clinical presentation and treatment approaches

Curr Rev Musculoskelet Med. 2009 Jun; 2(2): 94–104.

¹ and ²

Kimberley Middleton

¹Department of Physical Medicine and Rehabilitation, University of Washington Medical Center, Seattle, WA USA

David E. Fish

²Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250 16th Street, 7th Floor Tower Building Room 745, Santa Monica, CA 90404 USA

¹Department of Physical Medicine and Rehabilitation, University of Washington Medical Center, Seattle, WA USA

²Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250 16th Street, 7th Floor Tower Building Room 745, Santa Monica, CA 90404 USA

Corresponding author.

Received 2007 Nov 26; Accepted 2009 Feb 25.

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Abstract

Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable. Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine. Back pain has been termed as “an illness in search of a disease. ” Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative. We will elaborate on these degenerative processes and their clinical implications. We will further discuss diagnostic approaches and the efficacy of existing treatment options.

Keywords: Low back pain, Spondylosis, Osteophyte, Degenerative disk disease, Intervertebral osteochondrosis

Introduction

Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives [1–3]. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks [4]. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population [5, 6]. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable [7].

Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country [8]. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine [9]. Back pain has been termed as “an illness in search of a disease” [10]. Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative [11, 12].

We will elaborate on these degenerative processes and their clinical implications. We will further discuss the diagnostic approaches and the efficacy of existing treatment options.

Tackling the terminology

The terms lumbar osteoarthritis, disk degeneration, degenerative disk disease, and spondylosis are used in the literature to describe anatomical changes to the vertebral bodies and intervertebral disk spaces that may be associated with clinical pain syndromes.

Spinal osteoarthritis (OA) is a degenerative process defined radiologically by joint space narrowing, osteophytosis, subchondral sclerosis, and cyst formation [13, 14]. Osteophytes included within this definition fall into one of the two primary clinical categories [14]. The first, spondylosis deformans describes bony outgrowths arising primarily along the anterior and lateral perimeters of the vertebral end-plate apophyses. These hypertrophic changes are believed to develop at sites of stress to the annular ligament and most commonly occur at thoracic T9–10 and lumbar L3 levels [15]. These osteophytes have minimal effect on intervertebral disk height [16] and are frequently asymptomatic, with only rare complications arising from their close anatomic relationship to organs anterior to the spine [15].

By contrast, intervertebral osteochondrosis describes the formation of more pathological end-plate osteophytes, associated with disk space narrowing, vacuum phenomenon, and vertebral body reactive changes [16]. If protruding within the spinal canal or intervertebral foramina, these bony growths may compress nerves with resulting radiculopathy or spinal stenosis. Moreover, these bony projections may limit joint mobility and invade other organs or tissues [14]. The term “osteoarthritis” suggests pathology limited to bone. Nevertheless, in this context, it has clear implications for the health of neighboring disks and nerve roots.

Comparatively, degenerative disk disease (DDD) refers to back pain symptoms attributable to intervertebral disk degeneration. Such pathologic changes include disk desiccation, fibrosis, and narrowing. The anulus may bulge, fissure, or undergo mucinous degeneration. Also included within the anatomic definition of DDD are defects and sclerosis of the end-plates, and osteophytes at the vertebral apophyses [16]. With these bony changes included in the radiographic description of both OA and DDD, there exists diagnostic overlap between the conditions. As a result, these terms are often used interchangeably in the medical literature to describe similar phenomena.

Spondylosis of the lumbar spine, the subject of this paper, is a term with many definitions. In the literature, it has been utilized in many different contexts, employed synonymously with arthrosis, spondylitis, hypertrophic arthritis, and osteoarthritis. In other instances, spondylosis is considered mechanistically, as the hypertrophic response of adjacent vertebral bone to disk degeneration (although osteophytes may infrequently form in the absence of diseased disks) [17]. Finally, spondylosis may be applied nonspecifically to any and all degenerative conditions affecting the disks, vertebral bodies, and/or associated joints of the lumbar spine [17, 18]. For purposes of this review, we will use this final, broad definition of spondylosis, recognizing the high incidence of coincident degenerative changes, and the dynamic interplay between adjacent disks, vertebra, and nerves that create the clinical pain syndromes within the axial spine and associated nerves.

Epidemiology

Degenerative spine changes are remarkably common in population studies. Symmons’ et al. [19] study of individuals aged 45–64 years identified 85.5% of participants to demonstrate osteophytes within the lumbar spine. O’Neill et al. [20] explored osteophytosis within a UK adult population over age 50 years, finding 84% of men and 74% of women to demonstrate at least one vertebral osteophyte, with increased incidence among individuals with more physical activity, self reported back pain, or higher BMI scores. Despite marked variability within the population, men appear to have more significant degenerative changes than women, both with regard to number and severity of osteophyte formation [20].

Radiographic evidence of degenerative disease of the lumbar spine among asymptomatic individuals is impressive. MRI imaging in asymptomatic patients over age 60 years reveals disk protrusions in 80% [21] and degenerative spinal stenosis in 20% [11]. A study comparing radiographic evidence of spine degeneration among categories of men who were without pain, with moderate pain, or with severe lower back pain found similar frequency of disk space narrowing and bone spurs among all three groups [22].

Furthermore, degenerative changes may appear in young individuals without decades of spine loading. Lawrence [23] found 10% of women aged 20–29 to demonstrate evidence of disk degeneration. Lumbar spondylosis, while affecting 80% of patients older than 40 years, nevertheless was found in 3% of individuals aged 20–29 years in one study [15]. The high incidence of degeneration among young and asymptomatic individuals highlights the challenge involved in establishing causality between imaging findings and pain symptoms in affected patients.

Pathogenesis

The high incidence of simultaneous degenerative changes to the intervertebral disk, vertebral body, and associated joints suggests a progressive and dynamic mechanism, with interdependent changes occurring secondary to disk space narrowing [17].

Intervertebral disks are believed to undergo what Kirkaldy Willis and Bernard [24] first coined a “degenerative cascade” (Fig. ) of three overlapping phases that may occur over the course of decades. Phase I (Dysfunction Phase) describes the initial effects of repetitive microtrauma with the development of circumferential painful tears of the outer, innervated anulus, and associated end-plate separation that may compromise disk nutritional supply and waste removal. Such tears may coalesce to become radial tears, more prone to protrusion, and impact the disk’s capacity to maintain water, resulting in desiccation and reduced disk height. Fissures may become ingrown by vascular tissue and nerve endings, increasing innervation and the disk’s capacity for pain signal transmission [25]. Phase II (Instability Phase) is characterized by the loss of mechanical integrity, with progressive disk changes of resorption, internal disruption, and additional annular tears, combined with further facet degeneration that may induce subluxation and instability. During Phase III (Stabilization Phase), continued disk space narrowing and fibrosis occurs along with the formation of osteophytes and transdiscal bridging [26].

The spectrum of pathological changes in facial joints and the disk and the interaction of these changes. The upper light horizontal bar represents dysfunction, the middle darker bar instability, and the lower dark bar stabilization

Schneck presents a further mechanical progression, building upon this degenerative cascade of the intervertebral disk, to explain other degenerative changes of the axial spine. He proposes several implications of disk space narrowing. Adjacent pedicles approximate with a narrowing of the superior–inferior dimension of the intervertebral canal. Laxity due to modest redundancy of the longitudinal ligaments enables bulging of the ligamentum flavum and potential for spine instability. Increased spine movement permits subluxation of the superior articular process (SAP), causing a narrowed anteroposterior dimension of the intervertebral and upper nerve root canals. Laxity may also translate into altered weight mechanisms and pressure relationships on vertebral bone and joint spaces believed to influence osteophyte formation and facet hypertrophy to both inferior and superior articular processes with risks for projection into the intervertebral canal and central canal, respectively. Oblique orientations of the articular processes may further cause retrospondylolisthesis, with resulting anterior encroachment of the spinal canal, nerve root canal, and intervertebral canal [17].

Biochemical research exploring osteophyte formation supports the above process. Osteophyte lipping is believed to form at periosteum [27] through the proliferation of peripheral articular cartilage which subsequently undergoes endochondral calcification and ossification [28]. Changing weight mechanics and pressure forces as well as alterations in oxygen tension and dynamic fluid pressure appear to be influential factors in osteophyte formation [14]. Mesenchymal stem cells of the synovium or periostium are likely precursors, with synovial macrophages and a milieu of growth factors and extracellular matrix molecules acting as probable mediators in this process [29].

Clinical presentation

Pain within the axial spine at the site of these degenerate changes is not surprising as nociceptive pain generators have been identified within facet joints, intervertebral disks, sacroiliac joints, nerve root dura, and myofascial structures within the axial spine [9].

These degenerative anatomical changes may culminate in a clinical presentation of spinal stenosis, or narrowing within the spinal canal [30] through progressive ingrowth of osteophytes, hypertrophy of the inferior articular process [31], disk herniation, bulging of the ligamentum flavum [17], or spondylolisthesis. The clinical result: a constellation of pain symptoms encompassed in the term neurogenic claudication (NC). NC may include (to varying extents) lower back pain, leg pain, as well as numbness and motor weakness to lower extremities that worsen with upright stance and walking, and improve with sitting and supine positioning [30].

