What is degenerative spondylolisthesis. How does it differ from other types of spondylolisthesis. What are the common symptoms of this condition. How is degenerative spondylolisthesis diagnosed and classified. What non-operative treatments are available. When is surgery necessary for degenerative spondylolisthesis.

Understanding Degenerative Spondylolisthesis: A Comprehensive Overview

Degenerative spondylolisthesis is a spinal condition characterized by the forward slippage of one vertebra over the vertebra below it. This condition primarily affects the lumbar spine, with the L4-L5 segment being the most common site of occurrence. Unlike other forms of spondylolisthesis, the degenerative type is not caused by a bone defect but rather results from age-related wear and tear on the spine.

Typically, degenerative spondylolisthesis is more prevalent among older adults, particularly women over the age of 60. The condition can lead to various symptoms and complications, including spinal stenosis, nerve compression, and chronic pain. Understanding the causes, symptoms, and treatment options for degenerative spondylolisthesis is crucial for both patients and healthcare providers.

Causes and Risk Factors of Degenerative Spondylolisthesis

The primary cause of degenerative spondylolisthesis is the natural aging process and its effects on the spine. As we age, several factors contribute to the development of this condition:

• Breakdown of cartilage in the facet joints
• Degeneration of intervertebral discs
• Weakening of ligaments supporting the spine
• Loss of bone density (osteoporosis)
• Changes in spinal alignment due to poor posture or repetitive stress

Are certain individuals more susceptible to developing degenerative spondylolisthesis? Indeed, several risk factors increase the likelihood of this condition:

• Advanced age (particularly over 60)
• Female gender
• Obesity
• Occupations involving heavy lifting or repetitive spinal stress
• Genetic predisposition to spinal degeneration
• History of spinal trauma or previous back surgery

Recognizing the Symptoms of Degenerative Spondylolisthesis

The symptoms of degenerative spondylolisthesis can vary widely among individuals. Some people may experience no symptoms at all, while others may suffer from debilitating pain and neurological issues. Common symptoms include:

• Lower back pain, especially after physical activity
• Pain radiating into the buttocks and legs (sciatica)
• Muscle spasms in the lower back
• Leg weakness or numbness
• Tight hamstring muscles
• Altered gait or limping
• Difficulty standing for long periods or walking long distances

Can degenerative spondylolisthesis cause neurological symptoms? In severe cases, particularly when spinal stenosis develops, patients may experience neurological symptoms such as:

• Bladder or bowel dysfunction
• Weakness or paralysis in the legs
• Loss of sensation in the lower extremities
• Foot drop (difficulty lifting the front part of the foot)

Diagnostic Procedures for Degenerative Spondylolisthesis

Accurate diagnosis of degenerative spondylolisthesis is crucial for developing an effective treatment plan. Healthcare providers typically employ a combination of methods to diagnose this condition:

1. Medical history assessment: The physician will inquire about symptoms, their duration, and any factors that exacerbate or alleviate the pain.
2. Physical examination: This includes evaluating range of motion, checking for muscle weakness or sensory loss, and assessing reflexes.
3. Imaging studies:
   • X-rays: These can reveal vertebral slippage and help rule out other spinal conditions.
   • CT scans: Provide detailed images of bone structures and can help assess the degree of slippage.
   • MRI: Offers a comprehensive view of soft tissues, including nerves and intervertebral discs.
   • Myelogram: A specialized imaging technique that uses contrast dye to highlight nerve compression and abnormal spinal movement.

How is the severity of degenerative spondylolisthesis classified? The Meyerding Grading System is commonly used to classify the degree of vertebral 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 Grade II categories. Higher grades often indicate a need for more aggressive treatment approaches.

Non-Operative Treatment Options for Degenerative Spondylolisthesis

For many patients, especially those with Grade I or Grade II slippage, non-operative treatments can effectively manage symptoms and improve quality of life. These conservative approaches include:

1. Rest and activity modification: Temporarily limiting activities that exacerbate symptoms can help reduce pain and inflammation.
2. Physical therapy: A tailored exercise program can strengthen core and back muscles, improve flexibility, and enhance spinal stability.
3. Medications:
   • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief and inflammation reduction
   • Muscle relaxants to alleviate muscle spasms
   • Analgesics for pain management
4. Epidural steroid injections: These can provide temporary relief by reducing inflammation around compressed nerves.
5. Bracing: A lumbar brace can offer support and limit excessive movement, potentially reducing pain during activities.
6. Weight management: For overweight patients, losing excess weight can significantly reduce stress on the spine.
7. Lifestyle modifications: Ergonomic adjustments at work and home, as well as posture improvement, can help manage symptoms.

How long should patients try non-operative treatments before considering surgery? The duration of conservative treatment varies depending on individual factors, but generally, patients are advised to try non-operative approaches for at least 3-6 months before contemplating surgical intervention.

