What is degenerative spondylolisthesis. How does it affect the lumbar spine. What are the common symptoms of L4-L5 spondylosis. Which diagnostic methods are used to identify spondylolisthesis. What non-surgical and surgical treatments are available for this condition.

Understanding Degenerative Spondylolisthesis: A Comprehensive Overview

Degenerative spondylolisthesis is a spinal condition characterized by the forward slippage of one vertebra over the one below it. This condition primarily affects the lumbar spine, with the L4-L5 segment being the most commonly involved area. It typically results from age-related degenerative changes in the vertebral structure, causing the joints between the vertebrae to slip forward.

This condition is more prevalent among older adults, particularly females over 60 years of age. The gradual wear and tear on the spine lead to the breakdown of vertebral components, distinguishing it from isthmic spondylolisthesis, which involves a bone defect.

Who is at risk for developing degenerative spondylolisthesis?

Several factors can increase the likelihood of developing this condition:

• Age (typically over 60 years)
• Female gender
• Genetic predisposition
• Occupations involving repetitive spinal stress
• Obesity
• Previous spinal injuries or surgeries

Recognizing the Symptoms of L4-L5 Spondylosis

The symptoms of degenerative spondylolisthesis can vary widely among individuals. Some people may be asymptomatic, only discovering the condition during unrelated medical examinations. However, others may experience a range of symptoms that can significantly impact their quality of life.

What are the common symptoms of L4-L5 spondylosis?

Patients with symptomatic degenerative spondylolisthesis may experience:

• Low back pain, often exacerbated by physical activity
• Pain radiating into the buttocks and legs (sciatica)
• Muscle spasms in the lower back
• Leg weakness or numbness
• Tight hamstring muscles
• Irregular gait or limping
• Neurological symptoms in severe cases

It’s important to note that the severity of symptoms doesn’t always correlate with the degree of vertebral slippage. Some individuals with significant slippage may have minimal symptoms, while others with minor slippage may experience considerable pain and functional limitations.

Diagnostic Approaches for Degenerative Spondylolisthesis

Accurate diagnosis is crucial for effective management of degenerative spondylolisthesis. Spine specialists employ a combination of clinical assessment and advanced imaging techniques to confirm the diagnosis and determine the extent of the condition.

How is degenerative spondylolisthesis diagnosed?

The diagnostic process typically involves:

1. Comprehensive medical history review
2. Thorough physical examination
3. Imaging studies, including:
   • X-rays (to visualize vertebral alignment and rule out other conditions)
   • CT scans (for detailed bone imaging)
   • MRI scans (to assess soft tissue structures and nerve compression)
   • Myelography (in select cases to evaluate nerve compression)

During the physical examination, the physician will assess range of motion, balance, reflexes, muscle strength, and sensory function. These tests help identify any neurological deficits associated with the condition.

Grading Systems for Spondylolisthesis: Understanding Severity

To quantify the extent of vertebral slippage and guide treatment decisions, physicians use grading systems. The most commonly employed method is the Meyerding Grading System.

How does the Meyerding Grading System classify spondylolisthesis?

The Meyerding Grading System categorizes spondylolisthesis into five grades based on the percentage of vertebral body slippage:

• Grade I: 1-24% slippage
• Grade II: 25-49% slippage
• Grade III: 50-74% slippage
• Grade IV: 75-99% slippage
• Grade V (Spondyloptosis): 100% slippage

Most cases of degenerative spondylolisthesis fall into Grade I or II categories. Higher grades (III and above) are more likely to require surgical intervention due to increased instability and neurological compromise.

Non-Operative Management Strategies for L4-L5 Spondylosis

For many patients with degenerative spondylolisthesis, especially those with Grade I or II slippage, non-surgical treatments can effectively manage symptoms and improve quality of life.

What non-surgical treatments are available for degenerative spondylolisthesis?

Conservative management options include:

• Activity modification and temporary bed rest
• Physical therapy and exercise programs
• Pain medications (NSAIDs, muscle relaxants)
• Epidural steroid injections
• Spinal bracing
• Weight management
• Complementary therapies (acupuncture, chiropractic care)

These non-operative approaches aim to reduce pain, improve function, and prevent further progression of the condition. However, it’s important to note that degenerative spondylolisthesis can be progressive, and regular monitoring is essential to assess the effectiveness of conservative treatments.