Clinical presentations of radiculopathy may emanate from many sources, all of which can be explained by the degenerative process. Disk bulging may affect descending rootlets of the cauda equina, nerve roots exiting at the next lower intervertebral canal, or the spinal nerve within its ventral ramus, if protruding centrally, posterolaterally, or laterally, respectively [32]. Osteophyte lipping along the posterior aspect of vertebral bodies, along upper or lower margins, may similarly impinge upon the same neural structures as the bulging disk just described [17, 33]. Hypertrophic changes to the superior articular process may intrude upon nerve roots within the upper nerve root canal, dural sac, or prior to exiting from next lower intervertebral canal, depending on their projection [34]. These theoretical forms of impingement have been substantiated through cadaver studies. A 70% reduction or 30% residual diameter of neuroforminal space is cited as the critical amount of occlusion to induce neural compromise [15]. Moreover, compression of the posterior disk to less than 4 mm height, or foraminal height to less than 15 mm has also been determined as critical dimensions for foraminal stenosis and nerve impingement [35].

Etiology/risk factors

What factors mediate this degenerative progression? What leads a large portion of the population to manifest spondylosis, even early on in their lives? Given the substantial variability in the number and degree of spine changes observed in individuals and the wide range of clinical presentations, answers to these questions hold promise to broaden treatment options.

The influence of age

Large studies of osteoarthritis have long recognized the aging process to be the strongest risk factor for bony degeneration, particularly within the spine [36]. An extensive autopsy study in 1926 reported evidence of spondylitis deformans to increase in a linear fashion from 0% to 72% between the ages of 39 and 70 years [37]. A subsequent autopsy study by Miller et al. [38] similarly noted an increase in disk degeneration from 16% at age 20 to about 98% at age 70 years based on macroscopic disk degeneration grades of 600 specimens. Other studies corroborate this finding [20, 39].

The associations are nevertheless imperfect. Kramer [40] found increasing age to be significantly associated with osteophyte formation but not predictive of the degree of disk space narrowing observed in a retrospective review of radiographs of women. She observed significant variability, noting “although few younger women have high average scores, some older women have no radiographic sign of OA, while others are severely affected. ” Multiple studies have also demonstrated the presence of significant lumbar degeneration to be evident even within the first two decades [38, 39]. Such variability within members of the same age category suggests the influence of other contributing factors.

The impact of activity and occupation

Disk generation has long been associated with certain activities. Retrospective studies cite Body Mass Index (BMI), incident back trauma, daily spine loading (twisting, lifting, bending, and sustained nonneutral postures), and whole body vibration (such as vehicular driving) to be factors which increase both the likelihood and severity of spondylosis [20, 41]. While these correlations exist, a study following progressive radiographic changes in lumber DDD did not find significant associations with the extent of physical activity, noting only age, back pain, and associated hip OA to be predictive of DDD and osteophyte changes [42].

The role of heredity

Genetic factors likely influence the formation of osteophytes and disk degeneration. Spector and MacGregor [43] proposed that 50% of the variability found in osteoarthritis can be attributed to heritable factors. Similarly, twin studies evaluating the progression of degenerative changes in lumbar MRI imaging suggest that approximately half (47–66%) of the variance could be explained by genetic and environmental factors, attributing only 2–10% of variance to physical loading and resistance training [44]. Another twin study revealed a high degree of similarity in signal intensity, disk height narrowing, disk bulging, and end-plate changes [45]. A search for these underlying genetic factors has identified polymorphisms in genes regulating inflammatory pathways and a Vitamin D Receptor allele to correspond to radiographic progression of lumbar disk degeneration [46].

A functional adaptation?

Is osteophyte formation inherently pathological? van der Kraan and van den Berg question if osteophyte formation may represent a remodeling process, functionally adapting to the instability or the changes in the demands of the spine [14]. Likewise, Humzah and Soames [47] emphasize the dynamic and reparative qualities of the intervertebral disk, responding to variations in mechanical loading and influencing vertebral kinematics to extend this argument. Osteophytes may form in the absence of other degenerative processes, and cartilaginous damage may exist without corresponding osteophytes [14]. Although there remains a strong association between the presence of osteophytes and other degenerative spine changes, isolated instances of one without the other occur, in the absence of overt symptoms.

A diagnostic approach

The initial evaluation for patients with low back pain begins with an accurate history and thorough physical exam with appropriate provocative testing. These first steps are complicated by the subjectivity of patient experiences of chronic spinal pain and the inherent difficulty isolating the anatomic region of interest during provocative testing without the influence of neighboring structures.

Radiographic studies, whether plain film, CT, CT myelogram, or MRI, may provide useful confirmatory evidence to support an exam finding and localize a degenerative lesion or area of nerve compression. However, imaging is an imperfect science, identifying the underlying cause of LBP in only 15% of patients in the absence of clear disk herniation or neurological deficit [25]. Furthermore, there remains a frequent disconnection between the symptom severity and the degree of anatomical or radiographic changes [18]. While correlations between the number and severity of osteophytes and back pain exist [20, 22], the prevalence of degenerative changes among asymptomatic patients underlies the difficulty assigning clinical relevance to observed radiographic changes in patients with LBP.

Nerve compression symptoms by clinical history may also be confirmed by electromyographic studies demonstrating normal distal motor and sensory nerve conduction studies with abnormal needle exam. Diagnostic injections can facilitate localization by isolating and anesthetizing irritated nerve roots (via epidural), or by blocking suspected pain generators within facet joints, sacroiliac joints, or the disk space itself (via discography) [48].

Intervention and treatment options

Given our limited ability to isolate causative sources of chronic lower back pain, there is a little consensus with regard to a definitive treatment approach. Substantial variation in management by conservative and invasive approaches exists between practitioners throughout the country [8]. We will briefly describe these treatment options for the management of chronic low back pain syndromes within each of the four primary categories: physical therapy (and associated modalities and behavioral techniques), pharmacotherapy, injection therapy, and surgical intervention.

Exercise-based and behavioral interventions

Exercise therapy

Exercise therapy (ET) remains one of the conservative mainstays of treatment for chronic lumbar spine pain, and may be tailored to include aerobic exercise, muscle strengthening, and stretching exercises [49]. Significant variation in regimen, intensity, and frequency of prescribed programs presents challenges to assessing efficacy among patients [50]. One meta-analysis of the current literature exploring the role of ET in patients with varying duration of symptoms found a graded exercise program implemented within the occupational setting demonstrated some effectiveness in subacute LBP. Among those suffering chronic pain symptoms, small, but statistically significant improvements were observed among patients, with regard to pain reduction and functional improvement [49]. The optimal approach to exercise therapy in chronic low back pain sufferers appears to be those regimens involving an individually-designed exercise program emphasizing stretching and muscle strengthening, administered in a supervised fashion, with high frequency and close adherence. Such results are complemented by other conservative approaches, including NSAIDS, manual therapies, and daily physical activity [50].

Transcutaneous electrical nerve stimulation (TENS)

A “TENS” unit is a therapeutic modality involving skin surface electrodes which deliver electrical stimulation to peripheral nerves in an effort to relieve pain noninvasively. Such devices are frequently available in outpatient exercise therapy settings, with up to a third of patients experiencing mild skin irritation following treatment [51]. While one small study identified an immediate reduction in pain symptoms 1 h following TENS application, there remains little evidence of long-term relief. Another larger study did not discover significant improvement with TENS compared with placebo with regard to pain, functional status, or range of motion [52, 53].

Back school

Back School was introduced first in Sweden with the purpose of minimizing lower back pain symptoms and their reoccurrence through review with patients of lumbar anatomy, concepts of posture, ergonomics, and appropriate back exercises [54]. Two meta-analyses concluded that there is moderate evidence for improvement in both pain and functional status for chronic low back pain within short and intermediate time courses, when measured against other modalities such as exercise, joint manipulation, myofascial therapy, and/or other educational therapy [52, 54].

Lumbar supports

Lumbar back supports may provide benefit to patients suffering chronic LBP secondary to degenerative processes through several potential, debated mechanisms. Supports are designed to limit spine motion, stabilize, correct deformity, and reduce mechanical forces. They may further have effects by massaging painful areas and applying beneficial heat; however, they may also function as a placebo. There is moderate available evidence evaluating efficacy of lumbar supports within a mixed population of acute, subacute, and chronic LBP sufferers to suggest that lumbar supports are not more effective than other treatment forms; data is conflicting with regard to patient improvement and functional ability to return to work [52].

Traction

Lumbar traction applies a longitudinal force to the axial spine through use of a harness attached to the iliac crest and lower rib cage to relieve chronic low back pain. The forces, which open intervertebral space and decrease spine lordosis, are adjusted both with regard to level and duration and may closely be measured in motorized and bed rest devices. Temporary spine realignments are theorized to improve symptoms related to degenerative spine disease by relieving mechanical stress, nerve compression, and adhesions of the facet and annulus, as well as through disruption of nociceptive pain signals [52]. Nonetheless, patients with chronic symptoms and radicular pain have not found traction to provide significant improvement in pain nor daily functioning [55–57]. Little is known with regard to the risks associated with the applied forces. Isolated case reports cite nerve impingement with heavy forces, and the potential for respiratory constraints or blood pressure changes due to the harness placement and positioning [52].

