Spinal Conditions

Lumbar Spine

Lumbar Spine


The lumbar spine is responsible for supporting the upper body, hips and pelvis, for the transfer of forces across the upper and lower body and provides a stable base for our daily function.

The lumbar spine is the area most commonly reported to cause pain. It is most affected by the degenerative changes of the ageing process, mainly because it is at the bottom and therefore takes more load than other areas above.

Most low back pain is mechanical in nature. This means there is no structural abnormality, rather that pain is generated from the way the spine moves or copes with load associated with the relationships between joint motion, posture, muscle activation and endurance.

80- 85 % of people will have Low Back Pain in their lifetime
90% of people recover without any long-term effects
Recurrences are common but are not disabling

Although low back or low back related leg pain/radiculopathy (e.g. sciatica) is relatively common, most patients have significant improvement in pain and function within the first 4 weeks and are unlikely to require any tests or imaging (e.g.: X-ray, MRI).

Imaging (e.g X-ray, MRI) should only be requisitioned when it will direct a change in the plan of care for a patient. For example, if most people have non-serious symptoms that will either resolve independently or with conservative treatment, then imaging will not be required in managing their condition.

It is also notable that “abnormal findings” are very common and can be seen in both people with and without back pain, and in the young. For example, studies have shown approx. 50% of people in their 20’s and 90% of people over 50 years have degenerative discs. Over 25% of people in their 20’s have asymptomatic disc herniations.

Presence of structural ‘abnormalities” therefore cannot automatically be assumed to be the pain generator. Identification of these can often be unhelpful as it over-medicalises patient’s conditions, which has been shown to have negative effects on outcomes, recovery rate and overall wellbeing.

Imaging should be reserved for situations when either the patient has leg dominant pain (worse then the reported level of back pain), signs of neurological impairment, or when they have trialled a good quality conservative management program constituting active rehabilitation that has not been beneficial. E.g. physiotherapy or other rehab therapy with an exercise bias

Referrals for specialist intervention should follow the same reasoning: Most surgical procedures related to the spine are done for leg (or arm) dominant pain rather than back (or neck) pain.

If the patient has red flag signs and symptoms (indicators of serious spinal pathology) emergency referral (to ER) should be made:

  • Signs of Queue de cheval syndrome:
    • Saddle anaesthesia
    • Bilateral cord signs e.g. ataxic gait, sensory change in a “sock” or “glove” distribution.
    • Urinary retention or facial incontinence.
  • Severe or progressive neurological compromise e.g. multilevel myotomal weakness, sensory change
Other important red flags to consider, but that do not necessarily require immediate referral are:
  • Thoracic pain
  • Trauma
  • Unexplained weight loss
  • History of cancer
  • History of intravenous drug use, HIV+ or prolonged corticosteroids
  • Night pain: severe unrelenting constant pain

Preventative measures

General Advice:

Regular exercise Cardiovascular exercise and general activity play an important role in maintaining health and function. For deconditioned patients, the principle of “start low and go slow” should be used. Encourage patients to start an activity that they are comfortable doing and then increase gradually (10% week). Specific exercise for strength and flexibility, especially for the “core” muscles also assist the maintenance of a healthy back.

Maintain proper posture Choosing a good firm seat with proper back support is key to good sitting posture. Avoid prolonged periods of slouched sitting or lounging posture in couches and chairs. Consider placing a pillow or rolled towel in the small of the back and get up/change positions regularly. Once every hour is suggested, more frequently if there is pain.

Use good body mechanics If standing for long periods of time, rest one foot up on a step or stool intermittently. When lifting, let your legs do the work, bend your knees and hold the load close to your body. Avoid lifting, bending and twisting at the same time. Separate the actions if possible and find a lifting partner when the object is heavy or awkward.

Chronic Back pain Prevention:

Several factors have been found to increase the risk of developing chronic back pain
  • Poor pain coping behaviors
  • Poor health status
  • Mental health issues
  • Economic and social issues

To reduce the risk of chronicity it is important we address these “yellow flags” effectively. This can be done by reducing fear avoidance of activity, educating the patient regarding their condition and the appropriate recommended active rehabilitation, reducing the use of medications that have a risk of dependence e.g. opioids, and identifying coping strategies and goal setting.