Surgical Interventions for Advanced L4-L5 Spondylosis

While many patients respond well to non-operative management, surgical intervention may be necessary in certain cases. Surgery is typically considered when conservative treatments fail to provide adequate relief, neurological deficits are present, or the condition significantly impacts daily activities.

When is surgery recommended for degenerative spondylolisthesis?

Surgical treatment may be indicated in the following scenarios:

• Severe or progressive neurological symptoms
• Intractable pain unresponsive to conservative measures
• Significant functional limitations
• High-grade slippage (Grade III or above)
• Associated spinal stenosis causing nerve compression

What surgical procedures are commonly used to treat degenerative spondylolisthesis?

The most common surgical approach for degenerative spondylolisthesis is a combination of decompression and fusion. This typically involves:

1. Laminectomy: Removal of the lamina to relieve pressure on nerves
2. Spinal fusion: Joining adjacent vertebrae to stabilize the spine
3. Instrumentation: Use of hardware (screws, rods, cages) to enhance fusion and support

In some cases, minimally invasive techniques may be employed to reduce surgical trauma and promote faster recovery. The specific surgical approach is tailored to the individual patient’s condition, overall health, and surgeon’s expertise.

Post-Operative Care and Rehabilitation for L4-L5 Spondylosis

Following surgical intervention for degenerative spondylolisthesis, a comprehensive rehabilitation program is crucial for optimal recovery and long-term outcomes.

What does post-operative care involve for spondylolisthesis patients?

The post-operative care and rehabilitation process typically includes:

• Pain management strategies
• Gradual mobilization and physical therapy
• Occupational therapy to improve daily living activities
• Education on proper body mechanics and spine protection
• Nutritional support to promote healing
• Regular follow-up appointments to monitor fusion and overall progress

The duration and intensity of rehabilitation vary depending on the individual’s condition, the extent of surgery, and their overall health status. Most patients can expect a recovery period of several months before returning to full activities.

Long-Term Prognosis and Management of L4-L5 Spondylosis

Understanding the long-term outlook for patients with degenerative spondylolisthesis is essential for setting realistic expectations and developing appropriate management strategies.

What is the long-term prognosis for patients with degenerative spondylolisthesis?

The prognosis for degenerative spondylolisthesis varies depending on several factors:

• Severity of the condition at diagnosis
• Presence of neurological deficits
• Effectiveness of treatment approaches
• Patient compliance with rehabilitation and lifestyle modifications
• Overall health and comorbidities

Many patients experience significant improvement in symptoms and function with appropriate treatment, whether conservative or surgical. However, it’s important to recognize that degenerative spondylolisthesis is part of the broader spectrum of age-related spinal changes, and ongoing management may be necessary.

How can patients optimize their long-term outcomes?

To maximize long-term outcomes and minimize the risk of recurrence or progression, patients should:

• Maintain a healthy body weight
• Engage in regular, low-impact exercise to strengthen core and back muscles
• Practice good posture and ergonomics
• Avoid activities that place excessive stress on the lumbar spine
• Attend regular follow-up appointments with their spine specialist
• Promptly report any new or worsening symptoms

By adopting a proactive approach to spinal health and working closely with their healthcare team, patients with L4-L5 spondylosis can often achieve lasting improvements in their quality of life and functional capacity.

Emerging Treatments and Future Directions in L4-L5 Spondylosis Management

As our understanding of degenerative spondylolisthesis continues to evolve, researchers and clinicians are exploring innovative approaches to diagnosis, treatment, and prevention of this condition.

What are some promising areas of research in spondylolisthesis management?

Several exciting avenues of investigation are currently underway:

• Advanced imaging techniques for earlier detection and more precise grading
• Biological therapies to slow or reverse degenerative processes
• Minimally invasive surgical techniques with faster recovery times
• Artificial disc replacement as an alternative to fusion in select cases
• Personalized treatment algorithms based on genetic and biomechanical factors
• Wearable technology for real-time monitoring of spinal alignment and movement

While many of these approaches are still in the experimental stages, they hold promise for improving outcomes and expanding treatment options for patients with L4-L5 spondylosis.

How might future developments impact patient care?