Spine manipulation

Spine manipulation is a manual therapy approach involving low-velocity, long lever manipulation of a joint beyond the accustomed, but not anatomical range of motion. The precise mechanism for improvement in low back pain sufferers remains unclear. Manipulative therapy may function through: “(1) release for the entrapped synovial folds, (2) relaxation of hypertonic muscle, (3) disruption of articular or periarticular adhesion, (4) unbuckling of motion segments that have undergone disproportionate displacement, (5) reduction of disk bulge, (6) repositioning of miniscule structures within the articular surface, (7) mechanical stimulation of nociceptive joint fibers, (8) change in neurophysiological function, and (9) reduction of muscle spasm” [58].

Available research regarding its efficacy in the context of chronic LBP finds spinal manipulation to be “more effective” compared to sham manipulation with regard to both short- and long-term relief of pain, as well as short-term functional improvement [52]. Compared with other conventional, conservative treatment approaches such as exercise therapy, back school, and NSAID prescription, spinal manipulation appears comparable in its effectiveness both in short- and long-term benefits [52, 59]. Research exploring the safety of such therapy among trained therapists found a very low risk of complications, with clinically worsened disk herniation or cauda equina syndrome occurring in fewer than 1/3.7 million [60].

Massage therapy

Massage therapy for chronic LBP appears to provide some beneficial relief. Weighed against other interventions, it proved less efficacious than TENS and manipulation, comparable with corsets and exercise regimens, and superior to acupuncture and other relaxation therapies, when followed over a 1-year course. Such preliminary results need confirmation, and evaluation for cost-effectiveness, but nevertheless suggest a potential role in certain, interested patients [61].

Multidisciplinary back therapy: the bio-psychosocial approach

Psychopathology is well recognized for its association with chronic spinal pain, and, when untreated, its ability to compromise management efforts [25]. For this reason, patients may find relief through learned cognitive strategies, termed “behavioral”, or “bio-psychosocial” therapy. Strategies involving reinforcement, modified expectations, imagery/relaxation techniques, and learned control of physiological responses aim to reduce a patient’s perception of disability and pain symptoms. To date, evidence is limited with regard to the efficacy of operant, cognitive, and respondent treatment approaches [52].

Pharmacotherapy

Treatment efforts to control pain and swelling, minimize disability, and improve the quality of life with lumbar spondylosis often require medication to complement nonpharmacologic interventions. Extensive research efforts have explored the efficacy of different oral medications in the management of low back pain secondary to degenerative processes. Nonetheless, there remains no clear consensus regarding the gold-standard approach to pharmacologic management [62].

NSAIDS

NSAIDS are widely regarded as an appropriate first step in management, providing analgesic and anti-inflammatory effects. There is adequate data demonstrating efficacy in pain reduction in the context of chronic low back pain [63–66], with use most commonly limited by gastrointestinal (GI) complaints. COX2 inhibitors offer modest relief in chronic LBP and improved function in the long-term setting. While they elicit fewer GI complications, their utilization has been curbed due to evidence for increased cardiovascular risk with prolonged use [52].

Opioid medications

Opioid medications may be considered as an alternative or augmentive therapy for patients suffering from gastrointestinal effects or poor pain control on NSAID management. The practice of prescribing narcotics for chronic low back pain sufferers is extremely variable within practitioners, with a range of 3–66% of chronic LBP patients taking some form of opioid in various literature studies [67]. These patients tend to report greater distress/suffering and higher functional disability scores [68, 69]. Two meta-analyses suggest a modest short-term benefit of opioid use for treatment of chronic LBP while issuing a warning regarding the limited quality of available studies and the high rate of tolerance and abuse associated with long-term narcotic use within this patient population [62, 67].

Antidepressants

The use of antidepressants for treatment of LBP symptoms has also been explored considerably given their proposed analgesic value at low doses, and dual role in treatment of commonly comorbid depression that accompanies LBP and may negatively impact both sleep and pain tolerance [52]. Two separate reviews of available literature found evidence for pain relief with antidepressants, but no significant impact on functioning [70, 71].

Muscle relaxants

Muscle relaxants, taking the form of either antispasmodic or antispasticity medications, may provide benefit in chronic low back pain attributed to degenerative conditions. There remains moderate to strong evidence through several trials comparing either a benzodiazepine, or non-benzodiazepine with placebo that muscle relaxants provide benefit with regard to short-term pain relief and overall functioning [52, 62, 72].

Injection therapy

Epidural steroid injections

Epidural steroid injections (ESI) have become a common interventional strategy in the management of chronic axial and radicular pain due to degeneration of the lumbar spine. These injections may be performed through interlaminar, transforaminal, or caudal approaches. Usually by way of needles guided under fluoroscopy, contrast, then local anesthetic and steroid are infused into the epidural space at the target vertebral level and bathe exiting nerve roots. Symptomatic relief is theorized to occur through complementary mechanisms. Local anesthetics provide quick diagnostic confirmation, and therapeutically may short circuit the “pain spasm cycle” and block pain signal transmission [73]. Corticosteroids are well recognized for their capacity to reduce inflammation through blockade of pro-inflammatory mediators.

Within the span of less than one decade (1998–2005), the number of ESI procedures performed has increased by 121% [73]. Despite this widespread utilization, controversy remains regarding the efficacy of these injections, fueled by the expense and the infrequent but potential risks related to needle placement and adverse medication reactions. Available published data cites wide ranges in reported success rates due to variation in study designs, distinct procedural techniques, small cohorts, and imperfect control groups [74]. For example, prior to the year 2000, few efficacy studies of lumbar ESI utilized fluoroscopy to establish appropriate needle position. Research suggests that without fluoroscopic guidance confirmation, needle position may be inappropriate in as frequently as 25% of cases, even with experienced providers [75]. Review articles and practicing clinicians alike must interpret such methodological differences between studies to assemble opinions on efficacy and utility of ESI for LBP treatment.

One such review exploring efficacy of interlaminar lumbar injections concluded strong evidence for short-term pain relief and limited benefit for long-term benefit [73] citing, among many, randomized controlled trials (RCT) by Arden and Carette of unilateral sciatic pain, finding statistically significant improvement in up to 75% of patients with steroid/anesthesia versus saline injections at 3 weeks, with benefit waning by 6 weeks and 3 months, respectively [76, 77].

The same review evaluating the transforaminal injection approach to unilateral sciatica found strong evidence for short-term, and moderate evidence for long-term symptom and functional improvement, based on the findings from several RCT. Vad et al. [78] studied 48 patients with herniated nucleus pulposus or radicular pain, treated with transforaminal ESI versus trigger point injections, citing an 84% improvement in functional scoring compared with 48% in the control group, extending for a follow-up period of 1 year. Lutz et al. [79] treated and followed a different cohort of 69 patients with the same underlying diagnoses, with transforaminal ESI for 80 weeks demonstrating 75% of patients with a successful long-term outcome, defined as >50% reduction in pain scores. In spinal stenosis, transforaminal ESI has achieved >50% pain reduction, improved walking, and improved standing tolerance in symptomatic patients extending through 1 year follow-up [80]. Furthermore, prospective trials by Yang and Riew found patients with severe lumbar radiculopathies and spinal stenosis treated with transforaminal injections experienced such sustained functional and symptomatic benefits so as to avoid intended surgical intervention [81–83].

Facet injections

Facet joints, also termed zygapophysial joints, are paired diarthrodial articulations between adjacent vertebrae. These joints are innervated from the medial branches of the dorsal rami and, through anatomical studies, possess free and encapsulated nerve endings, mechanoreceptors, and nociceptors. Inflammation to the joint creates pain signals which are implicated in 15–45% of patients with low back pain [25].

Diagnostic blocks of the joint inject anesthesia directly into the joint space or associated medial branch (MBB). Systematic reviews of both retrospective and prospective trials reveal single diagnostic facet blocks carry a false-positive rate of 22% to 47% [84] and medial branch blocks of 17–47% in the lumbar spine [85].

Subsequent therapeutic injections are similarly performed through either approach, with systematic reviews concluding moderate evidence available for short-term and long-term pain relief with facet blocks [86]. This evidence stems from studies such as Fuch’s RCT showing significant pain relief, functional improvement, and quality of life enhancement at 3 and 6 month intervals [87]. By contrast, Carette et al. [88] found no meaningful difference in perceived benefit between patients treated with steroid versus saline (control) injection at 3 and 6 month intervals. Available literature of MBB similarly show moderate evidence for short- and long-term relief [86] based on RCT of MBB under fluoroscopy, showing significant relief (by means of pain relief, physical health, psychological benefit, reduced narcotic intake, and employment status), with 1–3 injections in 100% patients at 3 months, 75–88% at 6 months, and 17–25% at 1 year [89].

SI joint injections

The sacroiliac joint space is a diarthrodial synovial joint with debated innervation patterns that involve both myelinated and unmyelinated axons. Injury or inflammation at the joint creates pain signals which are implicated in 10–27% of patients with low back pain [25] and may also refer to the buttocks, groin, thigh, and lower extremities.