For patients with low back and/or leg symptoms <12 months duration, they can be referred to the ISAEC Low Back Pain Rapid Access Clinic. This rapid access clinic for acute and subacute low back symptoms will help patients receive personalised treatment plans to self-manage their condition, including all the above suggestions. (LINK TO ISAEC SECTION).

Top Tips for the Management of Back Pain

  1. Avoid bedrest: As prolonged rest and activity avoidance may lead to higher levels of pain, disability and lengthen recovery
  2. Exercise is beneficial: Even when you have back pain, stretching, strengthening, and simply moving more, have been shown to expedite recovery. If you are not sure what specific exercise is appropriate, consult a therapist who can guide this. However, any movement or activity you can do within your pain limits will likely help.
  3. Hurt doesn’t mean harm: Pain can be the result of physical or psychological issues unrelated to injury
  4. Good quality sleep: Will lessen stress and aid wellbeing, which expedites recovery
  5. Maintain a positive attitude: This has been shown to lessen pain severity and expedite recovery
  6. Stop smoking: as this reduces circulation, which helps get nutrients and oxygen to your bones and tissues for healthy functioning



Advise patients to exercise: any exercise that is started slowly and increased gradually will be beneficial if they can remain consistent


Medical Providers - Spine

Mechanical Back Pain

Mechanical back pain is a general term that describes pain caused by the dynamic day to day stress and strain on the structures of the spine that can not be accommodated by the body, rather than being caused by a structural abnormality.

Mechanical back pain accounts for approximately 95% of all back pain and includes pain produced by the joints, ligaments, discs, muscles and the relationship between all these structures. 

It is often diagnosed instead of spondylosis, degenerative discs, or facet arthropathy because of the high rate of concordance, and difficulty in confirming the specific pain generator. Management remains the same for all these conditions


The specific cause and/or source of the pain usually cannot always be identified and often has multiple contributory factors. This may include:
  • Poor muscle control or muscle imbalance around the spine
  • General lack of physical fitness so the body is unable to distribute normal stress and strain forces
  • Poor posture
  • Poor seating or a sedentary lifestyle
  • Incorrect bending and lifting actions


  • Pain in lower back
  • Pain radiating down into the buttock and/or leg
  • Muscle spasm

Diagnosis / Treatment

  • Lack of radiating pain or neurological symptoms
  • Usually gradual onset
  • Changes with activity and position
No further testing or investigations are necessary unless the doctor suspects a cause other than “mechanical back pain”, as it responds well to conservative management which is very effective at resolving symptoms. This includes:

  • Heat/ice (can alternate both 20 min 2-3X/day)
  • NSAIDs (Advil/Ibuprofen) or over the counter pain relief (Tylenol/Acetaminophen) medication
  • Muscle relaxants may be indicated for some although evidence is equivocal
  • Positive mindset (mindfulness/meditation)
  • Massage therapy
  • Physiotherapy
  • Spinal mobilisation/manipulation
  • Active Therapy is essential e.g.:
    • Physical activity – walking, swimming. Whichever activity is chosen it should be performed with “pacing” e.g. when begun, it is done at a low level for a short time that does not cause a worsening of symptoms. This is the baseline and increasing beyond this should be gradual
    • Maintenance and/or return to normal activities promptly

A physiotherapist, evidence-based chiropractor or other therapy professional can help inform the patient on the possible causes and provide education about postural changes, strengthening and stretching exercises for the patient’s back and core muscles. The approach should encourage activity over rest or passive treatments, and an individualised plan for returning the patient to their activities of daily living and work as required. A home program encouraging regular long-term active exercise has been shown to be the most effective treatment approach.

Surgery is not indicated for mechanical low back pain.

Spondylosis/Degenerative Disc Disease
Spondylosis, or degenerative disc disease, osteoarthritis, and wear and tear refers to the normal age-related changes of the vertebrae and discs. It can be present anywhere in the spine, but it most often occurs in the cervical and lumbar spine because these areas typically produce more movement and carry more load.


