Weight loss is a back surgery alternative

Ross Hauser, MD., Caring Medical Florida, Fort Myers
Danielle R. Steilen-Matias, MMS, PA-C., Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
David N. Woznica, MD., Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois

Abdominal fat causes back and spinal nerve pain

  • There is a lot of confusion in the medical community regarding the role of obesity and back pain.
  • Some researchers say that obesity plays a strong role in increasing back pain, others say obesity has none or little impact.
  • More evidence is being published that abdominal obesity does cause mechanical stress on the spine and that abdominal fat is an inflammation making factory attacking spinal nerves.

We know that people do not like to hear that the joint and back pain problems they face are made worse by abdominal obesity. But the evidence is mounting that when you wake up in the morning with that back pain, with that numbness extending into your feet, that your belly is A if not THE culprit in your problems. The goal of this article is to help provide you with reliable information that will make you look down and look at your belly and realize that big belly is not your friend and for some, will cause you to lose your independence.

Research: There is a link between a big belly and back pain.
Common sense: There is a link between a big belly and back pain

Researchers at the Medical University of Graz in Austria conducted a study that lasted over 35 years. (1) They followed patients throughout their lives to determine what impact abdominal obesity had on their back pain and general health. Here is what 35 years of research revealed:

  • Compared to people with normal weight, people with obesity more often reported a poor health status
  • Compared to people with normal weight, people with obesity reported earlier loss of mobility and researchers noted a greater earlier death risk.
  • Obesity-associated diseases and disorders, such as type 2 diabetes mellitus, cardiovascular diseases, malignant tumors, and back pain are on the rise.

Note: When someone comes into one of our clinics, one of the greatest fears they have is the loss of independence, loss of mobility, and the need to depend on others to help them get around. The evidence is clear, people rid themselves of these fears when they embark on a program to get rid of their big belly.

The evidence presented by the Austrian team:

  • Obesity is associated with a higher prevalence of low back pain.
  • This problem is more pronounced in women.
  • While the researchers observed the highest prevalence of back pain among obese women, the increase of and the greatest risk for back pain were highest among obese men.
  • Special emphasis should be placed on obese individuals when planning low back pain prevention strategies. A moderate level of physical activity is recommended to prevent back pain.

For many people, it would seem obvious, a large belly is putting mechanical stress on the spine and that is the cause of back problems.

When there is back pain and there are problems of being sedentary, you have to move.

Big belly causes stress and mechanical load in a bad back – weight loss is very good in many cases

The further your belly sticks out the more back pain

  • In the Journal of back and musculoskeletal rehabilitation, doctors at the University Hospital Zürich in Switzerland found that “outer abdominal fat,” fat that is furthest from the spine caused significant pressure to accelerate facet joint osteoarthritis.(2)

L5-S1 problems? A lot of it may be due to weight stress

  • Doctors writing in Journal of Biomechanics found that increased body weight substantially increased the load on the L5-S1 segment of the lower spine, especially in a flexed (curved) postures.(3)

Big Belly? Don’t lift anything heavy

  • In the work-place injury-related journal Work, doctors suggest that severely obese individuals are likely at an increased risk of lifting-related low back pain compared with normal weight individuals.(4)

People do recognize weight is a problem and want help in losing the big belly in agricultural / rural communities 

  • In the Journal of neurosciences in rural practice (5) neurosurgeons at West Virginia University noted: “The relationship between back pain and obesity is well characterized; therefore, the neurosurgical consultant visit for back pain may be a key interventional opportunity for weight loss. . . Incorporation of patient education regarding the relationship of weight loss to back pain and other weight-related comorbidities is well received in a rural specialist consultation setting. Improved communication with primary care physicians regarding this message and further supportive actions may improve follow-through, and therefore success of ultimate weight loss interventions.”

And so and so on, numerous studies on mechanical load as the cause of back pain in obese people.

Neuropathic pain not from musculoskeletal damage was higher in overweight and obese patients. In other words, the weight is causing the pain whether you hurt your back or not

There have been many studies that suggest that it is not the physical load of carrying the extra weight that is causing back pain in obese and overweight patients, but inflammation caused by excess fat changing the body environment to that of chronic inflammation.  Please see our article: Excessive weight and joint pain – the inflammation connection.