There is moderate evidence to support the use of both diagnostic and therapeutic blocks of the SI joint [25]. Pereira treated 10 patients with MRI-guided bilateral SI joint injections of steroid, eight of whom reported “good to excellent” pain relief persisting through 13 months follow-up [90]. Maugers compared corticosteroid versus placebo injections under fluoroscopic guidance in SI joints of 10 symptomatic patients, reporting patient benefit only in the corticosteroid group. That benefit waned slowly over time, from 70% of patients at 1 month, to 62% at 3 months, and 58% at 6 months [91]. At this point, there is limited evidence to support radiofrequency neurotomy (ablation procedure) of the SI joint [92].

A recent meta-analysis provided the following guiding principles with regard to the frequency these procedures should be implemented in clinical practice. In cases of ESI, facet, and sacroiliac injections, diagnostic injections should be considered at intervals of no sooner than 1–2 weeks apart. Therapeutic injections may be performed at most every 2–3 months, provided the patient experiences greater than 50% relief within 6 weeks. Injections should be performed only as they are medically necessary given their associated risks and significant costs [25].

Intradiscal nonoperative therapies for discogenic pain

Discogenic pain has been identified as the source in 39% of patients with chronic low back pain. As described above, a cascade of effects induces the changes in the disk which generate pain. Discography seeks, when noninvasive imaging has failed, to identify damaged disks through injection of fluid into disk levels, in an attempt to reproduce patient symptoms. The technique’s utility remains controversial given significant potential for false positives. Provoked pain may be alternatively represent central hyperalgesia, reflect the patient’s chronic pain or psychological state, or result from technical difficulty due to the procedure itself [93].

If a diseased disk is identified, several treatment options exist. In addition to surgical correction, there are minimally invasive options. Both Intradiscal electrothermal therapy (IDET) and Radiofrequency posterior annuloplasty (RPA) involve electrode placement into the disk. Heat and electrical current coagulate the posterior anulus, and in doing so, strengthen collagen fibers, seal figures, denature inflammatory exudates, and coagulate nociceptors [25]. Current evidence provides moderate support for IDET in discogenic pain sufferers. Preliminary studies of RPA provide limited support for short term relief, with indeterminate long-term value. Both procedures have associated complications, including catheter malfunction, nerve root injuries, post-procedure disk herniation, and infection risk [25].

Surgical options

Surgical interventions are generally reserved for patients who have failed conservative options. Patients must be considered as appropriate “surgical candidates,” taking into consideration medical comorbidities as well as age, socioeconomic status, and projected activity level following a procedure [18]. Many surgical approaches have been developed to achieve one of the two primary goals: spinal fusion or spine decompression (or both).

Spinal fusion is considered in patients with malalignment or excessive motion of the spine, as seen with DDD and spondylolisthesis. Several surgical fusion approaches exist, all involving the addition of a bone graft to grow between vertebral elements to limit associated motion. Decompression surgery is indicated for patients with clear evidence of neural impingement, correcting the intrusion of bone or disk as might be seen in spinal or foraminal stenosis, disk herniation, osteophytosis, or degenerative spondylolisthesis. Despite dramatic increases in the number of procedures performed over the last several decades, there remains controversy as to the efficacy of these procedures in resolving chronic low back unresponsive to conservative management.

Controversy arises, in part, due to the inherent challenges of comparing the available research. Systematic reviews cite the heterogeneity of current trials which evaluate different surgical techniques with differing comparison groups and limited follow-up, frequently without patient-centered or pain outcomes included [18]. Some case series reveal promising results [94]. Nonetheless, a recent meta-analysis of 31 randomized controlled trials, concluded, “[there is] no clear evidence about the most effective technique of decompression for spinal stenosis or the extent of that decompression. There is limited evidence that adjunct fusion to supplement decompression for degenerative spondylolisthesis produces less progressive slip and better clinical outcomes than decompression alone.” Another review, noting no statistically significant improvement in patients undergoing fusion compared with nonsurgical interventions commented, “surgeons should recommend spinal fusion cautiously to patients with chronic low back pain. Further long-term follow-ups of the studies reviewed in this meta-analysis are required to provide more conclusive evidence in favor of either treatment” [95].

Conclusion

Lumbar spondylosis is a complicated diagnosis. We chose to define it broadly as degenerative conditions of the spine, but definitions vary widely within the literature. While it may not present a challenge to identify radiographically, its pervasiveness throughout all patient populations makes the exact diagnosis of symptomatic cases extremely difficult. Moreover, there is no current concrete, gold-standard treatment approach to the diverse range of patient presentations despite substantial research efforts to identify conservative and more invasive methods of managing symptoms and slowing progressive decline. Given the morbidity of low back pain within the population and its social and economic implications, this area will continue to be a critical research focus. Important clues are in place, from genetic studies, risk factor analysis, and explorative treatment approaches. These efforts, and future endeavors will no doubt fine-tune and present means to tackle not only symptoms, but confront progression, and ultimately prevention of disease in years to come.

Open Access

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clinical presentation and treatment approaches

Curr Rev Musculoskelet Med. 2009 Jun; 2(2): 94–104.

¹ and ²

Kimberley Middleton

¹Department of Physical Medicine and Rehabilitation, University of Washington Medical Center, Seattle, WA USA

David E. Fish

²Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250 16th Street, 7th Floor Tower Building Room 745, Santa Monica, CA 90404 USA

¹Department of Physical Medicine and Rehabilitation, University of Washington Medical Center, Seattle, WA USA

²Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250 16th Street, 7th Floor Tower Building Room 745, Santa Monica, CA 90404 USA

Corresponding author.

Received 2007 Nov 26; Accepted 2009 Feb 25.

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

This article has been cited by other articles in PMC.

Abstract

Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable. Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine. Back pain has been termed as “an illness in search of a disease.” Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative. We will elaborate on these degenerative processes and their clinical implications. We will further discuss diagnostic approaches and the efficacy of existing treatment options.

Keywords: Low back pain, Spondylosis, Osteophyte, Degenerative disk disease, Intervertebral osteochondrosis

Introduction

Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives [1–3]. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks [4]. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population [5, 6]. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable [7].

Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country [8]. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine [9]. Back pain has been termed as “an illness in search of a disease” [10]. Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative [11, 12].

We will elaborate on these degenerative processes and their clinical implications. We will further discuss the diagnostic approaches and the efficacy of existing treatment options.

Tackling the terminology

The terms lumbar osteoarthritis, disk degeneration, degenerative disk disease, and spondylosis are used in the literature to describe anatomical changes to the vertebral bodies and intervertebral disk spaces that may be associated with clinical pain syndromes.

Spinal osteoarthritis (OA) is a degenerative process defined radiologically by joint space narrowing, osteophytosis, subchondral sclerosis, and cyst formation [13, 14]. Osteophytes included within this definition fall into one of the two primary clinical categories [14]. The first, spondylosis deformans describes bony outgrowths arising primarily along the anterior and lateral perimeters of the vertebral end-plate apophyses. These hypertrophic changes are believed to develop at sites of stress to the annular ligament and most commonly occur at thoracic T9–10 and lumbar L3 levels [15]. These osteophytes have minimal effect on intervertebral disk height [16] and are frequently asymptomatic, with only rare complications arising from their close anatomic relationship to organs anterior to the spine [15].

By contrast, intervertebral osteochondrosis describes the formation of more pathological end-plate osteophytes, associated with disk space narrowing, vacuum phenomenon, and vertebral body reactive changes [16]. If protruding within the spinal canal or intervertebral foramina, these bony growths may compress nerves with resulting radiculopathy or spinal stenosis. Moreover, these bony projections may limit joint mobility and invade other organs or tissues [14]. The term “osteoarthritis” suggests pathology limited to bone. Nevertheless, in this context, it has clear implications for the health of neighboring disks and nerve roots.

Comparatively, degenerative disk disease (DDD) refers to back pain symptoms attributable to intervertebral disk degeneration. Such pathologic changes include disk desiccation, fibrosis, and narrowing. The anulus may bulge, fissure, or undergo mucinous degeneration. Also included within the anatomic definition of DDD are defects and sclerosis of the end-plates, and osteophytes at the vertebral apophyses [16]. With these bony changes included in the radiographic description of both OA and DDD, there exists diagnostic overlap between the conditions. As a result, these terms are often used interchangeably in the medical literature to describe similar phenomena.

Spondylosis of the lumbar spine, the subject of this paper, is a term with many definitions. In the literature, it has been utilized in many different contexts, employed synonymously with arthrosis, spondylitis, hypertrophic arthritis, and osteoarthritis. In other instances, spondylosis is considered mechanistically, as the hypertrophic response of adjacent vertebral bone to disk degeneration (although osteophytes may infrequently form in the absence of diseased disks) [17]. Finally, spondylosis may be applied nonspecifically to any and all degenerative conditions affecting the disks, vertebral bodies, and/or associated joints of the lumbar spine [17, 18]. For purposes of this review, we will use this final, broad definition of spondylosis, recognizing the high incidence of coincident degenerative changes, and the dynamic interplay between adjacent disks, vertebra, and nerves that create the clinical pain syndromes within the axial spine and associated nerves.