Degeneration occurs in all our bones and joints over time and is an inevitable part of aging. The degenerative process starts in people in their 20s, and 80% of women and 95% of men over 65 years have evidence of such changes on imaging. There are genetic links to developing earlier spondylosis, or occupational stresses e.g. poor posture, or manual labour may also be relevant.

Generally, the joint surfaces may become roughened. There may be weakening and thickening of ligaments attaching onto the spine, and bone spurs may develop on the margins of the bones which can protrude into joint spaces. The discs may dehydrate, making them thinner and less able to absorb shock, increasing the compression of adjacent joints (which will increase their workload and expedite the rate of degeneration). Degenerative changes may contribute to other conditions that may cause pain e.g. Spinal Stenosis.

Symptoms & Diagnosis

  • Spondylosis often has no symptoms, although localised discomfort without radiation can sometimes be felt
  • Gradual progressive onset, although occasionally a mild trauma e.g. a slip or trip may expedite the development of symptoms
  • It is usually worse after periods of inactivity e.g. in the morning or after prolonged sitting, and better after movement or as the day goes on
  • Local pain on palpation of paraspinal areas
  • Imaging is not usually required as it will not change the recommended plan of care


Conservative treatment is usually all that is necessary to treat spondylosis/degenerative change.
  • Heat/cold application
  • NSAIDs (Advil/Ibuprofen) and/or pain relief (Tylenol/Acetaminophen) medications
  • Muscle relaxants (although there is limited evidence to support their use, they can be useful on a case by case basis)
  • Physiotherapy or evidence-based chiropractic, to provide postural and lifestyle education and appropriate stretching and strengthening exercise which will improve the patient’s general fitness, build strength, endurance and general flexibility for the spine and core. A home program will be provided to help the patient with self-management of their symptoms
  • A graded cardiovascular exercise program (walking, cycling, swimming)
  • A positive attitude (e.g.: meditation/mindfulness)
  • Daily exercise to stretch and warm up to activity for the day
  • Weight loss
  • Smoking cessation

You can try recommending the following basic exercises for this condition.

Patients should be educated that they should go “low and slow” e.g. start with a small number of repetitions or load and increase as tolerated (10% per week). If the exercises aggravate symptoms, they should be discontinued and the patient advised to seek advice from a health professional.

Knee to Chest
Supine Twist Beginner
Pelvic Tilt
Curl Ups
Spinal Stenosis

Central spinal stenosis is a narrowing of the spinal canal, usually caused by degenerative changes e.g. arthritic bone changes (bone spurs), disc herniation as the discs age and dehydrate, and thickening of the ligamentum flavum which can buckle into the spinal canal. This will take up more space within the spinal canal, leaving less available for the nerves.

Alternatively, foraminal stenosis can occur at the neural foramina, reducing the space available for the nerve roots as they exit the spine. The nerve structures can become irritated or physically pinched, causing neck/back and radiating arm/leg pain, weakness, and/or tingling or numbness that radiate down a single, or both arms/legs from the neck/back. This is known as neurogenic claudication.

If stenosis occurs in the cervical or thoracic spine it can cause compression of the spinal cord which is known as myelopathy. In addition to the pain detailed above, there may be unsteadiness when walking, poor coordination, dexterity and balance. Suspected myelopathy should be immediately investigated and if necessary referred to orthopaedics / neurosurgery.

Contributory factors

  • Age-related degenerative changes in spine
  • Previous spine surgery or injury
  • Heredity/Genetics
  • Disc herniation  
  • Scoliosis: lateral curves or rotational changes can cause naturally smaller foraminal spaces, and uneven load that will create uneven patterns of wear.

Symptoms & Diagnosis

  • Pain radiating down the legs (or arms) with or without pain in the spine itself. (Usually reported as heaviness, burning, or deep aching, although sharp shooting could be possible too.)
  • Pain worse with spine extension (where the joint spaces are naturally smaller) e.g. standing, walking, bending backwards
  • Pain is better with flexion e.g. sitting, bending forwards, lying in a foetal position
  • Positive “shopping cart sign” where the pain is better when they lean onto something e.g. shopping cart, walker etc.
  • Intermittent weakness, tingling, numbness in leg(s)/arms
  • Balance and coordination can be reduced e.g. ataxic gait, tripping, stumbling, difficulty to coordinate their legs, or drop foot

Significant central stenosis can reproduce symptoms of Queue de cheval, and therefore needs to be treated immediately.

