasive techniques provide less tissue trauma and can shorten the recovery period.

Cervical Discectomy (Cervical) It can be very effective in relieving pain caused by pinched nerve roots and spinal stenosis. During surgery, an intervertebral disc or multiple discs are surgically removed. A cervical discectomy is performed through a small incision in the front of the neck.After the disc is removed, the space between the vertebrae is filled with an artificial disc implant to maintain the correct distance between the vertebrae, which is physiologically supported by the disc.

Spinal disc replacement is performed to reduce back pain. During the operation, the damaged part of the disc or several discs is removed, replacing them with artificial ones – implants made of metal or other material. The discs are replaced in both the cervical and lumbar regions.

Kyphoplasty is a minimally invasive surgical procedure performed to treat osteoporotic vertebral fractures.To stabilize the damaged vertebra, a balloon is placed in its body, which is inflated very carefully in order to straighten the fracture sites and restore the anatomically correct shape of the vertebra. The balloon is then removed and an acrylic binder is injected into the vertebra to fix and maintain the correct height and shape of the vertebra.

Vertebroplasty is a minimally invasive surgical procedure performed to treat osteoporotic vertebral fractures. The fracture site is stabilized with a special binding agent that is injected into the fracture site.In the case of vertebroplasty, the initial physiological height and shape of the vertebra is not restored.

Facet joint injection . The facet joints are found at the back of the vertebrae between each pair of vertebrae. These joints provide stability to the spine and provide the ability to bend and rotate.

Osteoarthritis of the facet joints causes wear and tear on the cartilage of these joints. This usually causes severe pain. Earlier fractures and injuries to the vertebrae can cause cartilage wear.However, the most common cause is the aging process of the spine.

By injecting pain relievers and anti-inflammatory drugs into joints, injections can reduce pain caused by arthritis. For injection into the facet joints, local anesthesia is used, which is administered under radiographic guidance.

Epidural block. An effective and minimally invasive treatment that is used to treat the spinal cord and nerve roots.It is used in the case of various diseases of the lumbar spine by injecting long-acting steroid preparations into the epidural space of the spinal canal. This procedure can quickly reduce or eliminate pain caused by inflammation of the nerve structures.

90,000 Various methods affecting recovery from low back surgery

Regular exercise is important to restore back strength, gradually return to daily activities, and fully recover from lower back surgery.Your orthopedic surgeon and physical therapist may recommend that you exercise one to three times a day for 10-30 minutes for faster recovery. But these exercises must be done according to correct and completely safe principles so as not to damage your spine again. This article is a guide to exercise after lower back surgery.

Why do you need to exercise after spine surgery?

Spine surgery is an important step for the health of the body, and postoperative rehabilitation is a very important help for patients to get the best results from their surgery.Rehabilitation, which includes physical therapy and exercise, can help patients fully recover from spinal surgery in no time.

These exercises and rehabilitation perform the act of aligning and balancing the body. For example, if you buy a new tire for your car, the new tire will not last and will be destroyed if it is not aligned and balanced. Your spine surgery is like the new splints, and the role of physical therapy and exercise is to align, balance, and tune the motor to ensure the surgery has a positive effect.

There are several methods that physiotherapists commonly use to help a patient stay in good physical condition and recover from back injury and surgery.

  • Use suture bags to reduce pain
  • Position the spine in specific positions with braces
  • Training and execution of special sports movements
  • Using electrical devices

Many of these back pain relief methods are simple, easy, and trainable, and can be performed at home or at work throughout the day.It is surprising for many patients to learn how easy it is to use ice packs or change movements, postures and exercises to reduce postoperative pain.

When does exercise therapy start after back surgery?

Most surgeons recommend that patients take short walks and light stretching exercises in the first week after surgery. This is best done under the supervision of a physical therapist and surgeon.

The patient should move regularly from the first day after surgery.Even if it hurts a little. But if the pain is severe, you should stop walking. But according to the surgeons, the patient must walk and endure during the recovery period.

Between the first and seventh days after surgery, patients can begin to do basic stretching exercises, but to the extent that they do not feel pain. If the patient feels pain for any reason, these actions should be stopped.

Medium-level exercises are recommended for patients from the second to the sixth week, but all these movements must be agreed in advance with the doctor and physiotherapist.These movements stabilize the patient’s muscle strength.

And after the sixth week, advanced movement and use of the ball are necessary to strengthen the back, but it is still emphasized that none of the movements should be done until the surgeon approves.

The first stage of pedestrian treatment

People are more likely to be overweight after surgery due to limited mobility, especially in the first 2-3 weeks after surgery. Walking after lower back surgery is the most important exercise that is beneficial for burning calories.In addition, it helps restore muscle strength along the spine and helps the body recover from local inflammation caused by surgery. Walking improves blood flow throughout the body and makes it easier for oxygen and nutrients to reach the muscles and tissues of the spine.

The most important thing about walking after back surgery is to try to stand naturally while walking so that your spine is in a good position.

Elementary level exercises

These exercises are appropriate between the first and seventh days after surgery.

Ankle Pumps

1.Sleep on the back

2. Move your ankle up and down

3. Repeat this 10 times

Heel Slip

1.Sleep on the back

2.Carefully bend and straighten the knee

3.Lower your heel to the ground

4. Repeat this exercise 10 times

Belly Reduction

1. Lie on your back with your knees bent and your hands on your stomach and under your ribs

2.Tighten your abdominal muscles to pull your ribs back

3. Be careful not to hold your breath

4. Hold your stomach for about five seconds and then return to the starting position

5. Repeat this exercise 10 times

Wall Squat

1. Stand and lean your back against the wall

2.Place your feet about 30 cm in front of you

3. At the same time, gently bend your knees at an angle of 45 degrees

4.Hold for five seconds. Then return to standing position

5. Do this exercise 10 times.

Heel Rises

1. Stand and distribute your weight evenly on both legs

2. Slowly lift your heels off the ground. If necessary, seek help from the wall to maintain balance

3. Hold for five seconds, then slowly lower your heels.

4. Repeat this exercise ten times.

Raises Straight Leg

1.Lie on your back with one leg straight and one knee bent

2. Tighten your abdominal muscles to secure your back

3. Carefully lift your right leg 15-30 cm off the ground. Hold for one to five seconds and rest on the floor

4. Repeat this for each leg twice

Carefully check your leg in the air above, apply the wrong pressure to your lower back and I do not have five seconds in this case, wait a moment so that you get a ground paste with your leg discomfort.

Intermediate sports program

These exercises are suitable for the second to sixth week after surgery.

Stretch from one knee to chest

1. Lie on your back and bend your knees

2. Take the thigh from the back of the knee and pull the knee towards the chest

3. Remain in this position for 20 seconds and then slowly lower your leg

4. Do this five times for each leg

Hamstring Stretch

1.Lie on your back and bend your legs

2. Keep your thigh in the back and a little closer to the knee

3. Gently straighten the knee up until you feel a stretch in the back of the thigh

4. Hold for 20 seconds. Then gently return the foot to its original position

5. Do this five times for each leg

Advanced Level Sports Exercise

From week 6 onwards, you can add these exercises.

Hip Flexor Stretch

1.Lie on your back on the edge of the bed. Keep your knees close to your chest

2.Then slowly lower one leg to the bent position until you feel a stretch in the thigh muscles

3. Hold for about 20 seconds and then return to the starting position

4. Do this five times for each leg

Piriformis Muscle Stretch

1. Lie on your back and bend your knees

2.Cross one leg over the other

3.Pull the opposite knee towards your chest until you feel a stretch in your buttocks and thighs

4.Hold for 20 seconds then reset

5. Do this for five seconds for each leg.

Exercises to stabilize the back with a Swiss ball

In these exercises, the abdominal muscles should remain tense. Do each exercise for 60 seconds.