Epidemiology

Degenerative spine changes are remarkably common in population studies. Symmons’ et al. [19] study of individuals aged 45–64 years identified 85.5% of participants to demonstrate osteophytes within the lumbar spine. O’Neill et al. [20] explored osteophytosis within a UK adult population over age 50 years, finding 84% of men and 74% of women to demonstrate at least one vertebral osteophyte, with increased incidence among individuals with more physical activity, self reported back pain, or higher BMI scores. Despite marked variability within the population, men appear to have more significant degenerative changes than women, both with regard to number and severity of osteophyte formation [20].

Radiographic evidence of degenerative disease of the lumbar spine among asymptomatic individuals is impressive. MRI imaging in asymptomatic patients over age 60 years reveals disk protrusions in 80% [21] and degenerative spinal stenosis in 20% [11]. A study comparing radiographic evidence of spine degeneration among categories of men who were without pain, with moderate pain, or with severe lower back pain found similar frequency of disk space narrowing and bone spurs among all three groups [22].

Furthermore, degenerative changes may appear in young individuals without decades of spine loading. Lawrence [23] found 10% of women aged 20–29 to demonstrate evidence of disk degeneration. Lumbar spondylosis, while affecting 80% of patients older than 40 years, nevertheless was found in 3% of individuals aged 20–29 years in one study [15]. The high incidence of degeneration among young and asymptomatic individuals highlights the challenge involved in establishing causality between imaging findings and pain symptoms in affected patients.

Pathogenesis

The high incidence of simultaneous degenerative changes to the intervertebral disk, vertebral body, and associated joints suggests a progressive and dynamic mechanism, with interdependent changes occurring secondary to disk space narrowing [17].

Intervertebral disks are believed to undergo what Kirkaldy Willis and Bernard [24] first coined a “degenerative cascade” (Fig. ) of three overlapping phases that may occur over the course of decades. Phase I (Dysfunction Phase) describes the initial effects of repetitive microtrauma with the development of circumferential painful tears of the outer, innervated anulus, and associated end-plate separation that may compromise disk nutritional supply and waste removal. Such tears may coalesce to become radial tears, more prone to protrusion, and impact the disk’s capacity to maintain water, resulting in desiccation and reduced disk height. Fissures may become ingrown by vascular tissue and nerve endings, increasing innervation and the disk’s capacity for pain signal transmission [25]. Phase II (Instability Phase) is characterized by the loss of mechanical integrity, with progressive disk changes of resorption, internal disruption, and additional annular tears, combined with further facet degeneration that may induce subluxation and instability. During Phase III (Stabilization Phase), continued disk space narrowing and fibrosis occurs along with the formation of osteophytes and transdiscal bridging [26].

The spectrum of pathological changes in facial joints and the disk and the interaction of these changes. The upper light horizontal bar represents dysfunction, the middle darker bar instability, and the lower dark bar stabilization

Schneck presents a further mechanical progression, building upon this degenerative cascade of the intervertebral disk, to explain other degenerative changes of the axial spine. He proposes several implications of disk space narrowing. Adjacent pedicles approximate with a narrowing of the superior–inferior dimension of the intervertebral canal. Laxity due to modest redundancy of the longitudinal ligaments enables bulging of the ligamentum flavum and potential for spine instability. Increased spine movement permits subluxation of the superior articular process (SAP), causing a narrowed anteroposterior dimension of the intervertebral and upper nerve root canals. Laxity may also translate into altered weight mechanisms and pressure relationships on vertebral bone and joint spaces believed to influence osteophyte formation and facet hypertrophy to both inferior and superior articular processes with risks for projection into the intervertebral canal and central canal, respectively. Oblique orientations of the articular processes may further cause retrospondylolisthesis, with resulting anterior encroachment of the spinal canal, nerve root canal, and intervertebral canal [17].

Biochemical research exploring osteophyte formation supports the above process. Osteophyte lipping is believed to form at periosteum [27] through the proliferation of peripheral articular cartilage which subsequently undergoes endochondral calcification and ossification [28]. Changing weight mechanics and pressure forces as well as alterations in oxygen tension and dynamic fluid pressure appear to be influential factors in osteophyte formation [14]. Mesenchymal stem cells of the synovium or periostium are likely precursors, with synovial macrophages and a milieu of growth factors and extracellular matrix molecules acting as probable mediators in this process [29].

Clinical presentation

Pain within the axial spine at the site of these degenerate changes is not surprising as nociceptive pain generators have been identified within facet joints, intervertebral disks, sacroiliac joints, nerve root dura, and myofascial structures within the axial spine [9].

These degenerative anatomical changes may culminate in a clinical presentation of spinal stenosis, or narrowing within the spinal canal [30] through progressive ingrowth of osteophytes, hypertrophy of the inferior articular process [31], disk herniation, bulging of the ligamentum flavum [17], or spondylolisthesis. The clinical result: a constellation of pain symptoms encompassed in the term neurogenic claudication (NC). NC may include (to varying extents) lower back pain, leg pain, as well as numbness and motor weakness to lower extremities that worsen with upright stance and walking, and improve with sitting and supine positioning [30].

Clinical presentations of radiculopathy may emanate from many sources, all of which can be explained by the degenerative process. Disk bulging may affect descending rootlets of the cauda equina, nerve roots exiting at the next lower intervertebral canal, or the spinal nerve within its ventral ramus, if protruding centrally, posterolaterally, or laterally, respectively [32]. Osteophyte lipping along the posterior aspect of vertebral bodies, along upper or lower margins, may similarly impinge upon the same neural structures as the bulging disk just described [17, 33]. Hypertrophic changes to the superior articular process may intrude upon nerve roots within the upper nerve root canal, dural sac, or prior to exiting from next lower intervertebral canal, depending on their projection [34]. These theoretical forms of impingement have been substantiated through cadaver studies. A 70% reduction or 30% residual diameter of neuroforminal space is cited as the critical amount of occlusion to induce neural compromise [15]. Moreover, compression of the posterior disk to less than 4 mm height, or foraminal height to less than 15 mm has also been determined as critical dimensions for foraminal stenosis and nerve impingement [35].

Etiology/risk factors

What factors mediate this degenerative progression? What leads a large portion of the population to manifest spondylosis, even early on in their lives? Given the substantial variability in the number and degree of spine changes observed in individuals and the wide range of clinical presentations, answers to these questions hold promise to broaden treatment options.

The influence of age

Large studies of osteoarthritis have long recognized the aging process to be the strongest risk factor for bony degeneration, particularly within the spine [36]. An extensive autopsy study in 1926 reported evidence of spondylitis deformans to increase in a linear fashion from 0% to 72% between the ages of 39 and 70 years [37]. A subsequent autopsy study by Miller et al. [38] similarly noted an increase in disk degeneration from 16% at age 20 to about 98% at age 70 years based on macroscopic disk degeneration grades of 600 specimens. Other studies corroborate this finding [20, 39].

The associations are nevertheless imperfect. Kramer [40] found increasing age to be significantly associated with osteophyte formation but not predictive of the degree of disk space narrowing observed in a retrospective review of radiographs of women. She observed significant variability, noting “although few younger women have high average scores, some older women have no radiographic sign of OA, while others are severely affected.” Multiple studies have also demonstrated the presence of significant lumbar degeneration to be evident even within the first two decades [38, 39]. Such variability within members of the same age category suggests the influence of other contributing factors.

The impact of activity and occupation

Disk generation has long been associated with certain activities. Retrospective studies cite Body Mass Index (BMI), incident back trauma, daily spine loading (twisting, lifting, bending, and sustained nonneutral postures), and whole body vibration (such as vehicular driving) to be factors which increase both the likelihood and severity of spondylosis [20, 41]. While these correlations exist, a study following progressive radiographic changes in lumber DDD did not find significant associations with the extent of physical activity, noting only age, back pain, and associated hip OA to be predictive of DDD and osteophyte changes [42].

The role of heredity

Genetic factors likely influence the formation of osteophytes and disk degeneration. Spector and MacGregor [43] proposed that 50% of the variability found in osteoarthritis can be attributed to heritable factors. Similarly, twin studies evaluating the progression of degenerative changes in lumbar MRI imaging suggest that approximately half (47–66%) of the variance could be explained by genetic and environmental factors, attributing only 2–10% of variance to physical loading and resistance training [44]. Another twin study revealed a high degree of similarity in signal intensity, disk height narrowing, disk bulging, and end-plate changes [45]. A search for these underlying genetic factors has identified polymorphisms in genes regulating inflammatory pathways and a Vitamin D Receptor allele to correspond to radiographic progression of lumbar disk degeneration [46].

A functional adaptation?

Is osteophyte formation inherently pathological? van der Kraan and van den Berg question if osteophyte formation may represent a remodeling process, functionally adapting to the instability or the changes in the demands of the spine [14]. Likewise, Humzah and Soames [47] emphasize the dynamic and reparative qualities of the intervertebral disk, responding to variations in mechanical loading and influencing vertebral kinematics to extend this argument. Osteophytes may form in the absence of other degenerative processes, and cartilaginous damage may exist without corresponding osteophytes [14]. Although there remains a strong association between the presence of osteophytes and other degenerative spine changes, isolated instances of one without the other occur, in the absence of overt symptoms.