Now researchers are suggesting a relationship between neuropathic pain and obesity with an inflammation connection. In a paper from the University of Tokyo, doctors made these observations:

  • Being overweight negatively affects musculoskeletal health;
    • obesity is considered a risk factor for osteoarthritis and chronic low back pain.
  • Neuropathic pain that did not arise from musculoskeletal damage was higher in overweight and obese patients.
  • Paroxysmal pain (sudden acute pain) was more severe, suggesting that neural damage might be aggravated by obesity-associated inflammation.(6)

Pain in your back was clearly made worse by carrying a belly load. Now add to that pain made worse by high blood sugar

A well-cited study in the Journal of the Peripheral Nervous System, found that nerve sensory thresholds were metabolically altered which could lead to a future clinical neuropathy.(7) What was suspected of metabolically altering the spinal nerves? Hyperinsulinemia and insulin sensitivity. 

Doctors at the University of Calgary writing in the journal Osteoarthritis and Cartilage examined obese laboratory animals and found that obesity causes inflammatory osteoarthritis. The inflammation attacking the joints of the animals was caused by a high fat/high sugar diet.(8)

This type of research is helping doctors understand metabolic inflammation, obesity and back pain

This was confirmed by French researchers in Current Opinion in Rheumatology, who suggested that the rising prevalence of hand osteoarthritis is from obesity and since the hand does not bear weight, this suggests that the role of systemic inflammatory mediators in fat cells cause inflammation signaling to be sent out and attack joints.(9)

Please see our article Excessive weight and joint pain – the inflammation connection for more on this subject.

Back surgery and the problems of obesity

A 2016 study published in the Chiropractic & Manual Therapies (10) made these observations:

  • There appears to be an association between obesity and disability as well as obesity and the most severe pain.
  • Individuals who gained weight (5 or more pounds) were less likely to report improvement in most severe pain.
  • Research demonstrated that obese people treated for low back pain will experience better outcomes when they lose weight, particularly in cases of morbid obesity
  • An enlarged abdomen (big belly) as a result of obesity has been shown to cause early degeneration of discs, which is associated with low back pain.
  • Obesity is associated with disc degeneration because increases in body weight lead to tear and wear on discs and joints, increasing the physical demands on muscles and ligaments.

In a recently published article in the American Journal of Bone and Joint Surgery, researchers examined the effect that obesity has on patients managed for symptomatic lumbar disc herniation. They studied a group of patients who underwent back surgery and a group of patients who had more conservative non-surgical treatments. Both groups showed significantly less improvement as it related to problems of obesity.(11)

The same was found in newer research from St. Olavs University Hospital, in Norway for patients having surgery for lumbar spinal stenosis. The researchers noted: “Obese patients were less likely to achieve a minimal clinically important difference.”(12)

In February 2017, researchers at Cornell, Clemson, the University of Georgia, and Xi’an Jiaotong University in China, completed a study which found that :

  • Overweight and obese patients, as compared to normal/underweight respondents, were more likely to develop lower back problems and IDD (Internal disc disruption).(13)

A component of failed spinal surgery is obesity

A study in The Spine Journal said that a component of failed spinal surgery was obesity. This recent research was the first to examine obesity’s role in recurrent disc herniation after spinal surgery.

“Obesity was a strong and independent predictor of recurrent (disc herniation) after lumbar microdiscectomy. Surgeons should incorporate weight loss counseling into their preoperative discussions with patients.”(14)

There is even suggestion from University researchers in Rome, who wrote in the European spine journal that elevated cholesterol levels and triglycerides have a role: “patients with symptomatic herniated lumbar disc showed statistically significant higher triglyceride concentration  and total cholesterol concentration. Serum lipid levels may be a risk factor for [symptomatic disc herniation]. An enhanced understanding of these factors holds the promise of new approaches to the prevention and management.”(15)

How beneficial is spinal surgery for obese patients?

Any procedure that offers a patient relief of their symptoms is a good procedure. But how much risk should a patient take and for how much relief?

Let’s look at two studies FAVORABLE to spinal surgery for obese patients

The question of how obese patients respond to surgery as compared to non-obese patients was tackled by doctors at the Department of Neurosurgery, University of Alabama at Birmingham. In this September 2017 study, the doctors looked at obese and non-obese patients treated with lumbar laminectomy for symptomatic lumbar spinal stenosis.