Lying on the floor

1. Lie on your back with bent knees and back muscles on the ball

2.Pull one arm up and the other down and around the body

3. Now slowly raise your arm over your head to the opposite foot on the ball. Simultaneously lift the opposite leg slightly. You don’t need to raise your arms and legs too much. Then go back to original state

4. Now do it with the opposite arm and leg

Sitting on a ball

1. Sit on the ball and place your feet on the floor. The hips on the ball and knees must have a ninety degree angle

2.Then extend one of the arms up and lift the heel on the opposite side of the ground. Do the same with the other arm and leg. Finally try to lift your feet five inches off the ground

Standing with ball

1. Stand with your back to the wall and place the ball between your waist and the wall

2. Gently bend your knees 45-90 degrees. Hold for five seconds. Then straighten your knees

3. You can do this by bending your arms up and down while bending your knees

4.Lie on your stomach on the ball

5. Place your hands on the floor in front and move slightly to move the ball from under your belly to your feet. Then move back again so that the ball returns under the belly

6. Be careful not to bend your back

When can I start playing sports after surgery?

There are a number of factors that determine when you can return to normal physical activity after lower back surgery.

  • What actions did you take?
  • How are you doing?
  • What is your doctor’s opinion about your return to normal exercise?

In the case of a merge operation, if the operation is performed in only one location, you may have to wait two to three months to resume your workout.If the fusion is done on multiple beads, you may have to wait four to six months.

For less invasive methods, the waiting time is at least four weeks.

Please note that before you want to return to your previous workout, the surgical site must be completely healed and painless, and all postoperative symptoms must disappear. Your doctor may use X-rays to assess your progress.

And remember to do all your exercises slowly, follow your doctor’s advice and listen to your body’s reactions. If you feel short of breath, chest pain, or dizziness while exercising, you should stop exercising because these symptoms indicate excessive pressure on your back.

All these exercises for your faster recovery. Any kind of excessive pressure and any mistake can increase your back problems.

Do these exercises and send them to people who have had spinal surgery to help their health.

Herniated disc | ortoped-klinik.com

What are the causes of a herniated disc?

Not surprisingly, herniated discs occur so often: the 23 discs that we have act as a buffer and shock absorber between the vertebrae. Thanks to them, tremendous flexibility of the spine is possible. They can withstand enormous loads: lateral forces and levers to increase the load that occur during certain movements.They carry loads that are many times the weight of our body.

What causes a herniated disc?

In the womb, the disc feeds on its own blood vessels. After giving birth, he receives nutrients and fluids passively, through the so-called diffusion. It absorbs into itself like a sponge, especially at night, when lying down, water and nutrients from the surrounding tissue fluid. During the day, part of the fluid due to body weight in the standing and sitting position is again displaced from the intervertebral disc.Thus, our growth decreases during the day and returns at night. The size of the difference in height in the morning and in the evening can be up to several centimeters.

This ability of the disc to recover (regenerate) decreases with age. Therefore, over time, it decreases in size. We see this process in a decrease in height in old age. Of all the tissues of the human body, the disc is the most susceptible to degenerative changes. It loses its elasticity and stability.

Loss of elasticity also applies to the rigid annulus fibrosus that surrounds the intervertebral disc.Cracks and cracks form in it, into which a soft mass from the middle of the intervertebral disc can penetrate. At the same time, the pressure on the fiber of the ring increases due to a decrease in the height of the intervertebral disc. This can cause the nucleus and the annulus to bulge – just like in a rubber ball that is squeezed between the palms.

From this point on, it is said that there is a bulging of the intervertebral disc (protrusion). The inner part of the nucleus penetrates through the outer rings, a disc herniation is observed (Discusprolaps or Nucleus-pulposus-Prolaps).

Why are there pains in the back and legs with a herniated disc?

The discs are located very close to the nerve endings of the trunk of the spine. When a disc bulge or disc herniation occurs, the escaping matter can affect the adjacent nerves. This can lead to the fact that the nerve roots are pinched. Nerve roots are parts of an electrical line that connects the brain and body parts.

In the lumbar spine, for example, they transmit commands to move the leg muscles.They are also responsible for transmitting pain signals. If something is pressing on the nerves, it usually causes pain in the limbs to which they lead. In addition, sensory disturbances such as numbness, tingling, or even paralysis may occur.

When a herniated disc breaks through the rigid fibrous ring, it can press very hard on the surrounding tissue and nerve roots. This pressure, in turn, causes leg pain or back pain. When the disc is bulging, less tissue comes out than with a hernia.Therefore, with a herniated disc, sensory disturbances and paralysis are much more often observed.

How is a herniated disc diagnosed?

Diagnosis of a herniated disc requires a thorough medical examination and often in different directions. MRI or CT scans are used to diagnose and identify the affected segment that has a herniated disc. However, it should be noted that if a herniated disc is visible on MRI scans, but no other symptoms are observed, surgical methods are not used.

Examination of the intervertebral discs and the round canal of the spine using the contrast method complements the diagnosis of herniated intervertebral discs.

Treatment options for herniated disc:

The main treatment for disc disease is to remove disc tissue or reduce effusion to relieve pressure on the nerve roots. Depending on the location, type and stage of the disease, a number of minimally invasive procedures are possible, such as nucleoplasty, Rat pain catheter, Disk-FX, endoscopic discectomy, spinal disc transplant, or open microsurgical removal of a herniated disc.

In anticipation, however, all possible conservative methods of treatment must be exhausted, because a large number of herniated discs respond very well to treatment. An exception is disc herniation, leading to paralysis. In this case, as a rule, a quick removal of the herniated intervertebral disc is used to avoid irreversible consequences of the affected nerves.

Lumbar spine surgery in Germany

The spine is the supporting element of the human skeleton.Back pain significantly limits the quality of life. © Filip_Krstic, istock

The most severe back pain is often located in the lower spine. The lumbar region is the main element of the human axial skeleton. Compared to other parts of the spine, the vertebral bodies that take on the load are rather small. Movement in an upright position places a tremendous stress on the vertebral joints of the lumbar spine.

Due to wear, the intervertebral discs lose their buffer and shock-absorbing functions, as a result of which they no longer accumulate fluid and decrease in volume.As a rule, fluid, important for cartilage tissue, reappears at night. However, with age, this process stops, which leads to long-term atrophy of the intervertebral discs.

All of the above facts are the reason for the gradual loss of muscle tension and the gradual deterioration of human motor capabilities. The lumbar spine is bent forward with a bulge. Gradually, this leads to a pathology such as lumbar lordosis, which increases the load on the internal organs.As a result, people have to deal with unbearable pain in the spine, which can radiate to the arms and legs. Also, in the region of the lumbar spine, movements occur that pass from the body to the legs. During this process, such muscle elements as the flexor muscle of the hip joint or the so-called adductors (adductors of the thigh) are involved. It is for this reason that during the examination, a specialist in the treatment of back pathologies should pay attention to the condition of the patient’s pelvis and legs.

Causes of pain in the lumbar spine

Causes of back pain:

  • Herniated disc
  • Lumbago (backache)
  • Developmental anomalies with displacement (scoliosis, fusion of vertebrae, wedge-shaped vertebra)
  • Muscle imbalance
  • Inflammatory processes (rheumatoid diseases, infections)
  • Osteoporosis
  • Bone fractures
  • Tumor formations and metastases

Damaged intervertebral disc with reduced height due to lack of fluid.© joint-surgeon

Over time, various loads can lead to irreversible injuries of the spinal discs. In this case, it is worth highlighting such a pathology as a herniated disc. One of the signs of this disease is the pressure of a separate part of the intervertebral disc on one of the largest nerve trunks of the spine, which, in addition to back pain, also causes typical pain in the legs.

One of the causes of pain in the back, which could not be diagnosed for a long time, is the so-called discogenic pain, which appears as a result of the ingrowth of vessels and fibers of pain sensitivity, especially the annulus fibrosus, into the intervertebral disc.As a result, the person develops pressing pain in the back. At the progressive stage of the disease, there is a possibility of developing osteochondrosis, that is, wear of the intervertebral disc and damage to adjacent vertebral bodies.