It is important to rule-out several differential diagnoses which may present in similar ways:

  • Vascular claudication: check the patient’s history for possible vascular risk factors e.g. high BP and other conditions, temperature or colour changes in the extremities.
  • Referred pain from the hip joint


Symptoms are best managed with conservative treatment such as physiotherapy. Evidence exists showing that a rehabilitation treatment course focusing on exercises encouraging flexion, core strengthening and pacing of general activity, with avoidance of extension, are just as effective as surgery for spinal stenosis with far less adverse side effects.

Conservative treatment

  • Relative rest and/or activity modification e.g. pacing. Separate activity into shorter periods, with time to sit or do bending exercises in between bouts of activity.  
  • NSAIDS (Advil/Ibuprofen) and/or pain relief (Tylenol/Acetaminophen) medication
  • Neuropathic medications can be helpful e.g.: Pregabalin (Lyrica), Gabapentin.
  • Exercise and stretching
    • movements that encourage forward bending (flexion)
    • avoid backwards bending (extension)
  • Physiotherapy / Evidence based chiropractic
  • Daily graded exercise to improve physical condition/fitness
    • walking with a gait aid or Nordic poles
    • bicycling
    • aquafit
  • Massage
  • Acupuncture may be beneficial
  • Heat
  • Weight loss
  • Postural re-education

You can try recommending the following basic exercises for this condition. 

Patients should be educated to use the flexion-based postures for immediate pain relief and hence they can be done at times when the pain is aggravated throughout the day. The strengthening exercises should be paced e.g. start with a small number of repetitions once daily and increase only as tolerated.  If these exercises aggravate symptoms, they should be discontinued and the patient advised to seek advice from a health professional.

Neuropathic Medications

Evidence exits to suggest that tricyclic antidepressants, anti-convulsants, and SNRIs are beneficial for significant, although not always full, relief of neuropathic pain (but not other neuro symptoms). They can also be considered in patients with concurrent mood or sleep disorders. Medications in these classes need to be taken regularly and adequately titrated to a therapeutic dosage over time.


Imaging may be required if the patient presents with leg dominant neurogenic claudication. Unless there are red flags, or specific, progressive or multilevel neurological compromise, the conservative treatment detailed above should be trialled first.

The best method for imaging stenosis is an MRI scan. This will detail both bony and soft tissue changes that can reflect the type of treatment required to address the nerve irritation or compression. It should only be considered if the results will affect management plans.  

EMG is only recommended to differentiate from alternate causes of symptoms polyneuropathy.

Guided epidural steroid (cortisone) injections may be used to provide relief for leg dominant symptoms of stenosis, although evidence regarding effectiveness is equivocal. Their use is therefore normally reserved for those patients who have clear indications of neural irritation without compression which would reduce neural function e.g. pain > weakness or reflex changes.  Alternatively, they can also be used ongoing (max 3 x year) for chronic pain management in patients who are not good surgical candidates.

Surgical treatment

Surgery may be required if there is significant impingement of the nerves that limit function and quality of life significantly. This is performed to minimise leg symptoms.

Unless there is acute, or progressive neurological compromise or symptoms of Queue de cheval, usually patients need to have trialled a good quality conservative management plan including all the above recommendations for at least 3 months before surgery is considered.

The best candidates for successful surgery are those who are motivated. Medically well, non-smokers, whose pain eases with forward flexion, and have single-level vs widespread symptomatic stenosis.

A decompression or in some cases a laminectomy is performed. This is often done as a day surgery with return to normal daily activities within 2-6 weeks.

Spinal fusion may be performed if there needs to be more extensive tissue removal that may compromise the stability of the spine.  This involves a short hospital stay. Recovery to normal activities will take approximately 6-12 weeks.

Rehabilitation after surgery will be dictated by the surgeon. Usually it is advocated to do physiotherapy or other therapies that focus on progressive back and core strengthening exercises and graded return to functional stresses.