  • At baseline, obese patients had significantly more back pain, more leg pain, lower EQ-5D scores (EuroQol 5 dimensions questionnaire is a measurement of general health) and higher Oswestry Disability Index scores (measuring mobility and disability)
  • Initially, both none obese and obese patient groups had significant improvement. However, at 3 months postoperatively, obese patients continued to report greater leg pain and higher disability scores relative to non-obese patients. By 12 months leg pain and higher disability scores were equal in both the obese and non-obese groups.

What to make of this?

The researchers concluded: “obese patients with symptomatic lumbar spinal stenosis may require longer to recover after decompression but can expect to reach equivalent outcomes of similarly treated (non-obese) patients”(16)

In the second favorable study, Spanish doctors writing in the medical journal Neurocirugia (Neurosurgery) write of the growing evidence that connects the metabolic processes within the adipose tissue, preferentially abdominal fat, with a low-intensity chronic inflammatory state that causes back pain.

They suggest: Some meta-analyses have confirmed an increase of complications following lumbar spine surgery (mainly infections and venous thrombosis) in obese subjects.

However, functional outcomes after lumbar spine surgery are favorable although inferior to the non-obese population, acknowledging that obese patients present with worse baseline function levels and the prognosis of conservatively treated obese cohorts is much worse.(17)

A 2015 study from doctors at University hospital researchers in the United Kingdom also supported surgery for obese patients.

  • They found despite:
    • obese patients having greater intra-operative blood loss,
    • more complications and
    • longer duration of surgery
    • pain and functional outcome are similar to non-obese patients.
    • Based on these results, obesity is not a contraindication to lumbar spinal fusion.(18)

For obese and non-obese patients pain and functional outcome are similar to non-obese patients. So if the surgery failed, it was not the fault of the obesity.

Again, this all comes down to lifestyle choices to accelerate healing or make healing more difficult.

The Spinal ligament repair injection treatment option Prolotherapy

Need help beyond weight loss? Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on research and clinical results, H3 Prolotherapy (H3 is a type of Prolotherapy named after three of its leading physician innovators Hackett-Hemwall-Hauser) is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle.

In this video Danielle R. Steilen-Matias, MMS, PA-C ., explains and demonstrates a Prolotherapy treatment into the lumbar spine.

Video Summary and Learning Points

  • Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
  • Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate repair of the ligament attachment to the bone.
  • We treat the whole low back area to include the sacroiliac or SI joint. In this video, the patient’s sacroiliac area in being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
  • I’ve marked with a black crayon all down the midline of this patient’s back  and then I have a horizontal line drawn where her pain stops. This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
  • It’s important to note that this particular patient is actually not sedated in any way so even though it is a lot of shots and a lot of injections through the skin which can be painful, patients tend to tolerate it really well the whole procedure goes relatively quickly
  • At 2:20 I’m just making sure that I get the sacroiliac or SI ligaments as well as the iliolumbar ligament to help strengthen the low back.
  • After treatment we want the patient to take it easy for about 4 days.
  • Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.

If you have questions about Obesity and Back Pain, get help and information from our Caring Medical staff