A diagnostic approach

The initial evaluation for patients with low back pain begins with an accurate history and thorough physical exam with appropriate provocative testing. These first steps are complicated by the subjectivity of patient experiences of chronic spinal pain and the inherent difficulty isolating the anatomic region of interest during provocative testing without the influence of neighboring structures.

Radiographic studies, whether plain film, CT, CT myelogram, or MRI, may provide useful confirmatory evidence to support an exam finding and localize a degenerative lesion or area of nerve compression. However, imaging is an imperfect science, identifying the underlying cause of LBP in only 15% of patients in the absence of clear disk herniation or neurological deficit [25]. Furthermore, there remains a frequent disconnection between the symptom severity and the degree of anatomical or radiographic changes [18]. While correlations between the number and severity of osteophytes and back pain exist [20, 22], the prevalence of degenerative changes among asymptomatic patients underlies the difficulty assigning clinical relevance to observed radiographic changes in patients with LBP.

Nerve compression symptoms by clinical history may also be confirmed by electromyographic studies demonstrating normal distal motor and sensory nerve conduction studies with abnormal needle exam. Diagnostic injections can facilitate localization by isolating and anesthetizing irritated nerve roots (via epidural), or by blocking suspected pain generators within facet joints, sacroiliac joints, or the disk space itself (via discography) [48].

Intervention and treatment options

Given our limited ability to isolate causative sources of chronic lower back pain, there is a little consensus with regard to a definitive treatment approach. Substantial variation in management by conservative and invasive approaches exists between practitioners throughout the country [8]. We will briefly describe these treatment options for the management of chronic low back pain syndromes within each of the four primary categories: physical therapy (and associated modalities and behavioral techniques), pharmacotherapy, injection therapy, and surgical intervention.

Exercise-based and behavioral interventions

Exercise therapy

Exercise therapy (ET) remains one of the conservative mainstays of treatment for chronic lumbar spine pain, and may be tailored to include aerobic exercise, muscle strengthening, and stretching exercises [49]. Significant variation in regimen, intensity, and frequency of prescribed programs presents challenges to assessing efficacy among patients [50]. One meta-analysis of the current literature exploring the role of ET in patients with varying duration of symptoms found a graded exercise program implemented within the occupational setting demonstrated some effectiveness in subacute LBP. Among those suffering chronic pain symptoms, small, but statistically significant improvements were observed among patients, with regard to pain reduction and functional improvement [49]. The optimal approach to exercise therapy in chronic low back pain sufferers appears to be those regimens involving an individually-designed exercise program emphasizing stretching and muscle strengthening, administered in a supervised fashion, with high frequency and close adherence. Such results are complemented by other conservative approaches, including NSAIDS, manual therapies, and daily physical activity [50].

Transcutaneous electrical nerve stimulation (TENS)

A “TENS” unit is a therapeutic modality involving skin surface electrodes which deliver electrical stimulation to peripheral nerves in an effort to relieve pain noninvasively. Such devices are frequently available in outpatient exercise therapy settings, with up to a third of patients experiencing mild skin irritation following treatment [51]. While one small study identified an immediate reduction in pain symptoms 1 h following TENS application, there remains little evidence of long-term relief. Another larger study did not discover significant improvement with TENS compared with placebo with regard to pain, functional status, or range of motion [52, 53].

Back school

Back School was introduced first in Sweden with the purpose of minimizing lower back pain symptoms and their reoccurrence through review with patients of lumbar anatomy, concepts of posture, ergonomics, and appropriate back exercises [54]. Two meta-analyses concluded that there is moderate evidence for improvement in both pain and functional status for chronic low back pain within short and intermediate time courses, when measured against other modalities such as exercise, joint manipulation, myofascial therapy, and/or other educational therapy [52, 54].

Lumbar supports

Lumbar back supports may provide benefit to patients suffering chronic LBP secondary to degenerative processes through several potential, debated mechanisms. Supports are designed to limit spine motion, stabilize, correct deformity, and reduce mechanical forces. They may further have effects by massaging painful areas and applying beneficial heat; however, they may also function as a placebo. There is moderate available evidence evaluating efficacy of lumbar supports within a mixed population of acute, subacute, and chronic LBP sufferers to suggest that lumbar supports are not more effective than other treatment forms; data is conflicting with regard to patient improvement and functional ability to return to work [52].

Traction

Lumbar traction applies a longitudinal force to the axial spine through use of a harness attached to the iliac crest and lower rib cage to relieve chronic low back pain. The forces, which open intervertebral space and decrease spine lordosis, are adjusted both with regard to level and duration and may closely be measured in motorized and bed rest devices. Temporary spine realignments are theorized to improve symptoms related to degenerative spine disease by relieving mechanical stress, nerve compression, and adhesions of the facet and annulus, as well as through disruption of nociceptive pain signals [52]. Nonetheless, patients with chronic symptoms and radicular pain have not found traction to provide significant improvement in pain nor daily functioning [55–57]. Little is known with regard to the risks associated with the applied forces. Isolated case reports cite nerve impingement with heavy forces, and the potential for respiratory constraints or blood pressure changes due to the harness placement and positioning [52].

Spine manipulation

Spine manipulation is a manual therapy approach involving low-velocity, long lever manipulation of a joint beyond the accustomed, but not anatomical range of motion. The precise mechanism for improvement in low back pain sufferers remains unclear. Manipulative therapy may function through: “(1) release for the entrapped synovial folds, (2) relaxation of hypertonic muscle, (3) disruption of articular or periarticular adhesion, (4) unbuckling of motion segments that have undergone disproportionate displacement, (5) reduction of disk bulge, (6) repositioning of miniscule structures within the articular surface, (7) mechanical stimulation of nociceptive joint fibers, (8) change in neurophysiological function, and (9) reduction of muscle spasm” [58].

Available research regarding its efficacy in the context of chronic LBP finds spinal manipulation to be “more effective” compared to sham manipulation with regard to both short- and long-term relief of pain, as well as short-term functional improvement [52]. Compared with other conventional, conservative treatment approaches such as exercise therapy, back school, and NSAID prescription, spinal manipulation appears comparable in its effectiveness both in short- and long-term benefits [52, 59]. Research exploring the safety of such therapy among trained therapists found a very low risk of complications, with clinically worsened disk herniation or cauda equina syndrome occurring in fewer than 1/3.7 million [60].

Massage therapy

Massage therapy for chronic LBP appears to provide some beneficial relief. Weighed against other interventions, it proved less efficacious than TENS and manipulation, comparable with corsets and exercise regimens, and superior to acupuncture and other relaxation therapies, when followed over a 1-year course. Such preliminary results need confirmation, and evaluation for cost-effectiveness, but nevertheless suggest a potential role in certain, interested patients [61].

Multidisciplinary back therapy: the bio-psychosocial approach

Psychopathology is well recognized for its association with chronic spinal pain, and, when untreated, its ability to compromise management efforts [25]. For this reason, patients may find relief through learned cognitive strategies, termed “behavioral”, or “bio-psychosocial” therapy. Strategies involving reinforcement, modified expectations, imagery/relaxation techniques, and learned control of physiological responses aim to reduce a patient’s perception of disability and pain symptoms. To date, evidence is limited with regard to the efficacy of operant, cognitive, and respondent treatment approaches [52].

Pharmacotherapy

Treatment efforts to control pain and swelling, minimize disability, and improve the quality of life with lumbar spondylosis often require medication to complement nonpharmacologic interventions. Extensive research efforts have explored the efficacy of different oral medications in the management of low back pain secondary to degenerative processes. Nonetheless, there remains no clear consensus regarding the gold-standard approach to pharmacologic management [62].

NSAIDS

NSAIDS are widely regarded as an appropriate first step in management, providing analgesic and anti-inflammatory effects. There is adequate data demonstrating efficacy in pain reduction in the context of chronic low back pain [63–66], with use most commonly limited by gastrointestinal (GI) complaints. COX2 inhibitors offer modest relief in chronic LBP and improved function in the long-term setting. While they elicit fewer GI complications, their utilization has been curbed due to evidence for increased cardiovascular risk with prolonged use [52].

Opioid medications

Opioid medications may be considered as an alternative or augmentive therapy for patients suffering from gastrointestinal effects or poor pain control on NSAID management. The practice of prescribing narcotics for chronic low back pain sufferers is extremely variable within practitioners, with a range of 3–66% of chronic LBP patients taking some form of opioid in various literature studies [67]. These patients tend to report greater distress/suffering and higher functional disability scores [68, 69]. Two meta-analyses suggest a modest short-term benefit of opioid use for treatment of chronic LBP while issuing a warning regarding the limited quality of available studies and the high rate of tolerance and abuse associated with long-term narcotic use within this patient population [62, 67].