Often, the spine becomes unstable, which leads to pain during movement. The spine’s reaction to bone loss can lead to repeated progressive leg pain due to narrowing of the spinal canal and nerve structures. This clinical picture, the medical term for which is “spinal stenosis”, usually represents the final stage of long-term pathology of the lumbar spine.

When is lumbar spine surgery necessary?

Warning signs that indicate the need for an operation:

  • Bladder dysfunctions (incontinence)
  • Dysfunctions of the rectum
  • Syndrome of transverse lesion of the lower spinal cord (cauda equina syndrome)
  • Paralysis (paresis)
  • Sensory disturbances, numbness
  • Rapidly worsening drug-resistant pain

Treatment of back pain depends directly on its cause.Basically, general therapeutic measures such as heat therapy and cryotherapy, therapeutic exercises, manual therapy, electrotherapy, as well as traditional techniques help reduce pain and sometimes completely cure the patient. In addition, patients are advised to protect their back during daily activities. Half an hour of proper exercise a day can prevent deformities and back pain. If these recommendations do not lead to the desired result, the patient is recommended special treatment, for example, in a specialized clinic.Sometimes back pain can only be cured with surgery.

In the event of significant limitations in the quality of life due to pain, impaired motor functions and numbness, the patient should decide to undergo surgery in the lumbar spine. Clinical aspects indicating the need for surgical treatment are neurological pathologies (numbness, paralysis, tingling), as well as other deficits. In most cases, surgery should be performed early in the disease.This will allow the surgeon to perform an intervertebral disc replacement that can relieve pressure on the spinal cord in the lumbar spine.

What surgical treatment of the lumbar spine does the orthopedic medical center Gelenk-Klinik offer?

Depending on the cause of back pain, Gelenk-Klinik uses various methods of surgical treatment.

During an endoscopic operation, the surgeon performs all manipulations through a small incision, after which no scars are formed on the soft parts of the tissue and no bone substance is lost.

Minimally invasive operations are carried out through the “keyhole”. They require only minimal incisions and are capable of covering interventions aimed at treating pain and herniated discs. Compared to the traditional so-called open microsurgical technique, minimally invasive surgery means faster recovery and pain relief for patients.

However, not all diseases of the spine are subject to endoscopic minimally invasive treatment.Sometimes a patient’s diagnosis requires open surgery, for example, when it is necessary to release the nerve root without removing a significant part of the joint.

After regular consultations and taking into account the personal needs of the patient, the specialists of Gelenk-Clinic decide on the time of the procedure, as well as the type of operation. The postoperative physiotherapy plan is also tailored to your needs.

Nucleotomy

Nucleotomy is a surgical procedure aimed at treating protrusion of the intervertebral disc.In the case of such an incomplete hernia, namely a pathological process in which the intervertebral disc bulges into the spinal canal, the fibrous ring, which has a protective effect on the nucleus pulposus, is not damaged. Thus, the nucleotomy allows you to cure the pathology without using open surgery. During this operation, a high-frequency probe is inserted into the intervertebral disc. Using an electric probe, which is inserted under constant X-ray control, the surgeon contracts the nucleus until the pressure on the spinal nerve stops.More than 80% of all patients of Gelenk-Clinic were satisfied with this method of surgery and returned to their previous way of life.

Endoprosthetics of the intervertebral disc

For more than ten years, the implantation of an artificial intervertebral disc has been a reliable and most commonly used method of treating damaged spinal discs. In addition, endoprosthesis of the intervertebral disc is a promising alternative to the relatively well-established and proven (spinal fusion) technique for immobilizing individual vertebrae.Endoprosthetics should help the patient to restore mobility, as well as the original functions of the intervertebral disc. In addition, this operation should help minimize or completely eliminate symptoms such as chronic back pain and neurological disorders. The prosthesis is a replacement for the natural intervertebral disc and protects the spine from various degenerations, as well as ensures its long-term stabilization.

Spondylodesis – fixation of the vertebrae

Surgery to fix the vertebral bodies for stabilization has a long history.By its structure, the human spine is mobile and elastic. After spinal fusion, mobility in this segment is lost. © Viewmedica

Due to the progressive wear of the spine, the space between the vertebrae narrows, as a result of which the spine becomes unstable, and the vertebrae are displaced forward, backward or sideways. If all the possibilities of conservative treatment have been exhausted and minimally invasive surgical techniques do not promise the desired result, surgical immobilization of the painful area is the only way out.The affected area is fixed with a combination of special screws and small connecting screws. Modern technologies allow this intervention to be carried out using a minimally invasive technique, through minimal incisions in the skin. This operation does not guarantee complete relief from symptoms, but the patient can expect significant improvement in pain in the lumbar spine.

What kind of doctor performs the surgery on the lumbar spine?

One of the features of Gelenk Clinic is the trusting relationship between doctors and patients.That is why your attending physician will take care of you from the first examination to the operation of the meniscus tear. He will also monitor your condition after the operation. Thus, in Gelenk-Clinic you will have a contact person to whom you can contact at any time convenient for you. The best neurosurgeon and highly qualified specialist in the field of spine surgery is Dr. David-Christopher Kubos.

Preparation for surgery on the lumbar spine

An extensive clinical trial is conducted first and the results are presented to the patient based on imaging diagnostics.The clinical examination consists of an explanatory conversation with a doctor and a physical examination of the patient. Imaging examination implies X-ray diagnostics, which provides a complete picture of the state of the patient’s spine in the “lying” and “standing” positions, that is, under load.In addition, an important preoperative element is MRI (magnetic resonance imaging), which helps to determine or exclude the presence of injuries intervertebral discs and spinal nerves.Also, before the operation, bone density is measured in order to establish the degree of bone stability and to exclude osteoporotic changes.

If the results of the above studies do not interfere with the operation, a preoperative consultation is held with the patient, during which the surgeon talks about the course of the intervention, and also explains all possible complications. After that, the anesthesiologist speaks with the patient, who will once again check his state of health before anesthesia. Lumbar surgery is performed after the permission of the surgeon and anesthesiologist, usually the day after the examination.

What type of anesthesia is used in the surgical treatment of the lumbar spine?

Spine operations are performed under general anesthesia.To do this, the anesthesiologist uses a combination of anesthetics specially selected for the patient. During the operation, you sleep soundly and do not feel pain. The anesthesiologist is always there. He checks your vital signs regularly and makes sure you stay awake.

What kind of aids are needed after surgery?

During the first days after surgery on the lumbar spine, it is necessary to be careful and move as little as possible.For this, the patient will be made a special orthosis-fixator, which he will need to wear for 2-6 weeks. This construction stabilizes the spine and limits sudden movements.

Is there any pain after lumbar spine surgery?

Operation is a process associated with unpleasant sensations. We try to keep pain to a minimum. As soon as the effect of general anesthesia ends, the patient is given an intravenous pain reliever or pills.Surgeons, as well as all employees of our clinic will provide you with maximum painlessness after spinal surgery ..

What are the conditions of stay at Gelenk-Klinik?

Solitary ward at Gelenk-Klinik in Gundelfingen. © joint-surgeon

During your inpatient stay at the clinic, you are in a single room with a shower and toilet. Each room has towels, a bathrobe and slippers. Also, you will have a mini bar, safe and TV. You must bring your own medicines, comfortable clothing and nightwear with you.After surgery, the patient is cared for by experienced nursing staff and professional physiotherapists 24 hours a day. Typically, a hospital stay does not exceed three days. Your relatives can stay at a hotel a few steps from the clinic. We will gladly take care of your hotel reservations and will be happy to arrange treatment for you in Germany.

What should you pay attention to after the operation?