1 Großschädl F, Freidl W, Rásky É, Burkert N, Muckenhuber J, Stronegger WJ. A 35-year trend analysis for back pain in Austria: the role of obesity. PloS one. 2014 Sep 10;9(9):e107436.[Google Scholar]
2 Jentzsch T, Geiger J, Slankamenac K, Werner CM.Obesity measured by outer abdominal fat may cause facet joint arthritis at the lumbar spine. J Back Musculoskelet Rehabil. 2014 Jun 24.[Google Scholar.]
3 Hajihosseinali M, Arjmand N, Shirazi-Adl A. Effect of body weight on spinal loads in various activities: a personalized biomechanical modeling approach. Journal of biomechanics. 2015 Jan 21;48(2):276-82.[Google Scholar.]
4 Singh D, Park W, Hwang D, Levy M. Severe obesity effect on low back biomechanical stress of manual load lifting. Work. 2015 Jan 1;51(2):337-48.[Google Scholar]
5 Sedney CL, Haggerty T, Dekeseredy P. A short weight loss intervention in a neurosurgical subspecialist clinical setting. Journal of neurosciences in rural practice. 2018 Oct;9(04):492-5. [Google Scholar]
6 Hozumi J, Sumitani M, Matsubayashi Y, Abe H, Oshima Y, Chikuda H, Takeshita K, Yamada Y. Relationship between Neuropathic Pain and Obesity. Pain Research and Management. 2016 Mar 29;2016.[Google Scholar]
7 Miscio G, Guastamacchia G, Brunani A, Priano L, Baudo S, Mauro A. Obesity and peripheral neuropathy risk: a dangerous liaison. Journal of the peripheral nervous system. 2005 Dec 1;10(4):354-8.[Google Scholar]
8 Collins KH, Reimer RA, Seerattan RA, Leonard TR, Herzog W. Using diet-induced obesity to understand a metabolic subtype of osteoarthritis in rats. Osteoarthritis Cartilage. 2015 Feb 3. pii: S1063-4584(15)00028-X. doi: 10.1016/j.joca.2015.01.015.[Google Scholar]
9 Berenbaum F, Eymard F, Houard X. Osteoarthritis, inflammation and obesity. Curr Opin Rheumatol. 2013 Jan;25(1):114-8.[Google Scholar]
10 Ewald SC, Hurwitz EL, Kizhakkeveettil A. The effect of obesity on treatment outcomes for low back pain. Chiropractic & Manual Therapies. 2016;24:48. doi:10.1186/s12998-016-0129-4.[Google Scholar]
11 Rihn JA, Kurd M, Hilibrand AS, Lurie J, Zhao W, Albert T, Weinstein J. The influence of obesity on the outcome of treatment of lumbar disc herniation: analysis of the Spine Patient Outcomes Research Trial (SPORT). The Journal of bone and joint surgery. American volume. 2013 Jan 2;95(1):1.[Google Scholar]
12 Giannadakis C, Nerland US, Solheim O, Jakola AS, Gulati M5, Weber C6, Nygaard ØP, Solberg TK, Gulati S. Does obesity affect outcomes after decompressive surgery for lumbar spinal stenosis? – A multicenter observational registry-based study. World Neurosurg. 2015 Jun 19. pii: S1878-8750(15)00768-8. doi: 10.1016/j.wneu.2015.06.020.[Google Scholar.]
13 Sheng B, Feng C, Zhang D, Spitler H, Shi L. Associations between Obesity and Spinal Diseases: A Medical Expenditure Panel Study Analysis. Int J Environ Res Public Health. 2017 Feb 13;14(2). pii: E183.[Google Scholar.]
14  Meredith DS, Huang RC, Nguyen J, Lyman S. Obesity increases the risk of recurrent herniated nucleus pulposus after lumbar microdiscectomy. The Spine Journal. 2010 Jul 31;10(7):575-80.[Google Scholar.]
15  Longo UG, Denaro L, Spiezia F, Forriol F, Maffulli N, Denaro V. Symptomatic disc herniation and serum lipid levels. European Spine Journal. 2011 Oct 1;20(10):1658-62.[Google Scholar.]
16 Elsayed G, Davis MC, Dupépé EC, McClugage SG, Szerlip P, Walters BC, Hadley MN. Obese (Body Mass Index> 30) Patients Have Greater Functional Improvement and Reach Equivalent Outcomes at 12 Months Following Decompression Surgery for Symptomatic Lumbar Stenosis. World Neurosurgery. 2017 Sep 1;105:884-94.[Google Scholar.]
17 Delgado-López PD, Castilla-Díez JM. Impact of obesity in the pathophysiology of degenerative disk disease and in the morbidity and outcome of lumbar spine surgery. Neurocirugia (Asturias, Spain). 2017 Jul 24.[Google Scholar.]
18 Lingutla KK, Pollock R, Benomran E, Purushothaman B, Kasis A, Bhatia CK, Krishna M, Friesem T. Outcome of lumbar spinal fusion surgery in obese patients: a systematic review and meta-analysis. Bone Joint J. 2015 Oct;97-B(10):1395-404. doi: 10.1302/0301-620X.97B10.35724[Google Scholar]

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