Antidepressants

The use of antidepressants for treatment of LBP symptoms has also been explored considerably given their proposed analgesic value at low doses, and dual role in treatment of commonly comorbid depression that accompanies LBP and may negatively impact both sleep and pain tolerance [52]. Two separate reviews of available literature found evidence for pain relief with antidepressants, but no significant impact on functioning [70, 71].

Muscle relaxants

Muscle relaxants, taking the form of either antispasmodic or antispasticity medications, may provide benefit in chronic low back pain attributed to degenerative conditions. There remains moderate to strong evidence through several trials comparing either a benzodiazepine, or non-benzodiazepine with placebo that muscle relaxants provide benefit with regard to short-term pain relief and overall functioning [52, 62, 72].

Injection therapy

Epidural steroid injections

Epidural steroid injections (ESI) have become a common interventional strategy in the management of chronic axial and radicular pain due to degeneration of the lumbar spine. These injections may be performed through interlaminar, transforaminal, or caudal approaches. Usually by way of needles guided under fluoroscopy, contrast, then local anesthetic and steroid are infused into the epidural space at the target vertebral level and bathe exiting nerve roots. Symptomatic relief is theorized to occur through complementary mechanisms. Local anesthetics provide quick diagnostic confirmation, and therapeutically may short circuit the “pain spasm cycle” and block pain signal transmission [73]. Corticosteroids are well recognized for their capacity to reduce inflammation through blockade of pro-inflammatory mediators.

Within the span of less than one decade (1998–2005), the number of ESI procedures performed has increased by 121% [73]. Despite this widespread utilization, controversy remains regarding the efficacy of these injections, fueled by the expense and the infrequent but potential risks related to needle placement and adverse medication reactions. Available published data cites wide ranges in reported success rates due to variation in study designs, distinct procedural techniques, small cohorts, and imperfect control groups [74]. For example, prior to the year 2000, few efficacy studies of lumbar ESI utilized fluoroscopy to establish appropriate needle position. Research suggests that without fluoroscopic guidance confirmation, needle position may be inappropriate in as frequently as 25% of cases, even with experienced providers [75]. Review articles and practicing clinicians alike must interpret such methodological differences between studies to assemble opinions on efficacy and utility of ESI for LBP treatment.

One such review exploring efficacy of interlaminar lumbar injections concluded strong evidence for short-term pain relief and limited benefit for long-term benefit [73] citing, among many, randomized controlled trials (RCT) by Arden and Carette of unilateral sciatic pain, finding statistically significant improvement in up to 75% of patients with steroid/anesthesia versus saline injections at 3 weeks, with benefit waning by 6 weeks and 3 months, respectively [76, 77].

The same review evaluating the transforaminal injection approach to unilateral sciatica found strong evidence for short-term, and moderate evidence for long-term symptom and functional improvement, based on the findings from several RCT. Vad et al. [78] studied 48 patients with herniated nucleus pulposus or radicular pain, treated with transforaminal ESI versus trigger point injections, citing an 84% improvement in functional scoring compared with 48% in the control group, extending for a follow-up period of 1 year. Lutz et al. [79] treated and followed a different cohort of 69 patients with the same underlying diagnoses, with transforaminal ESI for 80 weeks demonstrating 75% of patients with a successful long-term outcome, defined as >50% reduction in pain scores. In spinal stenosis, transforaminal ESI has achieved >50% pain reduction, improved walking, and improved standing tolerance in symptomatic patients extending through 1 year follow-up [80]. Furthermore, prospective trials by Yang and Riew found patients with severe lumbar radiculopathies and spinal stenosis treated with transforaminal injections experienced such sustained functional and symptomatic benefits so as to avoid intended surgical intervention [81–83].

Facet injections

Facet joints, also termed zygapophysial joints, are paired diarthrodial articulations between adjacent vertebrae. These joints are innervated from the medial branches of the dorsal rami and, through anatomical studies, possess free and encapsulated nerve endings, mechanoreceptors, and nociceptors. Inflammation to the joint creates pain signals which are implicated in 15–45% of patients with low back pain [25].

Diagnostic blocks of the joint inject anesthesia directly into the joint space or associated medial branch (MBB). Systematic reviews of both retrospective and prospective trials reveal single diagnostic facet blocks carry a false-positive rate of 22% to 47% [84] and medial branch blocks of 17–47% in the lumbar spine [85].

Subsequent therapeutic injections are similarly performed through either approach, with systematic reviews concluding moderate evidence available for short-term and long-term pain relief with facet blocks [86]. This evidence stems from studies such as Fuch’s RCT showing significant pain relief, functional improvement, and quality of life enhancement at 3 and 6 month intervals [87]. By contrast, Carette et al. [88] found no meaningful difference in perceived benefit between patients treated with steroid versus saline (control) injection at 3 and 6 month intervals. Available literature of MBB similarly show moderate evidence for short- and long-term relief [86] based on RCT of MBB under fluoroscopy, showing significant relief (by means of pain relief, physical health, psychological benefit, reduced narcotic intake, and employment status), with 1–3 injections in 100% patients at 3 months, 75–88% at 6 months, and 17–25% at 1 year [89].

SI joint injections

The sacroiliac joint space is a diarthrodial synovial joint with debated innervation patterns that involve both myelinated and unmyelinated axons. Injury or inflammation at the joint creates pain signals which are implicated in 10–27% of patients with low back pain [25] and may also refer to the buttocks, groin, thigh, and lower extremities.

There is moderate evidence to support the use of both diagnostic and therapeutic blocks of the SI joint [25]. Pereira treated 10 patients with MRI-guided bilateral SI joint injections of steroid, eight of whom reported “good to excellent” pain relief persisting through 13 months follow-up [90]. Maugers compared corticosteroid versus placebo injections under fluoroscopic guidance in SI joints of 10 symptomatic patients, reporting patient benefit only in the corticosteroid group. That benefit waned slowly over time, from 70% of patients at 1 month, to 62% at 3 months, and 58% at 6 months [91]. At this point, there is limited evidence to support radiofrequency neurotomy (ablation procedure) of the SI joint [92].

A recent meta-analysis provided the following guiding principles with regard to the frequency these procedures should be implemented in clinical practice. In cases of ESI, facet, and sacroiliac injections, diagnostic injections should be considered at intervals of no sooner than 1–2 weeks apart. Therapeutic injections may be performed at most every 2–3 months, provided the patient experiences greater than 50% relief within 6 weeks. Injections should be performed only as they are medically necessary given their associated risks and significant costs [25].

Intradiscal nonoperative therapies for discogenic pain

Discogenic pain has been identified as the source in 39% of patients with chronic low back pain. As described above, a cascade of effects induces the changes in the disk which generate pain. Discography seeks, when noninvasive imaging has failed, to identify damaged disks through injection of fluid into disk levels, in an attempt to reproduce patient symptoms. The technique’s utility remains controversial given significant potential for false positives. Provoked pain may be alternatively represent central hyperalgesia, reflect the patient’s chronic pain or psychological state, or result from technical difficulty due to the procedure itself [93].

If a diseased disk is identified, several treatment options exist. In addition to surgical correction, there are minimally invasive options. Both Intradiscal electrothermal therapy (IDET) and Radiofrequency posterior annuloplasty (RPA) involve electrode placement into the disk. Heat and electrical current coagulate the posterior anulus, and in doing so, strengthen collagen fibers, seal figures, denature inflammatory exudates, and coagulate nociceptors [25]. Current evidence provides moderate support for IDET in discogenic pain sufferers. Preliminary studies of RPA provide limited support for short term relief, with indeterminate long-term value. Both procedures have associated complications, including catheter malfunction, nerve root injuries, post-procedure disk herniation, and infection risk [25].

Surgical options

Surgical interventions are generally reserved for patients who have failed conservative options. Patients must be considered as appropriate “surgical candidates,” taking into consideration medical comorbidities as well as age, socioeconomic status, and projected activity level following a procedure [18]. Many surgical approaches have been developed to achieve one of the two primary goals: spinal fusion or spine decompression (or both).

Spinal fusion is considered in patients with malalignment or excessive motion of the spine, as seen with DDD and spondylolisthesis. Several surgical fusion approaches exist, all involving the addition of a bone graft to grow between vertebral elements to limit associated motion. Decompression surgery is indicated for patients with clear evidence of neural impingement, correcting the intrusion of bone or disk as might be seen in spinal or foraminal stenosis, disk herniation, osteophytosis, or degenerative spondylolisthesis. Despite dramatic increases in the number of procedures performed over the last several decades, there remains controversy as to the efficacy of these procedures in resolving chronic low back unresponsive to conservative management.

Controversy arises, in part, due to the inherent challenges of comparing the available research. Systematic reviews cite the heterogeneity of current trials which evaluate different surgical techniques with differing comparison groups and limited follow-up, frequently without patient-centered or pain outcomes included [18]. Some case series reveal promising results [94]. Nonetheless, a recent meta-analysis of 31 randomized controlled trials, concluded, “[there is] no clear evidence about the most effective technique of decompression for spinal stenosis or the extent of that decompression. There is limited evidence that adjunct fusion to supplement decompression for degenerative spondylolisthesis produces less progressive slip and better clinical outcomes than decompression alone.” Another review, noting no statistically significant improvement in patients undergoing fusion compared with nonsurgical interventions commented, “surgeons should recommend spinal fusion cautiously to patients with chronic low back pain. Further long-term follow-ups of the studies reviewed in this meta-analysis are required to provide more conclusive evidence in favor of either treatment” [95].