As research progresses, we can anticipate several potential benefits for patients:

• More accurate and earlier diagnosis, allowing for prompt intervention
• Expanded non-surgical treatment options with improved efficacy
• Less invasive surgical procedures with reduced complications and faster recovery
• Improved ability to predict which patients are most likely to benefit from specific treatments
• Enhanced strategies for preventing the onset or progression of degenerative spondylolisthesis

While these advancements are exciting, it’s important to remember that the foundation of effective management remains a comprehensive, patient-centered approach that considers individual needs, preferences, and circumstances.

Degenerative Spondylolisthesis Treatment & Surgery

Spondylolisthesis – Degenerative

Spondylolisthesis is a spinal condition in which one vertebra slips forward over the vertebra below. Degenerative spondylolisthesis, usually occurs in the lumbar spine, especially at L4-L5. It is the result of degenerative changes in the vertebral structure that cause the joints between the vertebrae to slip forward. This type of spondylolisthesis is most common among older female patients, usually those over the age of 60.

Symptoms
Symptoms of spondylolisthesis may include the following:

• Pain, especially after exercise, in the low back, thighs, and/or legs that radiates into the buttocks and/or down the legs (sciatica)
• Muscle spasms
• Leg weakness
• Tight hamstring muscles
• Irregular gait or limp

Some people with spondylolisthesis are symptom free and only discover the disorder when seeing a doctor for another health problem. However, the forward slip of the vertebral body in severe cases of degenerative spondylolisthesis often leads to spinal stenosis, nerve compression, pain and neurological injury.

What Causes Degenerative Spondylolisthesis?

Degenerative spondylolisthesis is usually the result of age and “wear and tear” on the spine that breaks down vertebral components. It is different from isthmic spondylolisthesis in that there is no bone defect. Spinal stenosis tends to occur in the early stages of degenerative spondylolisthesis.

Diagnosis

Correct diagnosis is obviously essential. Dr. Lonner utilizes the latest diagnostic technologies, combined with examinations by expert physicians, to ensure that the diagnosis is accurate. Diagnostic tools include:

• Medical history. You will be asked about your symptoms, their severity, and the treatments you have already tried.
• Physical examination. You will be carefully examined for limitations of movement, problems with balance, pain, loss of reflexes in the extremities, muscle weakness, loss of sensation or other signs of neurological damage.
• Diagnostic tests. Generally, we start with x-rays, which allow us to rule out other problems such as tumors and infections. We may also use a CT scan or MRI to confirm the diagnosis. In some patients a myelogram will be used. This is a test that involves the use of a liquid dye that is injected into the spinal column to show the degree of nerve compression, slippage between involved vertebrae, and abnormal movement.

Classification of Spondylolisthesis

There are several methods used to “grade” the degree of slippage ranging from mild to most severe. We will discuss with you the extent of your spondylolisthesis.

In general, physicians use the Meyerding Grading System for classifying slips. This is a relatively easy to understand system. Slips are graded on the basis of the percentage that one vertebral body has slipped forward over the vertebral body below. Thus a Grade I slip indicates that 1-24% of the vertebral body has slipped forward over the body below. Grade II indicates a 25-49% slip. Grade III indicates a 50-74% slip and Grade IV indicates a 75%-99% slip. If the body completely slips off the body below it is classified as a Grade V slip, known as spondyloptosis.

Dr. Lonner will consider the degree of slip, and such factors as intractable pain and neurological symptoms, when deciding on the most suitable treatment. Most degenerative spondylolisthesis cases involve Grade I or Grade II. As a general guideline, the more severe slips (especially Grades III and above) are most likely to require surgical intervention.

Non-Operative Treatment

For most cases of degenerative spondylolisthesis (especially Grades I and II), treatment consists of temporary bed rest, restriction of the activities that caused the onset of symptoms, pain/ anti-inflammatory medications, steroid-anesthetic injections, physical therapy and/or spinal bracing.

Degenerative spondylolisthesis can be progressive – meaning the damage will continue to get worse as time goes on. In addition, degenerative spondylolisthesis can cause stenosis, a narrowing of the spinal canal and spinal cord compression. If the stenosis is severe, and all non-operative treatments have failed, surgery may be necessary.

Surgical Treatment

Surgery is rarely needed unless the case is severe (usually Grade III or above), neurological damage has occurred, the pain is disabling, or all non-operative treatment options have failed.