Discogenic low back pain/ with or without Sciatica

Disc herniations, bulges, prolapses or extrusions all mean a compromise of the structural integrity of the intervertebral disc through sudden, continuous or repeated stress.

The outer wall of the annulus fibrosus contains nerve fibers that may be affected by an injury and cause pain. Due to the position of the disc in close proximity to the exiting nerve roots, it is possible for them to become irritated or pinched. In this situation there can be disruption of the normal messaging of the nerve eg radiculopathy.

Disc bulges are normal and at least 25% of the population has them without any associated symptoms. However, those who do experience discogenic back pain are commonly aged 30-60 years old.

Approximately 80-90% of patients with an acute episode of discogenic back pain/sciatica will recover with conservative management over time (minimum 12 weeks) without surgery. 


  • Repetitive or prolonged trunk flexion, or bending and twisting activities
  • Poor posture
  • Injury or trauma
  • Smoking - research shows an increased incidence in smokers
  • Poor core muscle control around the spine
  • Sedentary lifestyle: prolonged sitting, reclined or slouch sitting
  • Obesity

Symptoms & Diagnosis

  • Decreased movement, often worst with bending or sitting
  • Abnormal sensation eg pins and needles or numbness in the leg
  • Pain reported as shooting, burning or cramping
  • Weakness in leg or foot
  • Worse with sneezing or coughing
  • Positive straight leg raise test
  • Usually one-sided

There is usually no need for an X-Ray unless the patient’s back pain is due to a fall, accident or other trauma.

An MRI is unnecessary unless the pain is leg dominant eg the leg pain is worse than the back pain, or has been present for more than 3 months and is unchanged following a good quality conservative treatment plan.



  • Activity modification:
    • Avoid bed rest
    • Avoid prolonged sitting
    • Encourage the patient to stay active – go for several short walks during the day or do other exercise as pain allows
  • Maximize good posture – advise the patient to use a small pillow, rolled up towel or lumbar roll in the small of their back to maintain the natural arch of the low back.
  • Education including positions of relief – e.g. lying prone to ease pain.
  • Apply cold or alternating hot/cold (15-20 minutes every 2 hrs)
  • NSAIDS (Advil/Ibuprofen) and/or pain relief (Tylenol/Acetaminophen) medication
  • For patients with leg dominant symptoms neuropathic medications (e.g.: Lyrica, Gabapentin) can be beneficial
  • Physiotherapy
  • Acupuncture
  • Spinal mobilization in some patients
  • Ergonomic workplace assessment
  • Exercise and general physical activity (walking, swimming)

It is important to encourage the patient to remain as active as possible. Movement will decrease pain and stiffness and help expedite recovery. Educate patients that hurt does not equal harm. It is possible that some activities which are uncomfortable are still beneficial and will ease as activity increases slowly. Encourage a return to work as soon as possible as this reduces disability.

The McKenzie Method is a therapist-led system of assessment and treatment based on symptomology that starts with extension exercises and avoidance of flexion. This method has been shown to produce good results and it is advocated to try this if the patient’s symptoms display a preference for extension movements.

Neuropathic medications

Evidence exits to suggest that tricyclic antidepressants, anti-convulsants, and SNRIs are beneficial for significant, although not always full, relief of neuropathic pain (but not other neuro symptoms). They can also be considered in patients with concurrent mood or sleep disorders. Medications in these classes need to be taken regularly and adequately titrated to a therapeutic dosage over time.

Surgical treatment

Surgery for lumbar disc herniation is performed for reduction of leg dominant pain due to a pinched nerve. This is a day surgery procedure where a small incision approximately 1-1.5 inches in length is made and the disc material that is causing compression or irritation is removed (discectomy).

Occasionally this may be combined with a decompression procedure, where a small amount of bone around the disc herniation is also removed to reduce the likelihood of future recurrence.