After spinal surgery, care must be taken and abrupt movements must be avoided.Depending on the medical indication, you will be referred for manual therapy to eliminate dysfunctions of the musculoskeletal system. After about 6 weeks of physical rest, the patient is allowed to play sports again. Since special absorbable sutures are used during the operation, the stitches do not need to be removed. Therefore, it is allowed to take a shower already on the 7th day.

  • Inpatient treatment: 2-5 days
  • Recommended stay in the clinic: 10-14 days
  • Possible return home: 7 days after
  • Recommended return flight: in 14 days
  • Taking a shower is allowed: after 7 days
  • Recommended sick leave: 4 weeks (depending on professional activity)
  • When sutures are removed: not available due to the use of absorbable sutures
  • When can you drive again: 2 weeks
  • Outpatient physiotherapy: 2 weeks

What is the cost of the operation?

In addition to the cost of the lumbar spine surgery, it is necessary to take into account the additional costs of diagnostics, doctor’s appointments and aids (e.g.orthoses). If you are planning to undergo physiotherapy in Germany after shoulder surgery, we will be happy to help you arrange appointments with specialists and provide you with an appropriate cost estimate.

Information regarding the cost of hotel accommodation and subsequent treatment in a rehabilitation clinic can be found on the website of the medical institution itself. We will be happy to assist you in organizing rehabilitation treatment in Germany.

How to make an appointment for a lumbar spine surgery for a foreign patient?

If you want to undergo lumbar spine treatment in Germany, you will need to provide us with up-to-date MRI scans and X-ray results.Thus, the doctors of Gelenk-Clinic will be able to assess the condition of the intervertebral discs, vertebrae and facet joints. You can send these documents through our website. After that, within 1-2 working days, you will be sent all the necessary information, a preliminary treatment plan, as well as a final cost estimate.

Foreign patients can make an appointment as soon as possible according to their personal time. We will be happy to help you with visa processing after the amount of this service specified in the cost estimate is received on our account.If for some reason your visa application is denied, this amount will be refunded in full.

For patients from abroad, we try to reduce the time between the preliminary examination and the operation itself. Thus, you will not need to come to the clinic several times. During both inpatient and outpatient treatment of the shoulder joint, you can use the services of the staff of the Patient Management Department, whose staff speaks several foreign languages ​​(eg.English, Russian, Spanish, Portuguese). We also provide assistance in finding an interpreter (eg in Arabic), the payment of which is made by the patient on a separate basis. We will be happy to help you organize a transfer, find a hotel and show you how to spend your free time in Germany in an interesting way for you and your family members.

90,000 octeoxondrosis, protrusion, hernia? How to treat?

08.01.2019

According to statistics, half of the world’s population has back problems and each of us at least once in our life has experienced all the delights of pain in the neck or lower back.Back pain has a wide variety of origins. One of the most insidious causes of spinal pain is a herniated disc. Severe pain is the first manifestation of a hernia, which makes a person begin to worry about their health. Pain can be constant or come on unexpectedly and inexplicably, for example, when sneezing or simple and habitual movement. About how to get rid of a hernia and become a healthy person, how to prevent serious consequences of the disease, about where the boundaries of conservative treatment are and when an operation is needed, we asked Vadim Anatolyevich Zotov, a neurosurgeon at the Reaviz Multidisciplinary Clinic.

What is a herniated disc and why does it appear?

– The herd of the intervertebral disc is an illness in which part of the disc is protruding into the spinal canal with compression of the spinal structures. The main reasons for the appearance of intervertebral hernias are: overweight and a sedentary lifestyle, excessive physical exertion, poor posture and past injuries of the spine. Even ordinary osteochondrosis increases the risk of herniated discs.There are factors associated with the characteristics of the profession. At risk are athletes, truck drivers, workers in production, whose activities are associated with prolonged vibration exposure.

How to notice the signs of a hernia in time? When should a person sound the alarm?

– The most common signs of a hernia include back pain, followed by leg pain, and lower back pain may decrease or disappear. The pain is relieved by flexing the leg at the hip or knee, and worse by maintaining any other position.People suffering from this disease are forced to change their position every 10-20 minutes. The pain increases with coughing, sneezing, or straining. Alert should be pain in the neck, passing into the arm, numbness and weakness in the arm, sharp dizziness when turning the head. An urgent visit to a doctor is necessary in case of disruption of the bladder, the appearance of progressive muscle weakness in the limbs.

Can conservative treatment help and how long does the effect last?

– Conservative treatment often relieves the exacerbation of the process, eliminates pain and allows a person to return to their usual way of life.But you can get a lasting long-term effect of treatment only by eliminating the causes of disc herniation. These include weight correction, prolonged physical education aimed at strengthening the muscle corset and eliminating instability of the spinal segment, and in the presence of concomitant diseases of the musculoskeletal system, wearing corrective insoles or other external stabilization devices.

What modern methods of treatment can you suggest if conservative treatment did not give the desired result?

-Very effective methods that complement the traditional conservative treatment are therapeutic and drug blockades, facetoplasty – the introduction of a synovial fluid prosthesis into the intervertebral joints.

Are there situations when a herniated disc needs to be operated on urgently? What are the indications for surgery?

-A large disc herniation that compresses several roots of the spinal cord can lead to the development of cauda equina syndrome. This condition includes urinary retention, perineal numbness, paralysis in the feet and is an indication for emergency surgery. The indications for elective surgery are the ineffectiveness of conservative treatment with persistence of pain for 5-8 weeks, a progressive decrease in strength in the leg.All this is determined individually in each case.

When is complete spinal disc replacement necessary? What is an endoprosthesis?

-Total disc removal is performed in case of severe instability of the vertebral segment, the formation of spondylolisthesis, that is, “sliding” of one vertebra relative to the other. Such an operation must be complemented by one or another stabilization method. This can be the placement of pedicle screws or interspinous stabilization.In this case, the disc is replaced with a special implant – an endoprosthesis. A disc endoprosthesis is a mechanical movable device implanted into the intervertebral space, which maintains mobility in the segment. Currently, there are a large number of endoprostheses that significantly improve the outcome of the operation. These are prostheses of the disc, annulus fibrosus, prostheses of the vertebral bodies and intervertebral joints.

Can the operation ensure that the problem does not return?

– A good result of surgical treatment can be expected only under the condition of mutual efforts of the surgeon and the patient.After the operation, it is necessary to follow the doctor’s recommendations for a long time: as a rule, this is weight loss, exercise therapy classes and other rehabilitation measures. When these conditions are met, there are practically no relapses of the disease and after 4-5 days the patient will be able to return home. It depends on the severity of the initial condition and the extent of the operation performed.

Tell us about the possible complications of hernias, if they were not found in time or did not begin to deal with them?

– If the hernia is not eliminated, complications will soon appear.These include impaired control of urination and defecation, persistent paralysis of the lower extremities in the case of lumbar hernias, as well as complete paralysis in cervical hernias. Also, with hernias of the spine, instability of blood pressure, headaches, dizziness, pain in the heart caused by intercostal neuralgia, or dysfunction of internal organs, including genitals, often appear.

What advice would you give to people who have just started or have had symptoms of herniated discs for some time now? What diagnostic methods are used in this case?

First of all, you need to consult a neurosurgeon.For a more precise diagnosis and determination of treatment methods, possible indications for surgical treatment, the doctor will prescribe the necessary diagnostic tests. In the multidisciplinary clinic “Reaviz” you can undergo X-ray and computed tomography using the most modern equipment.

90,000 Brochure for patients with hip arthroplasty

This brochure is dedicated to people who are going to have hip replacement surgery. You have been diagnosed with a hip injury.You have undergone conservative treatment for a long time, used all possible drugs for pain relief. You were hoping that you could return to your normal life.