Surgical Interventions for Degenerative Spondylolisthesis

When conservative treatments fail to provide adequate relief or in cases of severe slippage (typically Grade III or above), surgical intervention may be necessary. The primary goals of surgery are to decompress affected nerves, stabilize the spine, and prevent further slippage. Common surgical procedures include:

1. Laminectomy and fusion: This is the most frequently performed surgery for degenerative spondylolisthesis. It involves:
   • Removing or trimming the laminae to widen the spinal canal and relieve nerve pressure
   • Fusing the affected vertebrae to prevent further slippage
   • Using hardware such as screws, rods, or interbody cages to enhance stability and promote fusion
2. Minimally invasive decompression and fusion: These techniques aim to achieve the same goals as traditional open surgery but with smaller incisions and less tissue damage.
3. Interspinous spacer devices: In some cases, these devices can be implanted to indirectly decompress the spinal canal without the need for fusion.

What factors influence the choice of surgical approach? The decision depends on several factors, including:

• The degree of slippage
• The presence and severity of spinal stenosis
• The patient’s overall health and age
• The surgeon’s expertise and preference
• The patient’s lifestyle and activity goals

Recovery and Long-Term Outlook for Degenerative Spondylolisthesis Patients

The recovery process and long-term prognosis for patients with degenerative spondylolisthesis can vary significantly depending on the severity of the condition and the chosen treatment approach. For those undergoing non-operative treatment:

• Symptom improvement may occur gradually over several weeks to months
• Regular follow-ups with healthcare providers are essential to monitor progress and adjust treatment as needed
• Ongoing physical therapy and exercise can help maintain spinal health and prevent symptom recurrence

For patients who undergo surgery, the recovery timeline typically includes:

1. Hospital stay: Usually 2-4 days, depending on the procedure and individual factors
2. Initial recovery: 4-6 weeks of limited activity to allow for proper healing
3. Physical therapy: Begins gradually, usually around 6-8 weeks post-surgery
4. Return to normal activities: Most patients can resume light activities within 3 months, with full recovery taking 6-12 months

Can degenerative spondylolisthesis recur after treatment? While treatment can effectively manage symptoms and prevent further slippage, the underlying degenerative process continues. This means that patients may experience new symptoms or adjacent segment degeneration over time. Regular follow-ups and maintaining a healthy lifestyle are crucial for long-term spinal health.

Preventing and Managing Degenerative Spondylolisthesis: Lifestyle Considerations

While it’s not always possible to prevent degenerative spondylolisthesis, certain lifestyle choices can help reduce the risk of developing the condition or minimize its progression:

• Maintaining a healthy weight to reduce stress on the spine
• Engaging in regular low-impact exercises to strengthen core and back muscles
• Practicing good posture and ergonomics in daily activities
• Avoiding smoking, which can accelerate disc degeneration
• Eating a balanced diet rich in calcium and vitamin D to support bone health
• Using proper lifting techniques to avoid unnecessary spinal stress

For individuals already diagnosed with degenerative spondylolisthesis, managing the condition often involves a multifaceted approach:

1. Adhering to prescribed treatment plans, whether conservative or post-surgical
2. Participating in regular physical therapy sessions to maintain spinal stability and flexibility
3. Utilizing pain management techniques, such as heat/cold therapy or meditation, to cope with chronic discomfort
4. Making necessary modifications to home and work environments to accommodate physical limitations
5. Joining support groups or seeking counseling to address the emotional aspects of living with a chronic condition

How can patients effectively communicate their symptoms and concerns to healthcare providers? Keeping a pain diary that tracks symptom intensity, duration, and triggers can be invaluable. This information helps doctors assess the progression of the condition and the effectiveness of current treatments, allowing for timely adjustments to the management plan.

Emerging Treatments and Research in Degenerative Spondylolisthesis

The field of spinal care is continually evolving, with ongoing research aimed at improving treatment outcomes for degenerative spondylolisthesis patients. Some areas of current interest include:

• Stem cell therapy: Investigating the potential of stem cells to regenerate damaged disc tissue and improve spinal stability
• Advanced imaging techniques: Developing more precise methods for early detection and monitoring of spinal degeneration
• Robotic-assisted surgery: Enhancing the accuracy and minimally invasive nature of spinal procedures
• Artificial disc replacement: Exploring alternatives to spinal fusion that preserve motion
• Personalized medicine: Tailoring treatments based on individual genetic and biomechanical factors

What role do clinical trials play in advancing treatment options? Clinical trials are crucial for evaluating the safety and efficacy of new treatments. Patients interested in participating in research studies should discuss this option with their healthcare providers, as it may offer access to cutting-edge therapies while contributing to the advancement of medical knowledge.