Recovery, including a return to work, occurs in 2-4 weeks for sedentary jobs and 4-8 weeks for work involving physical labour. There is a good success rate for significant reduction of leg pain or other symptoms, although it has also been shown that at 2 years and 5 years after onset of disc-related pain functional outcomes are generally the same between those who have surgery and those who don’t.
Sciatica is an umbrella term to describe a group of symptoms and not a specific condition. It refers to radiating leg pain, usually down one side.  There are multiple causes of sciatica including:

  • A disc bulge or herniation
  • Spinal stenosis
  • Spondylolisthesis
  • Piriformis syndrome
    • The sciatic nerve can become irritated as it runs through or under the piriformis muscle in the buttock, which reproduces pain that feels like sciatica. The piriformis muscle is a small muscle deep in the buttock. It can become tight, and irritate/compress the sciatic nerve that runs nearby causing pain/numbness/tingling in the buttock and leg as far as the foot.
  • Tumor
  • Infection
  • Disease -such as Diabetes
Sciatic pain can be significant but will usually subside and resolve on its own or with conservative treatment (In up to 12 weeks).


  • Activity modification
  • Education
  • Heat/ice (20 min 2-3 X/day – you may alternate)
  • Oral (Advil/Ibuprofen) or topical (Voltaren/Emulgel) NSAIDs and/or pain relief (Tylenol/Acetaminophen) medication
  • Neuropathic medication if neuropathic leg pain is reported
  • Muscle relaxants may be of benefit
  • Exercise (walking, swimming) within comfortable limits, progressing as able
  • Physiotherapy or evidence-based chiropractic
  • Spinal mobilization
  • Acupuncture
  • Massage therapy
  • Ergonomic workplace assessment

Neuropathic medications

Evidence exits to suggest that tricyclic antidepressants, anti-convulsants, and SNRIs are beneficial for significant, although not always full, relief of neuropathic pain (but not other neuro symptoms). They can also be considered in patients with concurrent mood or sleep disorders. Medications in these classes need to be taken regularly and adequately titrated to a therapeutic dosage over time.

Surgical treatment

Unless there is clear nerve impingement, such as from a disc herniation, surgical treatment is rarely necessary.
Spondylolysis /Spondylolisthesis

Spondylolysis is a naturally occurring defect, crack or stress fracture in the pars intercularis at the back of the vertebra (where the facet joins to the body).

It can occur in people of all ages, although children and adolescents are more vulnerable because they are still growing. It is more common in young athletes who practice sports that put repeated stress on the lower back, such as gymnastics, weight lifting, wrestling and football. It most commonly affects the vertebral levels of the low back. (L4/5 and L5/S1)

Spondylolisthesis occurs when one vertebra slips out of position in relation to the one above and below (usually forwards). It occurs most commonly in the lumbar spine at the L5/S1 level but can also occur in the cervical spine.

Depending on the amount of movement, it can be categorized as a low or high-grade spondylolisthesis. High grade slip occurs when more than 50% of the vertebra has moved out of alignment.

The presence of spondylolisthesis does not necessarily mean it is problematic. Most are asymptomatic and usually low grade. The stability of the spondylolisthesis refers to the likelihood the slip may increase with positional change. Most are stable with no treatment required.




There are several different causes:

Congenital spondylolisthesis is present at birth as an anomaly. This is more common in females. The spine usually adjusts and adapts to the deformity.

Isthmic spondylolisthesis is caused by a defect, crack or fracture in the pars interarticularis. The stability of the bone may be affected leading to the positional change. This most often occurs n highly active adolescents who play sports with repeated bending backwards (extension) movements (e.g. gymnastics, football, and wrestling). It often goes undetected when symptoms develop (local back pain) and may present incidentally in adulthood. This type of spondylolisthesis is more common in male.

Degenerative spondylolisthesis occurs from progressive age-related changes that cause a change in stability creating the positional change of a vertebra.  It is a slowly occurring process and often the spine adapts as a result. This occurs more in adults, especially women and those who are obese.

Traumatic spondylolisthesis occurs following a fracture in the facet joint structure of the vertebra and is caused by an accident/trauma.

Pathological spondylolisthesis occurs if the bone is affected by bone or connective tissue disorders, infection or tumour. 