In fact, there are no miracles. There comes a moment when life becomes unbearable and you cannot live without pain, walk without pain, movements in the joint are limited. You can no longer carry out everyday activities, you feel your own limitations in everyday life. This is usually accompanied by severe pain and limited mobility in the hip joint.Based on these symptoms, as well as on the data of a medical examination, doctors recommend that you have an artificial joint implantation. The purpose of our brochure is to familiarize you with the possibilities, features and benefits of total hip replacement surgery. We will try to help you prepare for your surgery and avoid unnecessary anxiety during your hospital stay.

Of course, this information does not replace consultation with your doctor, orthopedic surgeon, rehabilitation therapist and other medical personnel.If you have any questions or uncertainty about something, you should discuss it with specialists. Remember! The result of treatment will depend on the strict implementation of all the recommendations of the attending physician and your mood for recovery.
To better understand the possible operations, let’s try to imagine the anatomy of the hip joint.

So, the hip joint is a ball-and-socket joint. It is surrounded by muscles and ligaments and allows movement of the hip and the entire lower limb in all planes.In a healthy joint, smooth cartilage covers the head of the femur and the acetabulum of the pelvic joint. With the help of the surrounding muscles, you can not only support your weight when leaning on your leg, but also move. In this case, the head slides easily inside the acetabulum. In the diseased joint, the affected cartilage is thinned, has defects and no longer performs the function of a kind of “pad”. The articular surfaces altered by the disease rub against each other during movement, stop sliding and acquire a surface like sandpaper.The altered femoral head rotates with great difficulty in the acetabulum, and pain occurs. Soon, trying to get rid of pain, a person begins to limit movement in the joint. This, in turn, leads to shortening of muscles, ligaments and even greater contracture. The pressure exerted by the muscles on the femoral head increases; over a long period of time, the weakened bone is “crushed”, its shape changes, and flattened. As a result, the leg becomes shorter. Bone growths are formed around the joint (the so-called ossification or osteophytes).The altered joint can no longer fully perform its function.

What is total hip arthroplasty

Only an operation to completely replace the diseased joint or total hip arthroplasty can radically interrupt this entire chain of painful processes.

In principle, total arthroplasty is the replacement of a damaged joint with an artificial endoprosthesis. Total arthroplasty is one of the main achievements of this century.Many decades ago, the relatively simple design of the hip joint inspired doctors and medical technicians to create an artificial replica. Over time, research and improvement of the surgical technique and the materials used have led to tremendous advances in the field of total hip arthroplasty. The design of endoprostheses ideally follows the human anatomy. An endoprosthesis consists of two main parts: a cup and a stem. The ball-shaped head is located on the stem and inserted into the endoprosthesis cup.The materials used for the artificial joint are special metal alloys, ultra-strong polyethylene and ceramics, specially developed for arthroplasty. They provide excellent tissue compatibility, absolutely painless movement, maximum strength and durability of the endoprosthesis. Typically, the surfaces of the endoprosthesis in contact with each other include a ceramic or metal head mounted in a polyethylene cup. They can also be fully metallic or fully ceramic.

There are mainly three types of endoprosthesis fixation:

Endoprosthesis with cementless fixation , in which both the cup and the stem of the endoprosthesis are fixed in the bone without the use of bone cement. Long-term fixation is achieved by the invasion of the surrounding bone tissue into the surface of the endoprosthesis.

Cement-retained endoprosthesis , in which both the cup and the stem are fixed with special bone cement.

Hybrid (combined) endoprosthesis , in which the cup is cemented and the stem is cemented (i.e.It is fixed in the bone with a special bone cement.) There is a very wide range of models for all types of endoprostheses, produced in the required range of sizes. The choice of the required type of endoprosthesis is determined by the physiological characteristics, medical indications, as well as the age, weight and degree of physical activity of the patient. The correct choice greatly contributes to the success of the operation. An orthopedic traumatologist will conduct preoperative planning, which will determine the required size, model of the endoprosthesis and the location of its parts.However, during the operation, he must be able to install an endoprosthesis of a different size, making changes to the original plan. (It depends on the individual characteristics of the patient, the structure and density of the bone substance, the specific conditions and tasks of the operation being performed.)

Before the operation

The decision in favor of the operation mainly lies with the patient. In many cases, severe pain and taking a huge amount of analgesics (pain medications) make a person’s life so unbearable that surgery becomes vital.The exact time of the operation must be discussed taking into account all the necessary factors and features. It is necessary to properly prepare for the implantation of the endoprosthesis. Before the operation, you can contribute to a favorable course of the postoperative period, namely:

  • Stop smoking.
  • Normalize dead weight. If you are severely obese, your doctor may postpone surgery to give you time to lose weight (body mass index greater than 35 is a relative contraindication for arthroplasty due to the high risk of postoperative complications).
  • Reorganization of the oral cavity and other possible foci of chronic infection is required. Such preliminary preparation will reduce the risk of wound infection that accompanies any surgical intervention.
  • If you have any chronic diseases, be sure to go through all the necessary follow-up examinations so that you have time to correct their treatment.
  • There is always a certain amount of blood loss during total hip replacement surgery.This may necessitate a transfusion. In order to prevent immunological conflict or infection, it is advisable to prepare your own blood for transfusion during surgery. You should discuss this possibility with your doctor, and he will give you the necessary advice.

The aim of the operation is to place the endoprosthesis in the best possible way, to get freedom from pain and to restore working capacity. However, freedom from pain and movement without restrictions may not always be guaranteed.In some cases, the difference in the length of the limb can be partially compensated by selecting the optimal size of the endoprosthesis. But sometimes this may not be possible if, for example, the general condition of the patient is very serious. The difference in limb length can be corrected later, for example by using special orthopedic shoes or lengthening the thigh segment.

Currently, the quality of artificial joints, the technique of the operation have reached a very high level and have significantly reduced the risk of various postoperative complications.But, despite this, certain complications associated with inflammation of the tissues around the joint or with early loosening of the elements of the endoprosthesis are always possible. Strict adherence to the doctor’s recommendations will reduce the risk of complications.

Day of operation
The operation can be performed under general, combined or regional anesthesia (pain relief). Regional anesthesia of the lower limb affects the general condition to a lesser extent and is therefore preferred.In addition to the anesthesia, you will be given a sedative (sedative). During the operation, you will not experience any pain.

The day before the operation, the doctor will visit you to discuss the anesthesia and the course of the operation. He will then select the medication you can tolerate best and the most appropriate method of surgery. During the operation, the affected joint will be removed and replaced with an artificial one. Implantation will require an incision in the skin about 15 cm in length.Thus, the surgeon will be able to approach the hip joint, remove the affected femoral head and damaged acetabulum, and replace them with an artificial cup and stem with a ball-shaped head. After installing the cup and leg, the artificial joint is checked for mobility, and then the surgical wound is sutured. A drain introduced into the wound prevents the accumulation of oozing blood. After the operation, a pressure bandage (bandage) is applied and the first control X-ray is taken.

The entire operation usually takes 1.0-1.5 hours.

The artificial joint implantation procedure is a common operation. For this reason, the following information on possible complications should not be a cause for concern and should only be considered as general information for patients. The possible complications described below relate directly to the procedure for implanting an artificial joint. The general risk that exists in any operation is not mentioned here.

Hematomas (bruises)
These can appear after surgery and usually go away after a few days. The previously mentioned drains are installed to prevent large hemorrhages, i.e. for the evacuation of blood.

Thrombosis
Thrombosis (formation of blood clots) can result from increased blood clotting (blood clots can obstruct blood flow in the veins of the extremities), which can lead to pulmonary embolism (when the blood clot reaches the lungs).To reduce the risk of thrombosis, special drugs are prescribed, in the form of tablets or injections, before and after the operation, as well as elastic stockings or tight bandaging of the leg and foot and physiotherapy exercises.

Infection
Infection in the wound area is a rather rare complication and is usually successfully treated with antibiotics. However, deep infection can lead to loss of the endoprosthesis and the need for reoperation. For this reason, special attention is paid to sterility and protection against bacteria.In addition, antibiotics are prescribed before and after surgery.