The most common surgical procedure used to treat spondylolisthesis is called a laminectomy and fusion. In this procedure, the spinal canal is widened by removing or trimming the laminae (roof) of the vertebrae. This is done to create more space for the nerves and relieve pressure on the spinal cord. The surgeon may also need to fuse vertebrae together. If fusion is done, various devices (like screws or interbody cages) may be implanted to enhance fusion and support the unstable spine.

Patient Story of Degenerative Spondylolisthesis

Spondylolisthesis Symptoms, Diagnosis, and Treatments

Spondylolisthesis is a Latin term meaning slipped vertebral body (spinal bone).

“Spondylo”= vertebrae
“listhesis”=slippage

Spondylolisthesis in the lumbar spine is most commonly caused by degenerative spinal disease (degenerative spondylolisthesis), or a defect in one region of a vertebra (isthmic spondylolisthesis).

ON THIS PAGE

• What are the types of spondylolisthesis?
• Which type is most common?
• Symptoms
• Diagnosis
• Treatment

WHAT ARE THE TYPES OF SPONDYLOLISTHESIS?

Spondylolisthesis can be classified by into five groups (Newman (1976)):

• Group 1: dysplastic
• Group 2: isthmic
• Group 3: traumatic
• Group 4: degenerative
• Group 5: pathological

WHICH TYPE IS MOST COMMON?

Degenerative spondylolisthesis is very common, and occurs as a result of due to degeneration or wear and tear of the intervertebral discs and ligaments. Osteoarthritis of the facet joints can also play an important role in the development of instability and slippage. Degenerative spondylolisthesis usually occurs in people over 60 years of age.

In degenerative spondylolisthesis, what usually happens is that ongoing degeneration weakens the facet joints and disc, and (typically) the L4 vertebral body slips forward on the L5 vertebral body. Under normal circumstances, the L4-L5 segment is the one in the lumbar spine with the most movement. It is therefore most likely to slip when this process occurs. The next most common levels affected by degenerative spondylolisthesis are L3-L4 and L5-S1.

Isthmic spondylolisthesis occurs most often at L5-S1, and is more often seen in younger adults than degenerative spondylolisthesis. The cause is a defect in an important bridge bone (the pars interarticularis) of L5.

HOW IS SPONDYLOLISTHESIS GRADED?

Spondylolisthesis is graded according to the severity of the slippage. This is known as the Mayerding classification:

• Grade 1: <25% slip
• Grade 2: 25-50% slip
• Grade 3 50-75% slip
• Grade 4: 75-100% slip

When one vertebra slips entirely off the one below (>100% slip), this is known as spondyloptosis (see picture).

SYMPTOMS

Spondylolisthesis doesn’t usually have any symptoms. In fact, it is commonly seen on X-rays and CT scans as an ‘incidental’ finding. It may, however, produce significant symptoms and disability.

Back pain is the most common symptom of spondylolisthesis. This pain is typically worse with activities such as bending and lifting, and often eases when lying down.

As the spine attempts to stabilise the unstable segment, the facet joints enlarge and place pressure on the nerve root causing lumbar spinal stenosis and lateral recess stenosis.

As one bone slips forward on the other, a narrowing of the intervertebral foramen may also occur (foraminal stenosis). Severe nerve compression can therefore occur with pain, numbness and weakness in the legs. Sometimes loss of control of the bladder and/or bowels can occur due to pressure on the nerves going to these important structures.

DIAGNOSIS

Imaging studies including MRI and CT can show a slip, as well as narrowing (stenosis) or compressed nerves in the spinal canal.

The CT and MRI scans are usually obtained with the patient lying flat, however sometimes a slip may only be obvious when standing or bending forwards. This is why your neurosurgeon or spinal surgeon will sometimes obtain flexion, extension and standing X-rays, and occasionally a CT myelogram.

TREATMENT

Treatment for spondylolisthesis is similar to treatments for other causes of mechanical and compressive back pain. It is usually non-operative, and surgery is only necessary in a small percentage of patients.

MODIFIED ACTIVITIES

Your specialist may suggest that you modify some of your usual physical activities, this will help to help settle symptoms from mechanical back pain. Special braces are occasionally prescribed to ease back pain. Short periods of bed rest can sometimes help with very painful episodes.