Symptoms & Diagnosis

  • Intermittent persistent low back pain  
  • Worse with activity especially extension movements
  • Tender to touch locally at the specific level on the spine
  • Better with rest
    • Lying on back
  • Possible pain and fatigue with walking and standing
  • May have pain, weakness and/or numbness/tingling down the leg(s)
  • Loss of bowel or bladder control (rarely)

X-Rays may be performed in a variety of positions to assess for spondylolisthesis and to determine the grade and stability, which will impact further care. Normally directional images e.g. flexion and extension are taken and compared to assess the stability of the spondylolisthesis. Oblique X-Rays should be requisitioned if there is a question over the presence of pars defect.

An MRI will only be required if there is associated leg dominant pain and/or neurological symptoms. Unless there is acute, progressive or severe neurological compromise, patients should still trial a good quality conservative management program constituting active rehabilitation for at least 12 weeks first.


Most patients with symptomatic spondylolysis and low-grade (mild-moderate) spondylolisthesis improve with conservative treatments and can gradually return to sports and other activities.

Conservative treatment

  • Relative rest and avoiding sports that exert excessive stress on the spine eg those with repeated or stressful extension eg weightlifting, gymnastics
  • Light cardiovascular exercise (e.g. walking)
  • NSAIDS (Advil/Ibuprofen)
  • Heat
  • Bracing may be required
  • Flexion-based exercises and core muscle strengthening have been shown to achieve the best results.
  • Short-term avoidance of lumbar extension

Surgical treatment

Surgery is only considered for patients with unstable spondylolisthesis or leg dominant pain due to pinched nerves, and in some cases when back pain symptoms are not improving despite a period of good quality conservative treatment (at least 12 weeks). The goal of the surgery is to take pressure off the nerves and stabilise the spine.

This is achieved by a spinal fusion. A bone graft or synthetic substance is used, to promote bone growth between the affected segments of the spine and fuse the vertebrae together. Hardware eg screws, rods or cages are also used which will remain in situ permanently. Depending on whether one level or more of the spine is fused will determine the required length of stay. Recovery will normally take at least 12 weeks.
Spinal Fractures/ Compression Fractures - Osteoporosis

A fracture may occur because of trauma, or because of osteoporosis.

A traumatic spinal fracture can be a serious injury as the spinal cord can be injured resulting in permanent damage, although this is rare.

Osteoporosis occurs because of a loss of bone mineral density. This weakens bone making it prone to compression fractures. These tend to be less serious than traumatic fractures, and heal without any serious consequences. However, it can happen very suddenly as a result of a fall, getting up quickly, bending or reaching forward, or from a forceful sneeze or a cough. Sometimes people are not aware of these fractures as they do not always create pain.

The most often affected area is the junction between the mid and low back (thoracic and lumbar). There may be a loss of height or a Dowager’s hump may develop (a severely rounded upper back).

Women are affected by osteoporotic fractures 6 times more than men. Some post-menopausal women have rapid loss of bone after menopause which causes osteoporosis. Age-related bone loss is also a cause of osteoporosis and affects patients >70 years of age.


  • The patient’s symptoms, history and physical exam, with possibly an X-Ray to confirm a fracture. Sometimes a bone scan, CT and/or MRI are performed as well, which will help establish possible causes of the fracture, and rule-out pathological fracture.
  • Those at risk of osteoporosis can benefit from screening and management per best-practice guidelines.


  • Menopause
  • Low body weight or recent significant weight loss
  • Hyperthyroidism
  • Age (more common over 65 years)
  • Long term use of corticosteroids (due to certain diseases like rheumatoid arthritis)
  • Genetics
  • Smoking
  • Heavy alcohol consumption
  • Inadequate nutrition
  • Lack of weight-bearing exercise


  • Acute onset of local back pain (can be dull or sharp) felt where the break is located
  • Pain may radiate to the stomach or along the ribs
  • Worse with movement and changing position
  • Better with rest or lying down
  • Pain at night – difficulty sleeping
  • Intolerance to standing still or walking slowly - needing to walk fast or use walking aids

Conservative treatment

Most people who have a compression fracture will improve within 3 months without any specific treatment beyond:

  • Activity modification
  • Pain relief medication (Tylenol/Acetaminophen)
  • Bracing may be very occasionally used
  • Avoidance of heavy lifting
  • Use of walking aid (walking poles, walker with integrated seat)
  • Review options to reduce the risk of future fractures: e.g. dietary supplements, hormone replacement therapy, medications to treat osteoporosis (Fosamax, Didrocal, Actonel)

During recovery it is important to educate patients that hurt does not equal harm and that while the fracture is painful, it is important to move (within reason) and that this is not causing long term harm.