Dislocation (displacement), dislocation
They occur quite rarely (mainly in the early postoperative period, until soft tissues have healed) and usually occur only in cases of extreme physical activity or falls. As a rule, in this case, the doctor will carry out the reduction of the displaced endoprosthesis under anesthesia. The doctor must accurately inform you about the range of movements that are permissible at different times during rehabilitation.

Allergy
In very rare cases, tissue reactions may develop upon contact with an artificial joint. This reaction can be caused by a chromium – nickel allergy. By using the modern alloys available today, the risk of allergies is minimized.

After surgery
When you wake up, you need to do several exercises that reduce swelling of the limb and prevent blood clots from forming in the vessels. You need to perform them while lying in bed.

1. Breathing exercises. Raise your arms up, take a deep breath. Lower your arms through the sides down, take a deep, energetic exhalation. This exercise must be repeated 5-6 times a day

2. Foot pump. When you are in bed (or later when you are sitting in a chair) slowly move your feet up and down. Do this exercise several times every 5 or 10 minutes.

The first days after the operation are the most important.Your body is weakened by the operation, you have not yet fully recovered from anesthesia, but already in the first hours after waking up, try to remember more often about the operated leg, to monitor its position. As a rule, immediately after the operation, the operated leg is placed in the abducted position. A pillow is placed between the patient’s legs to allow for moderate dilution. The first day you will lie in bed. If any medical manipulations or examinations are required, you will be taken on a gurney.For 6-8 weeks after the operation, you will have to wear compression hosiery (bandage your legs with elastic bandages or wear compression stockings). You also need to remember that:

  1. Sleeping in the first days after surgery is necessary only on the back, preferably with a pillow or cushion between the legs
  2. You can turn only on the operated side, but not earlier than 7 days after the operation
  3. When turning in bed, put a pillow between your legs

To reduce the risk of dislocation of the endoprosthesis, do not bend the operated leg in the hip joint more than 90 degrees, rotate the leg in the operated joint, turning it toe in and out.That is, you are NOT FORBIDDEN:

  • Sit on low chairs, armchairs or beds
  • Squatting
  • Bend over below waist level, pick up objects from the floor
  • Pull the blanket over yourself in bed
  • Put on clothes (socks, stockings, shoes), bending over to your feet
  • Sleep on a healthy side without a pillow between the legs
  • Sit cross-legged, cross-legged
  • Turn to the side with the body without simultaneously turning the legs

Use the tips to make your daily life easier:

  • When sitting in bed or going to the toilet after surgery, you need to be careful to avoid excessive flexion in the operated joint.When you sit down on a chair, it should be high. A regular chair should be cushioned to increase its height. Low, soft seats (armchairs) should be avoided.
  • In some patients with advanced process, certain difficulties persist when putting on socks. We recommend using a simple device in the form of a stick with a clothespin at the end, or a special clip sold in prosthetic and orthopedic enterprises.
  • Wear shoes with a long-handled horn, try to purchase shoes without laces
  • Place the blanket next to you or use the blanket stretcher.
  • Shower on a non-slip mat using a long-handled washcloth and flexible shower.
  • Dedicate most of your free time to exercise therapy.

The first goal of exercise therapy is to improve blood circulation in the operated leg. It is very important to prevent blood stagnation, reduce swelling, and accelerate the healing of postoperative wounds. The next important task of physiotherapy exercises is to restore the strength of the muscles of the operated limb and restore the normal range of motion in the joints, the support of the entire leg.Remember that the frictional force in the operated joint is minimal. It is an articulated joint with perfect glide, so all problems with limiting the range of motion in the joint are solved not by passively developing it by swinging, but by actively training the muscles surrounding the joint.

In the first days after the operation, physiotherapy exercises are carried out while lying in bed. All exercises should be performed smoothly, slowly, avoiding sudden movements and excessive muscle tension.During exercise, correct breathing is important – inhalation usually coincides with muscle tension, exhalation – with their relaxation.

The first exercise is for the calf muscles. You have already used this exercise on the day of surgery. Bend your feet with slight tension towards yourself and away from yourself. The exercise should be performed with both legs for several minutes up to 4-5 times during an hour.
Ankle Rotation : Rotate the foot of the operated leg first clockwise and then in the opposite direction.Rotation is carried out only at the expense of the ankle joint, not the knee! Repeat the exercise 5 times in each direction.

Exercise for the quadriceps femoris : Tighten the muscle on the front of the thigh, try to straighten the knee, pressing the back of the leg against the bed. Hold in tension for 5 to 10 seconds.

Repeat this exercise 10 times for each leg (not only for the operated leg)

Knee flexion with heel support : Move the heel towards the buttocks, bending the knee and touching the heel to the bed surface.Don’t let your knee pivot towards the other leg or bend your hip more than 90 degrees. Repeat this exercise 10 times.

If at first it is difficult for you to perform the above exercise on the first day after the operation, then you can postpone it. If difficulties arise later, you can use a tape or rolled sheet to help tighten your foot.

Buttock Contractions : Contract the muscles of the buttocks and hold them tense for 5 seconds.Repeat the exercise at least 10 times.

Abduction Exercise: Move the operated leg as far as possible to the side and back. Repeat this exercise 10 times. If at first it is difficult for you to perform this exercise on the first day after the operation, then you can postpone it. Very often this exercise fails in the first days after the operation.

Straighten Leg Raise : Contract your thigh muscles so that the knee of the leg on the bed is fully extended.Then lift your leg a few centimeters from the surface of the bed. Repeat this exercise 10 times for each leg. If at first it is difficult for you to perform this exercise on the first day after the operation, then you can postpone it. Like the previous one, very often this exercise fails in the first days after the operation.

Continue all these exercises later, on the next second, third, and so on days after the hip replacement surgery.

First steps
In the first days after surgery, you must learn to get out of bed, stand, sit and walk so that you can do it safely yourself.We hope that our simple tips will help you with this.
Immediately you must remember that before sitting down or getting up, you must bandage your legs with elastic bandages or wear special elastic stockings for the prevention of vein thrombosis of the lower extremities !!!

Getting out of bed
As a rule, it is allowed to get up on the third day after the operation. The first time you get back on your feet, a physical therapy instructor or attending physician will help you.At this time, you still feel weak, so during the first days someone must definitely help you, supporting you. You may feel a little dizzy, but try to rely on yourself as much as possible. Remember, the faster you get up, the faster you will begin to walk on your own. The medical staff can only help you, but no more. Progress is entirely up to you.

So, get out of bed in the direction of the operated leg. Sit on the edge of the bed with your operated leg straight and in front.Before getting up, check that the floor is not slippery. Place both feet on the floor. You can also stand to the side of your healthy leg, provided that you do not bend the operated hip more than 90 degrees and do not bring it to the midline of the body. Using crutches and your non-operated leg, try to stand up.

If you want to go to bed, all actions are performed in the reverse order: first you need to put your healthy leg on the bed, then the operated one.

How to use crutches correctly

It is necessary to stand up and put the crutches forward a stride length and towards the toes.With your elbow slightly bent, keep your hips as straight as possible. Hold the crutch handles firmly when walking. When walking, touch the floor with the operated leg. Then increase the load on your leg by trying to step on it with a force equal to the weight of your leg or 20% of your body weight. You can determine the load using ordinary weights, on which you need to stand with the operated leg with the required load. Remember the feeling and try to step on your foot with this load when walking.

Attention: the main weight must be supported by palms, not armpits!

If you are allowed to use only one crutch, then the crutch must be on the side of your good leg.

How to sit down and stand up

To sit down, go to the chair with your back turned until you feel its edge. Move both crutches to the side of your good leg. Sit on a chair with the armrests in place and your operated leg extended.

Bend your legs at a small angle and sit up straight. Slide forward to get out of the chair. Grasp the armrests of the chair with your hands to stand on your healthy leg, slightly stretching the still operated leg. Then, grab the crutches with both hands to stand on the operated leg.