PHYSICAL REHABILITATION

A comprehensive physical rehabilitation program can assist in settling pain and inflammation, as well as improving mobility and strength. A combination of physiotherapy, hydrotherapy and clinical Pilates typically works well and is often recommended.
The aims of these physical therapies are to assist you in:

• managing your condition and controlling your symptoms
• correcting your posture and body movements to reduce back strain
• improving your flexibility and core strength

Some patients also benefit from chiropractic treatment osteopathy, remedial massage, and acupuncture.

PSYCHOLOGIST REVIEW

Having a review by a clinical psychologist can be helpful in for creating strategies to manage pain. It is also important to address any associated feelings of depression or anxiety, as these conditions can heighten your experience of pain.

MEDICATIONS

Medication often plays an important role in controlling pain and easing muscle spasms. It can also help you to get back to a normal sleep pattern. Long-term medication usage should be closely supervised as problems such as tolerance and dependence (addiction) are known to occur.

SURGERY

Surgery is only needed only if other non-surgical treatments are not keeping your pain at a manageable level. Surgical treatment for spondylolisthesis need to take into account both mechanical (instability) and compressive (nerve pressure) issues.
Nerve pressure usually involves surgical decompression, also known as a decompressive laminectomy. In order to deal with the compressive issues by taking pressure off the nerves, your surgeon may need to remove some or all of one or both facet joints, as well as portions of the lamina.

As the facet joints typically provide stability to the lumbar spine, the spine can spine to become loose and unstable, especially after some slippage has already occurred. A fusion is usually therefore recommended.

Similarly, a fusion is necessary to adequately deal with the mechanical issues of instability in spondylolisthesis.

Six types of fusion surgery are commonly recommended for the treatment of spondylolisthesis, depending upon individual patient factors:

1. Transforaminal lumbar interbody fusion (TLIF)
2. Posterior lumbar interbody fusion (PLIF)
3. Instrumented posterolateral fusion (pedicle screw fixation and posterolateral bone graft)
4. Anterior lumbar interbody fusion (carried out through the abdomen, rather than from the back)
5. Extracavitatory lateral interbody fusion (XLIF)
6. Oblique lateral interbody fusion (OLIF)

Spondylosis of the lumbosacral spine, symptoms, causes and treatment

Spondylosis of the lumbosacral spine is a disease that is characterized by damage to the joints of the lower back, the growth of osteophytes. Bone formations appear mainly along the anterior edge of the vertebrae, and the lateral regions are also affected. The pathological process is associated with excessive loads, unsatisfactory physical condition of a person. In parallel with this, muscle spasm is observed, which limits mobility in the lumbosacral region. If there is no adequate treatment, then the bone growths become larger, infringe on the nerve roots and spinal cord.

The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact a specialist.

Symptoms of the disease, signs

The initial stage of lumbar spondylosis proceeds almost imperceptibly. In the modern rhythm of life, many people do not pay attention to the slight stiffness in movement. The further the disease develops, the more noticeable the symptoms become:

• soreness in the loins, buttocks and legs;
• lameness, intense discomfort in calf muscles;
• inability to fully bend over.

The pain gets worse in the evening, and also when trying to move more or less actively. Often a person has to take forced postures. At 2-3 stages progress:

• paresthesia;
• loss of sensation of the skin of the buttocks;
• Difficulty in movements of the knee joints, leg abduction in the hip joints.

With an increase in the duration of the disease, the symptoms of spondylosis of the lumbosacral spine become more acute and interfere with a normal lifestyle. In some cases, the signs of pathology intensify when the weather changes.

It is important to distinguish osteochondrosis from spondylosis. With osteochondrosis, pain with pressure on the spinous processes is not noted. And for spondylosis, this is a characteristic manifestation. When it affects the lumbosacral spine, predominantly L3-L5 suffer. Osteochondrosis in most cases affects the L5-S1 vertebrae.

Causes of lumbar spondylosis

Pathological growth of bone tissue is caused by degenerative changes that lead to a deterioration in the mobility of the spinal column. They are provoked by:

• direct and indirect injuries of the local muscle-ligament apparatus;
• prolonged stay in a physiologically incorrect position;
• dynamic loads on the muscles with obvious hypodynamia;
• infectious lesions;
• neoplasms;
• genetic predisposition;
• overweight.