A physiotherapist or other therapeutic professional can help guide the patient’s functional activity.

Surgical treatment

Surgery is only required if a fracture is not stable and causes severe unrelenting pain that is not improving, or progressive/severe neurological dysfunction. This is rare. Vertebroplasty, or kyphoplasty, are minimally invasive treatments for patients with severe pain despite a trial of conservative measures. These techniques involve a method to help stabilize the fracture by the injection of “bone cement” into the vertebral body guided by interventional radiology.

Scoliosis is a deformity that develops in the structure of the spine that causes it to adopt an abnormal curve and/or a rotation in its alignment.  Usually this is a lateral curve but it can be any direction. This creates muscle imbalances, stress and strain on the structures of the spine, which can cause “mechanical back pain.  If the curve is severe the result can be significant back pain, difficulty breathing, heart problems and potential nerve/spinal cord compression although the latter are very rare. It is also possible to have scoliosis without pain.

Curves are measured by X-Ray and calculated in degrees and compared to “normal”. Studies show that an adult with a curve that measures <30° are considered moderate, and tend to remain the same over time, while those with a curve >50° can get worse over time. Usually patients should be monitored regularly by a doctor if there is significant or painful scoliosis.


There are different types of scoliosis

  • Idiopathic scoliosis. This type of scoliosis with no known cause accounts for 80% of scoliosis cases. It develops over time, often appearing during an adolescent growth spurt and it tends to run in families (in 30% of cases).
  • Congenital scoliosis
  • Neuromuscular scoliosis is caused by any medical condition that affects the nerves and muscles around the spine (e.g.: muscular dystrophy, cerebral palsy, spinal cord injury)
  • Degenerative scoliosis - As we age, it is also possible that scoliosis will develop due to normal but uneven age-related degeneration of the spinal structures (bones and discs).

Diagnosis & Symptoms

Symptoms are variable, dependent on the size and location of the scoliosis. In most cases symptoms are usually mild and shown to be well controlled with conservative treatment.

  • Minimal or no pain at all
  • Back pain
  • Uneven posture
  • Difference in shoulder height
  • Difference in hip height
  • Asymmetrical chest
  • Increased muscle on one side of the spine (visible with trunk flexion)
  • Poor tolerance to certain postures or activities – muscle fatigue
  • Leg pain and or numbness as well as intermittent claudication
  • X-Ray to confirm scoliosis

Conservative treatment

Scoliosis cannot be healed or changed with conservative treatment as it is a structural abnormality, but symptoms respond well to treatment including the following:

  • Regular exercise
  • NSAIDs (Advil/Ibuprofen) and/ or pain relief medication (Tylenol/Acetaminophen)
  • Bracing – a specially designed back brace to try to keep the curve from getting larger is more often prescribed to adolescents as their spine grows
  • Physiotherapy or other active rehabilitation– to help the patient manage the back pain through education, advice and exercise prescription including stretching, strengthening with general fitness activities and deep breathing exercises. This will ensure the patient's spine remains flexible, strong and decrease fatigue.
  • Massage

Surgical treatment

Surgery is considered only if there is postural imbalance due to the scoliosis. Or if there is associated radiating leg dominant pain (eg intermittent claudication). The goal is to restore sagittal balance eg alignment of head over pelvis, which can help to relieve back pain, improve the radiating leg symptoms and claudication as well as correct the deformity. The goal is not necessarily to “straighten” the spine.

Surgical options are based on the cause of the symptoms and the size and direction of the scoliosis. The surgical procedure is usually a combination of a decompression (making space for the nerves by removing the smallest amount of bone and tissue in the problem area) and fusion. Bone graft or a synthetic substance in conjunction with hardware such as screws, rods or cages are used. Surgery can be complex if the scoliosis is large, and recovery will take many weeks with some long term restrictions to the way the patient will be able to move and function.