Edward H. Simmons, M.D., past President American Back Society.
Circa 1994

In selection of patients for surgery to relieve mechanical low back disability, there are three essentials for success:  the surgeon must select the right patient, the right level (s), and the right operation.  In addition, among the more frequent causes of operative failure would include failure to evacuate the entire extruded disc, failure to recognize foraminal migration of a disc fragment, failure to recognize and relieve lateral recess entrapment, failure to recognize and relieve radicular kinking, failure to recognize and relieve facet impingement, performing a microdiscectomy for macrodisc disease, failure to combine stabilization with decompression when indicated, failure to recognize site of nerve root entrapment with spondylolisthesis, and operative trauma to a nerve root – the battered nerve root syndrome. 

Malcolm Pope Ph.D.
Circa 2002

Industry should try to reduce loads below the maximum permissible limit, whenever possible, below the action limit.  At the present time, 12% of the jobs in the U.S. exceed the maximum permissible limit and 40% exceed the action limit.  Factors that are important are the weight of the object, the distance from the body, the load distribution, the coupling of the hand to the object, the position of the object, the floor service, the space available and the frequency of activity and number of repetitions. 

H. Duane Saunders, MSPT
Circa 1997

In our effort to make the workplace safer, special attention should be directed towards jobs requiring forward bending and lifting, standing or sitting for prolonged periods of time and especially the slumped or forward bent posture.  If the healthcare practitioner understands the basic principles of ergonomics, in light of the workplace problems, he or she can be effective in helping business and industry make worksite modifications that will help prevent injuries.  This could be done for individual patients who are returning to work after a back injury, or can be done with systematic review of an entire work area.  The effective treatment and prevention must include evaluation of the worksite.

One must understand that most back injuries result from the cumulative effects of months or even years of poor posture, faulty body mechanics, stressful living and work habits, loss of flexibility and strength and a general lack of physical fitness. 

Thomas Dorman, M.D.
Circa 2001

Back pain maybe associated with pelvic dysfunction, including relaxation or dysfunction of the posterior sacroiliac ligaments.  These patients may report pain in the back, buttock and down the leg and may report episodes of unexpected sudden irregular giving-way, tendency to fall or actual falling.  They catch themselves without falling completely.  It is usually episodic and unexpected.  I view this problem as failure of the sacroiliac joint to properly brace and call it to slipping clutch syndrome. Ligaments become relaxed in part, because of shrinkage of the intervertebral disc end, in part from direct stretching and damage to the ligaments themselves. 

Arthur Steffee, M.D.
Circa 1989

The longer the lumbar fusion, there is more of a likelihood of getting into trouble at the top level of the fusion, even though it appears that it is possible and feasible to fuse the entire lumbar spine.  It is imperative that the surgeon locate the pathologic disc and fuse only those disc units that are causing the problem. 

J. David Cassidy, Ph.D. D.C.
Circa 1990

Basic science studies show that manipulation causes synovial joint cavitation, resulting in an increased range of motion and decrease in pain.  It is therefore most likely that manipulation exerts its main effect upon joint mobility, and this, in turn, results in a decrease in pain and an improvement in function. 

Robin McKenzie
Circa 1987

Management in the future must emphasize education for all patients.  Repeated movements that cause centralization of pain are effective in the treatment of nonspecific spinal disorders.  Rapid reduction of referred symptoms and abolition of pain is common when centralization of pain is used to determine appropriate direction of therapeutic motion. 

Parvis Kambin, M.D.
Circa 1989

The most common causes of failure of percutaneous lumbar discectomy are in the presence of lateral recess stenosis, undiagnosed sequestration, improper positioning of the sheath leading to an inadequate evacuation, and finally improper patient selection. 

William Kirkaldy-Willis, M.D.
Circa 1992

Sometimes prayer for physical healing has led to healing of emotional or spiritual ills.  This approach has been used in conjunction with scientific medical care and complimentary to it.  Prayer for a very sick person or for a person who is preoperative has frequently resulted in freedom from anxiety and fear, in addition to feelings of confidence and well-being, with less pain postoperatively and has often led to a more rapid recovery period.  Scientific wisdom without faith is harsh and cold.  Faith without wisdom is erratic and sometimes misleading.  The two together are colorful and warm-hearted.  I suggest to you that thought be given, and steps taken, to foster and strengthen the bonds between physicians, therapists and others engaged in treating back pain, and in addition, selected religious leaders concerned with spiritual healing. 

Renee Cailliet, M.D.
Circa 1998

The failed back patient actually begins at the very onset of the injury. A person discontent with their occupation or with their supervisor is a candidate for such failure.  Many industrially injured patients are unhappy with their jobs, their future, and bored with their work and have an adversarial relationship with their supervisors. 

Nikolai Bogduk, M.D.
Circa 1999

If patients still have pain after an epidural blockade with anesthetic, you are not going to stop that pain with surgery. 

Philip Greenman, D.O.
Circa 2000

The most commonly identified biomechanical dysfunction in the failed back syndrome, includes pelvic dysfunction, sacroiliac shear dysfunction, reduced sacroiliac anterior rotation, short-leg pelvic tilt syndrome, non-neutral coupling movement of the lumbar spine and muscle imbalance of the lower extremities. 

Harry K. Genant, M.D.
Circa 1996

The most important causes of the failed back surgery syndrome are recurrent disc herniation, postoperative fibrosis, lateral spinal stenosis, arachnoiditis, pseudarthrosis, and postoperative infection. 

Margarita Nordin, Ph.D.
Circa 1989

Testing devices that are available today do not tell anything about work capacity.  You must take the patient out to the workplace if you want to do a valid work capacity evaluation.