Cause the development of spondylosis age-related changes in the tissues of the spine, as well as constitutional predisposition. Abnormal growth of the bone structure can be observed under the influence of oncological diseases. Both hypo- and hyperdynamia pose a certain health hazard.

Effective treatments

The prescribed therapy should take into account the special properties of the human body. Treatment methods for lumbar spondylosis are aimed at: restoring a full blood supply; improvement of the condition of cartilage tissue; elimination of pain; strengthening muscles and ligaments.

Therapy includes pharmacological and non-pharmacological methods. Among medicines positive effect is exerted by:

• NSAIDs;
• muscle relaxants;
• preparations of natural cartilage components.

If the lumbar region is affected, spondylosis responds well to physiotherapeutic methods:

• acupuncture;
• ultrasound;
• paraffin packs;
• manual therapy;
• massage.

After relief of acute pain, exercise therapy is started. Therapeutic gymnastics has a restorative and healing effect.

What if the disease is not treated?!

With timely diagnosis and treatment, the prognosis is quite favorable. However, attempts to independently stop the pain syndrome or ignore the symptoms lead to the progression of the pathology. Over time:

• limbs become numb;
• mobility is sharply limited;
• muscles atrophy;
• partial or complete immobilization occurs.

Lumbar spondylosis responds well to treatment. It is important to contact a competent specialist who will make an accurate diagnosis and individually select a comprehensive treatment regimen.

Lumbar spondylosis – symptoms, causes, treatment

A neurologist treats this disease.

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Spinal spondylosis is a chronic disease resulting from degenerative-dystrophic processes of the fibrous ring of the intervertebral disc. Spondylosis is one of the types of osteopathies – diseases grouped according to common characteristic features: dystrophy of the structures of the spine, pain syndrome, limitation of mobility. It affects all parts of the spinal column, but most often the lumbosacral.

CMRT specialist tells

Kuchenkov A.V.

Orthopedist • Traumatologist • Surgeon • Phlebologist • Sports doctor • 25 years of experience

Publication date: May 18, 2021

Verification date: January 10, 2023

All facts have been verified by a doctor.

Contents of the article

Causes of spondylosis

Symptoms of spondylosis of the lumbosacral spine

The initial stage of the disease is characterized by a latent course. As the pathological process progresses, symptoms appear:

• Limited mobility in the lumbar spine.
• Unpleasant sensations in the buttocks and thighs after prolonged exertion on the legs
• Pain in the back after prolonged static posture

Deforming spondylosis of the lumbar spine gives the following symptoms:

• Lumbar pain when turning the body, when walking down stairs
• Lameness when pain radiates to the lower extremities

Antespondylolisthesis (displacement of the vertebrae relative to each other) causes pinching of the nerves of the “cauda equina”, which is located in the lower parts of the spinal cord. In the clinical picture, neurological symptoms come to the fore:

• Severe pain in the perineum, in the legs
• Development of paresthesia – a feeling of numbness, tingling, burning below the level of damage to the spinal segment: lower back, buttocks, legs
• Increasing weakness of the muscles of the lower extremities
• Disorder of the pelvic organs: violation of the process of urination, defecation

Stages of development of spondylosis

The process of degenerative changes in intervertebral discs with the formation of osteophytes successively goes through several stages:

I stage. There are initial changes in the fibrous tissues of the intervertebral disc: cracks, fractures, decreased elasticity. Single spiny bone growths (osteophytes) do not extend beyond the vertebral bodies. Symptoms characteristic of spondylosis of the lumbosacral spine are absent, the patient may sometimes be bothered by minor pain in the lumbar region.

Stage II. Active proliferation of osteophytes continues. Mobility in the damaged spinal segment decreases, pains join, the intensity of which increases with physical exertion, hypothermia.

Stage III . Complete destruction of cartilage. Bone growths, increasing in size, merge into rough osteophyte complexes connecting two or more vertebrae. This disrupts the normal mobility of the lumbar spine. When osteophytes compress the nerve roots of the spinal cord, neurological disorders develop, aggravated by a severe pain syndrome.

How to diagnose

If spinal spondylosis is suspected, diagnostics include:

• Collection of patient complaints, as well as information about the onset and course of the disease
• Clinical examination by a doctor with assessment of neurological status
• Instrumental examination: X-ray in frontal and lateral projection x, CT, MRI can detect pathological changes in bone, cartilage, soft tissues in the early stages.