1-4 days after surgery

Targets

  1. Learn to get out of bed and go to bed on your own.
  2. Learn to walk independently with crutches or a walker.
  3. Learn to sit on and off a chair on your own.
  4. Learn to use the toilet on your own.
  5. Learn to do the exercises.

Hazards

  1. Follow the rules to prevent dislocation of the endoprosthesis: observe the right angle rule, sleep with a pillow between the knees.
  2. Do not lie on your operated side. If you want to lie on your side, then lie down only on your healthy side, and be sure to place a pillow or roller between your knees.
  3. When you are lying on your back, do not constantly put a pillow or a roller under your knee – often you want to do so and a little flexion in the knee reduces pain, but if you keep the knee bent all the time, then it is very difficult to restore extension in the hip joint, it will be difficult to start walking …

Rehabilitation

  1. Anterior thigh muscle training (straight leg lift)
  2. Training of other muscles of the thigh (compression of the pillow between the legs)
  3. Glute workout (squeezing the buttocks)
  4. Work by the muscles of the lower leg (foot movements)
  5. When standing, fully straighten your leg
  6. The duration and frequency of walking with crutches is gradually increased.By 4-5 days after the operation, walking 100-150 meters 4-5 times a day is considered a good result.
  7. It is necessary to strive for a symmetrical load on the left and right legs (if the doctor permits such a load on the leg)
  8. Try not to limp — keep the steps shorter and slower, but not limp steps.
  9. By 4-5 days, go from “catching up” to normal gait (that is, when walking, place the operated leg further forward of the non-operated leg)

HOW TO UP AND DOWN THE STAIRS

Attention: do not take your first steps up the stairs yourself!

In 4-5 days after the operation, you need to learn to walk up the stairs.Climbing stairs requires both joint mobility and muscle strength, so it should be avoided if possible until complete recovery. But for many of us this is not possible, because even to the elevator in many houses you need to climb the stairs. If you have to use a ladder, you may need someone else’s help. Always use the opposite hand opposite the operated joint on the railing when climbing stairs and take one step at a time.

Climbing stairs:

1.Step up with your good leg.

2. Then move the operated leg up one notch.

3. Finally, place your crutch and / or cane on the same rung.

Descending stairs, reverse:

1. Place your crutch and / or cane on the step below.

2. Step down with the operated leg.

3. Finally, move your good leg down.

Remember the basic rule: A HEALTHY LEG IS ALWAYS ABOVE THE SICK!

When you learn to stand up and stand steadily, you can expand the complex of physiotherapy exercises.While doing these exercises while standing, hold onto a secure support (headboard, table, wall, or sturdy chair). Repeat each exercise 10 times during each session 3 times a day.

Standing Knee Raise : Raise the knee of the operated leg. Do not raise your knee above waist level. Hold your leg for two seconds, for the count of three, lower it.

Hip extension while standing : Slowly pull the operated leg back.Try to keep your back straight. Hold your leg for 2 or 3 seconds, then bring it back to the floor.

Standing leg abduction: Make sure your hip, knee, and foot are straight forward. Keep your body straight. Making sure that the knee is pointing forward at all times, move your leg to the side. Then slowly lower your leg back so that the foot is back on the floor.

AFTER DISCHARGE

  • Following your doctor’s instructions is very important for a speedy recovery:
  • If you use a walker or crutches while walking, ask your doctor how much weight you can use on the operated leg.Do not forget that, most likely, you will get tired faster than before. You should allow for 30 to 60 minute rest periods throughout the day.
  • It is easier and safer to sit down and get up from a chair, putting most of the weight on your hands. It is unacceptable to sit on low and soft chairs or beds. Cushions or sleeping pillows can be used to sit at a sufficient height.
  • A sufficiently high toilet seat will help reduce stress on the hip and knee joints when standing up and sitting on the toilet.
  • A screwed-in shelf at chest level in the shower avoids the need to bend down to retrieve toiletries when showering.
  • The seat (bench) in the bathroom will allow you to take a bath safely and comfortably in a seated position.
  • A long-handled washcloth should be used to wash the lower legs. For women to shave their legs, use a special razor extension.
  • Do not sweep, mop or vacuum the floor. You can use a long-handled mop to wash high or low items.
  • Driving is not prohibited, but instructions must be followed when getting in and out of the vehicle. You can place a cushion on the seat to increase the height of the seat. When traveling, try to push the seat back as much as possible, taking the half-reclined position.
  • Your doctor will most likely prescribe pain pills for you. Be sure to follow your doctor’s instructions for taking these medications.
  • A slight swelling of the tissues around the postoperative wound is not a deviation.Therefore, comfortable and loose clothing should be worn to prevent pressure on the wound. Ask your doctor or other qualified healthcare professional about how you should handle your surgical wound.

By 4-5 weeks after the operation, the muscles and ligaments grow together quite tightly, and this is exactly the time when it is time to increase the load on the muscles, restore their strength, the ability to balance, which is impossible without the coordinated work of all the muscles surrounding the hip joint.

All this is needed in order to move from crutches to canes and then begin to walk completely independently. It is impossible to give up crutches earlier, when the muscles are not yet able to fully hold the joint and even more so to react to possible non-standard situations (for example, a sharp turn).

Exercises with elastic band (with resistance). These exercises should be performed 10 times in the morning, afternoon and evening. Attach one end of the elastic band around the ankle of the operated leg, and the other end to a locked door, heavy furniture, or wall bars.To maintain balance, it is worth holding on to a chair or headboard.

Resistance Hip Flexion : Stand with your back against a wall or heavy object to which an elastic band is attached, slightly placing the operated leg to the side. Raise your leg forward, keeping your knee straight. Then slowly return your leg to its original position.

Resistance Hip Extension : Stand facing a wall or heavy object to which an elastic band is attached, with your operated leg slightly to the side.Extend your leg at the hip joint, keeping the knee straight. Then slowly return your leg to its original position.

Abduction of the leg with resistance in the standing position : Stand with your good side to the door or a heavy object to which the rubber tube is connected, and take the operated leg to the side. Slowly return your leg to its original position.

Walking : Use the cane until you are confident in your balance. At first, walk for 5-10 minutes 3-4 times a day.When your strength and endurance increase, you will be able to walk for 20-30 minutes 2-3 times a day. Once you are fully recovered, continue regular walking for 20-30 minutes 3-4 times a week to maintain the muscle strength achieved. Use the cane only on the side of your good leg.

ADVICE FOR THE FUTURE

  • Approximately 6-8 weeks after your surgery, your doctor may authorize you to drive and tell you about driving habits. If your car is not equipped with an automatic transmission, talk to your doctor about the resulting driving restrictions.Before entering the road, you should make sure that braking the car does not cause you discomfort.
  • Constipation is common in patients after surgery. It is caused by low mobility and pain medication. Talk to your doctor about your diet. If the doctor has no objection, then the menu should include fresh fruits and vegetables, and also drink eight full glasses of liquid every day.
  • Watch your weight – every extra kilogram will accelerate the wear and tear of your joint.Remember, there are no special diets for hip replacement patients. Your food should be rich in vitamins, all essential proteins, and mineral salts. None of the food groups has a priority over the others, and only together they can provide the body with complete healthy food.
  • Your artificial joint is a complex structure made of metal, plastic, ceramics, so if you are going to travel by plane, take care of obtaining a certificate of the operation performed, i.e.This can be useful when going through airport control. On long trips, take your endoprosthesis passport with you.
  • Remember that your joint contains metal, so deep warming up, UHF therapy on the area of ​​the operated joint using the transverse technique is undesirable.
  • Usually, when limb function is fully restored, patients have a desire to continue playing their favorite sports. But, taking into account the peculiarities of the biomechanics of the artificial joint, it is advisable to avoid those types of sports activities that are associated with lifting or carrying weights, sharp blows to the operated limb.Therefore, we do not recommend horse riding, running, jumping, weightlifting, etc. Walking (normal and Scandinavian), swimming, leisurely cycling and skiing are recommended.
  • Avoid colds, chronic infections, hypothermia – your artificial joint can become that “weak point”, which undergoes inflammation.