The Importance of a Multidisciplinary Approach to Degenerative Spondylolisthesis

Managing degenerative spondylolisthesis often requires a team of healthcare professionals working together to provide comprehensive care. This multidisciplinary approach may involve:

• Spine specialists (orthopedic surgeons or neurosurgeons)
• Pain management physicians
• Physical therapists
• Occupational therapists
• Radiologists
• Nutritionists
• Psychologists or psychiatrists

How does a multidisciplinary approach benefit patients? By addressing all aspects of the condition – physical, emotional, and functional – this comprehensive strategy can lead to better outcomes, improved quality of life, and more personalized care plans tailored to each patient’s unique needs and goals.

In conclusion, degenerative spondylolisthesis is a complex spinal condition that requires a nuanced understanding and a tailored approach to treatment. While it can significantly impact a person’s quality of life, advances in both conservative and surgical management options offer hope for symptom relief and improved function. By staying informed about the condition, actively participating in their care, and working closely with healthcare providers, patients can effectively manage degenerative spondylolisthesis and maintain their spinal health over the long term.

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

Explaining Spinal Disorders: Degenerative Spondylolisthesis

Home > Conditions > Degenerative Spondylolisthesis

Spondylolisthesis is a spinal condition in which one vertebra slips forward over the vertebra below. Degenerative spondylolisthesis usually occurs in the lumbar (low back) spine, more commonly at L4-L5 (4th and 5th lumbar vertebral levels). Spondylolisthesis can result from degenerative changes in the vertebral structure that causes the joints between the vertebrae to slip forward and may lead to spinal stenosis. Degenerative spondylolisthesis is most common among older female patients, usually over age 60.

Slip of L5 vertebra on sacrum

Symptoms

Some people with spondylolisthesis are symptom-free and discover the disorder when seeing their doctor for another health problem. Symptoms may include:

• Low back pain
• Sciatica ?Muscle spasms
• Leg weakness
• Tight hamstring muscles
• Irregular gait or limp

Diagnosis

Our comprehensive diagnostic process includes:

• Medical history. The doctor asks you questions about your symptoms, their severity, and treatments you have already tried.
• Physical examination. You are carefully examined for limitations of movement, problems with balance, and pain. During the exam, the doctor looks for loss of reflexes, muscle weakness, loss of sensation or other signs of neurological injury.
• Diagnostic tests. Most doctors start with x-rays. Spondylolisthesis is easily seen on a lateral (side) lumbar x-ray. If necessary, a CT scan or MRI may be ordered to see the spine’s tissues in greater detail.

X-ray showing spondylolosthesis

Lumbar spine MRI showing spondylolosthesis

Classification of Spondylolisthesis

Information from your medical file and imaging studies is used to grade the degree of vertebral slippage from mild to severe. The grade of your spondylolisthesis is explained to you along with what it means.

Doctors use the Meyerding Grading System to classify the degree of vertebral slippage. This system is easy to understand. Slips are graded on the basis of the percentage that one vertebral body has slipped forward over the vertebral body below.

• Grade I: 1-24%
• Grade II: 25-49%
• Grade III: 50-74%
• Grade IV: 75%-99% slip.
• Grade V: Complete slip (100%), known as spondyloptosis

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

Nonoperative Treatment

Most cases of degenerative spondylolisthesis are treated without surgery. Treatment may include:

• Short-term bed rest
• Activity restriction
• Over-the-counter or prescription pain medication
• Anti-inflammatory medication
• Muscle relaxants
• Steroid injections (i. e. epidural steroid injection)
• Physical therapy
• Bracing

Degenerative spondylolisthesis can be progressive. This means the spondylolisthesis worsens with time and may cause spinal stenosis. This is why it is important to follow-up with your doctor to monitor your treatment progress and spondylolisthesis.

Surgery

If your degenerative spondylolisthesis progresses or causes neurologic problems, such as incontinence, surgery may be recommended. Spinal instrumentation (i.e. rods, screws) and fusion (bone graft) are common procedures performed to stop slip progression and stabilize the spine. There are different types of instrumentation, bone graft and graft products, as well as procedures (some minimally invasive) to surgically treat degenerative spondylolisthesis. Your surgeon will explain how your surgery will be performed, as well as the benefits and risks of the procedure.

Bone model showing interbody cages, screws and rods

Conclusion 

Degenerative spondylolisthesis does not mean you have to live in pain. We can help you return to a healthy, pain-free and active life. For most patients this is accomplished with nonsurgical treatments. But, even if surgery is needed, be assured we will discuss all procedure risks and benefits and provide you with the best possible care.

In addition treatments, our medical professionals have a deep commitment to patient education. By helping you understand the cause of your condition, we can help you eliminate risk factors and instill spine healthy habits for a lifetime. While you are under our care, our medical staff will provide you with excellent information to help you recover, minimize risk factors, and stay healthy.

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.