Rehabilitation at the outpatient-polyclinic stage
Each patient needs an individual program, taking into account the concomitant pathology.The goal of rehabilitation is to form a correct gait and eliminate muscle imbalance.

During this period it can be recommended:

  • Physiotherapy:
  1. Magnetic therapy of the hip joint and lower limb area
  2. Calcium electrophoresis in the area of ​​the hip joint
  3. Electrical stimulation of the gluteal, quadriceps muscles of the thigh (DDT, SMT, Miorhythm, IFT)
  4. Phonophoresis of heparin on the area of ​​hematomas (if any)
  5. Hydrotherapy, swimming (after complete healing of the postoperative wound)
  6. Heat therapy (after 6 weeks)
  • Massage of the operated limb (allowed from 12-14 days after the removal of postoperative stitches).
  • Physiotherapy exercises
  1. Continue with the previous exercises.
  2. Special gymnastics lying on the side (non-operated), on the stomach, standing with support.
  3. Cycling
  4. Dosed walking

The “trouble-free” life of your new joint depends largely on the strength of its fixation in the bone. And it, in turn, is determined by the quality of the bone tissue surrounding the joint. Unfortunately, in many patients undergoing arthroplasty, the quality of bone tissue leaves much to be desired due to the existing osteoporosis.Osteoporosis is understood as the loss of bone’s mechanical strength. In many ways, the development of osteoporosis depends on the age, sex of the patient, diet and lifestyle. Women after 50 years are especially susceptible to this ailment. But regardless of gender and age, it is advisable to avoid the so-called risk factors for the development of osteoporosis. These include a sedentary lifestyle, the use of steroid hormones, smoking, and alcohol abuse. To prevent the development of osteoporosis, we recommend that patients give up highly carbonated drinks such as Pepsi-Cola, forfeits, etc.etc., be sure to include in your diet foods rich in calcium, for example: dairy products, fish, vegetables. If you develop symptoms of osteoporosis, you need to urgently discuss with your doctor the best ways to treat it.

Remember that your artificial joint does not last forever. The average service life of a normal endoprosthesis is 15-20 years, in the best cases it reaches 25 years. Of course, one should not constantly think about the inevitability of a second operation (especially since most patients manage to avoid it).Your new joint “loves” an attentive, neat attitude. It is very important that you remember this, stay in good physical shape and on your feet all the time. Given some of the caveats we talked about above, you can fully recover and return to a normal active life, to your favorite job or hobby.

What to do with pain in joints and back – Rossiyskaya Gazeta

Roszdravnadzor continues to help the readers of “RG – Week” to understand how to stay healthy and choose the right treatment.Today we will talk about the joints and the spine – a member of the public council of Roszdravnadzor, director of the National Medical Research Center of Traumatology and Orthopedics named after V.I. N.N. Priorova, Professor, Corresponding Member of the Russian Academy of Sciences Nikolai Zagorodny.

I am 77 years old, I often, especially at night, have pains in my back, arms, legs, so severe that I wake up and drink painkillers. I have tried everything, the doctors shrug their shoulders, they say that I have arthrosis.Isn’t arthrosis treated?

Raisa Zakharova, Moscow

Nikolay Zagorodny: Joint pain is one of the most common reasons for patients seeking medical help, the most common joint diseases are osteoarthritis and osteochondrosis of the spine. Patients often use simple terms for this disease – “arthrosis” or “salt deposition”.

According to various estimates, 12-20 percent of the population of different ages suffer from osteoarthritis in the world.Most often (in 43 percent of cases), the hip joint is affected, a little less often – the knee joint (34.3 percent), about 11 percent is in the shoulder. The remaining 12 percent are diseases of other joints. Every third disability is due to arthrosis.

Its main symptoms: pain in the joint, at the onset of the disease it occurs periodically – for example, during physical exertion, walking, prolonged standing, and disappears at rest. As the disease progresses, the pain becomes constant.

The cause of this disease is still unknown to science. But there are several preventive measures that can reduce the risks of its occurrence: do not overload the joints, avoid injuries, and do not gain excess weight. Overweight people are more likely to suffer from arthrosis, especially of the knee and hip joints.

Also at risk are people who are born with hypermobility of the ligamentous apparatus, very mobile ligaments – they are highly susceptible to trauma, which can contribute to the development of arthrosis.And young people with a diagnosis, which is not in Russia, but is abroad, – “weekend sports”. This is when a person leads a sedentary lifestyle all week, and then on weekends goes, for example, to a fitness center and begins to forcefully engage in sports, “ripping off” his joints and back. So if you do not go in for sports all the time, from day to day, you need to enter it very carefully, gradually.

If the joints began to hurt, it is worth adhering to several rules to reduce the load on them.

First, exclude running, jumping, deep squats, prolonged squatting. The condition of the joints worsens and the pain increases, fast and long walking, especially on uneven and rough terrain, ascents and descents from mountains, walking on stairs.

Secondly, lifting and carrying heavy objects should be avoided.

Thirdly, it is necessary to wear comfortable shoes, with a low (2-4 centimeters) wide heel with a soft elastic sole – it allows you to absorb the impact that spreads along the limb when the heel touches the ground.

Fourthly, use individually made insoles-instep support for foot pathology (longitudinal or transverse flat feet), and for loads and long walking – orthoses.

Osteoarthritis is usually treated in a complex way: by changing motor stereotypes, reducing body weight, unloading the affected joints, remedial gymnastics and massage, physiotherapy and medications that the doctor must select.

In severe cases, people undergo operations, including joint replacement.

I have back pain, especially at work (sedentary work in the office), and pain in my legs when walking. Doctors advised to do fitness. But I can’t because of the pain. They set up a blockade, but it did not help for long. Warming ointments were banned, and pain relievers are not all suitable for me. Doctors do not say anything definite. Are there simple methods for cases like mine?

Alexey Viktyunin, 36 years old, Moscow

Nikolay Zagorodny: Osteochondrosis is also a common disease.The main symptom is pain in the lower back, sometimes it “shoots” in the legs.

This disease occurs due to a lack of physical activity or vice versa – their excessive intensity (work associated with lifting or carrying weights, engaging in traumatic sports). Also, its appearance is facilitated by overweight, anomalies in the development of the spine, the presence of a herniated disc.

In the event of such pain, in no case should you self-medicate. You need to see a doctor right away.He must conduct an examination, including referring to an X-ray, MRI or CT scan. Then he will select the appropriate treatment.

You may need to avoid movements that trigger or increase pain. You should choose those positions of the body that do not cause pain or reduce it. Wear a lumbar corset (bandage) in the acute period. It serves to relieve pain, relieve stress on the spine, and stabilize the position. After the cessation of acute pain, it is advisable to put on a corset only before heavy physical exertion.Constant wearing is not recommended as it can weaken the muscles.

Physiotherapy procedures are prescribed on the recommendation of a doctor. You will also need therapeutic gymnastics, the exercises for which must be selected by the doctor on an individual basis. Also, the doctor may prescribe drug therapy.

It is important to eat right – excess weight creates risks for the spine

To prevent back pain, you need to regularly exercise, gymnastics, which forms a strong muscle corset around the spine.

Avoid overloading, sports in which sudden movements are possible, the danger of turning, twisting or abruptly stretching the spine is hidden. It is not recommended to train with a barbell. Always warm up before starting workouts or gymnastics. Swimming on the back in the pool, using a semi-rigid mattress and orthopedic pillow while sleeping is useful. And it is very important to eat right – excess weight increases the load on the spine.

Your questions for Roszdravnadzor specialists can be sent to the address: gusenkom @ yandex.