Conclusion

Lumbar spondylosis is a complicated diagnosis. We chose to define it broadly as degenerative conditions of the spine, but definitions vary widely within the literature. While it may not present a challenge to identify radiographically, its pervasiveness throughout all patient populations makes the exact diagnosis of symptomatic cases extremely difficult. Moreover, there is no current concrete, gold-standard treatment approach to the diverse range of patient presentations despite substantial research efforts to identify conservative and more invasive methods of managing symptoms and slowing progressive decline. Given the morbidity of low back pain within the population and its social and economic implications, this area will continue to be a critical research focus. Important clues are in place, from genetic studies, risk factor analysis, and explorative treatment approaches. These efforts, and future endeavors will no doubt fine-tune and present means to tackle not only symptoms, but confront progression, and ultimately prevention of disease in years to come.

Open Access

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clinical presentation and treatment approaches

Curr Rev Musculoskelet Med. 2009 Jun; 2(2): 94–104.

¹ and ²

Kimberley Middleton

¹Department of Physical Medicine and Rehabilitation, University of Washington Medical Center, Seattle, WA USA

David E. Fish

²Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250 16th Street, 7th Floor Tower Building Room 745, Santa Monica, CA 90404 USA

¹Department of Physical Medicine and Rehabilitation, University of Washington Medical Center, Seattle, WA USA

²Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250 16th Street, 7th Floor Tower Building Room 745, Santa Monica, CA 90404 USA

Corresponding author.

Received 2007 Nov 26; Accepted 2009 Feb 25.

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

This article has been cited by other articles in PMC.

Abstract

Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable. Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine. Back pain has been termed as “an illness in search of a disease.” Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative. We will elaborate on these degenerative processes and their clinical implications. We will further discuss diagnostic approaches and the efficacy of existing treatment options.

Keywords: Low back pain, Spondylosis, Osteophyte, Degenerative disk disease, Intervertebral osteochondrosis

Introduction

Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives [1–3]. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks [4]. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population [5, 6]. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable [7].

Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country [8]. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine [9]. Back pain has been termed as “an illness in search of a disease” [10]. Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative [11, 12].

We will elaborate on these degenerative processes and their clinical implications. We will further discuss the diagnostic approaches and the efficacy of existing treatment options.

Tackling the terminology

The terms lumbar osteoarthritis, disk degeneration, degenerative disk disease, and spondylosis are used in the literature to describe anatomical changes to the vertebral bodies and intervertebral disk spaces that may be associated with clinical pain syndromes.

Spinal osteoarthritis (OA) is a degenerative process defined radiologically by joint space narrowing, osteophytosis, subchondral sclerosis, and cyst formation [13, 14]. Osteophytes included within this definition fall into one of the two primary clinical categories [14]. The first, spondylosis deformans describes bony outgrowths arising primarily along the anterior and lateral perimeters of the vertebral end-plate apophyses. These hypertrophic changes are believed to develop at sites of stress to the annular ligament and most commonly occur at thoracic T9–10 and lumbar L3 levels [15]. These osteophytes have minimal effect on intervertebral disk height [16] and are frequently asymptomatic, with only rare complications arising from their close anatomic relationship to organs anterior to the spine [15].

By contrast, intervertebral osteochondrosis describes the formation of more pathological end-plate osteophytes, associated with disk space narrowing, vacuum phenomenon, and vertebral body reactive changes [16]. If protruding within the spinal canal or intervertebral foramina, these bony growths may compress nerves with resulting radiculopathy or spinal stenosis. Moreover, these bony projections may limit joint mobility and invade other organs or tissues [14]. The term “osteoarthritis” suggests pathology limited to bone. Nevertheless, in this context, it has clear implications for the health of neighboring disks and nerve roots.

Comparatively, degenerative disk disease (DDD) refers to back pain symptoms attributable to intervertebral disk degeneration. Such pathologic changes include disk desiccation, fibrosis, and narrowing. The anulus may bulge, fissure, or undergo mucinous degeneration. Also included within the anatomic definition of DDD are defects and sclerosis of the end-plates, and osteophytes at the vertebral apophyses [16]. With these bony changes included in the radiographic description of both OA and DDD, there exists diagnostic overlap between the conditions. As a result, these terms are often used interchangeably in the medical literature to describe similar phenomena.

Spondylosis of the lumbar spine, the subject of this paper, is a term with many definitions. In the literature, it has been utilized in many different contexts, employed synonymously with arthrosis, spondylitis, hypertrophic arthritis, and osteoarthritis. In other instances, spondylosis is considered mechanistically, as the hypertrophic response of adjacent vertebral bone to disk degeneration (although osteophytes may infrequently form in the absence of diseased disks) [17]. Finally, spondylosis may be applied nonspecifically to any and all degenerative conditions affecting the disks, vertebral bodies, and/or associated joints of the lumbar spine [17, 18]. For purposes of this review, we will use this final, broad definition of spondylosis, recognizing the high incidence of coincident degenerative changes, and the dynamic interplay between adjacent disks, vertebra, and nerves that create the clinical pain syndromes within the axial spine and associated nerves.

Epidemiology

Degenerative spine changes are remarkably common in population studies. Symmons’ et al. [19] study of individuals aged 45–64 years identified 85.5% of participants to demonstrate osteophytes within the lumbar spine. O’Neill et al. [20] explored osteophytosis within a UK adult population over age 50 years, finding 84% of men and 74% of women to demonstrate at least one vertebral osteophyte, with increased incidence among individuals with more physical activity, self reported back pain, or higher BMI scores. Despite marked variability within the population, men appear to have more significant degenerative changes than women, both with regard to number and severity of osteophyte formation [20].

Radiographic evidence of degenerative disease of the lumbar spine among asymptomatic individuals is impressive. MRI imaging in asymptomatic patients over age 60 years reveals disk protrusions in 80% [21] and degenerative spinal stenosis in 20% [11]. A study comparing radiographic evidence of spine degeneration among categories of men who were without pain, with moderate pain, or with severe lower back pain found similar frequency of disk space narrowing and bone spurs among all three groups [22].

Furthermore, degenerative changes may appear in young individuals without decades of spine loading. Lawrence [23] found 10% of women aged 20–29 to demonstrate evidence of disk degeneration. Lumbar spondylosis, while affecting 80% of patients older than 40 years, nevertheless was found in 3% of individuals aged 20–29 years in one study [15]. The high incidence of degeneration among young and asymptomatic individuals highlights the challenge involved in establishing causality between imaging findings and pain symptoms in affected patients.

Pathogenesis

The high incidence of simultaneous degenerative changes to the intervertebral disk, vertebral body, and associated joints suggests a progressive and dynamic mechanism, with interdependent changes occurring secondary to disk space narrowing [17].

Intervertebral disks are believed to undergo what Kirkaldy Willis and Bernard [24] first coined a “degenerative cascade” (Fig. ) of three overlapping phases that may occur over the course of decades. Phase I (Dysfunction Phase) describes the initial effects of repetitive microtrauma with the development of circumferential painful tears of the outer, innervated anulus, and associated end-plate separation that may compromise disk nutritional supply and waste removal. Such tears may coalesce to become radial tears, more prone to protrusion, and impact the disk’s capacity to maintain water, resulting in desiccation and reduced disk height. Fissures may become ingrown by vascular tissue and nerve endings, increasing innervation and the disk’s capacity for pain signal transmission [25]. Phase II (Instability Phase) is characterized by the loss of mechanical integrity, with progressive disk changes of resorption, internal disruption, and additional annular tears, combined with further facet degeneration that may induce subluxation and instability. During Phase III (Stabilization Phase), continued disk space narrowing and fibrosis occurs along with the formation of osteophytes and transdiscal bridging [26].

The spectrum of pathological changes in facial joints and the disk and the interaction of these changes. The upper light horizontal bar represents dysfunction, the middle darker bar instability, and the lower dark bar stabilization

Schneck presents a further mechanical progression, building upon this degenerative cascade of the intervertebral disk, to explain other degenerative changes of the axial spine. He proposes several implications of disk space narrowing. Adjacent pedicles approximate with a narrowing of the superior–inferior dimension of the intervertebral canal. Laxity due to modest redundancy of the longitudinal ligaments enables bulging of the ligamentum flavum and potential for spine instability. Increased spine movement permits subluxation of the superior articular process (SAP), causing a narrowed anteroposterior dimension of the intervertebral and upper nerve root canals. Laxity may also translate into altered weight mechanisms and pressure relationships on vertebral bone and joint spaces believed to influence osteophyte formation and facet hypertrophy to both inferior and superior articular processes with risks for projection into the intervertebral canal and central canal, respectively. Oblique orientations of the articular processes may further cause retrospondylolisthesis, with resulting anterior encroachment of the spinal canal, nerve root canal, and intervertebral canal [17].

Biochemical research exploring osteophyte formation supports the above process. Osteophyte lipping is believed to form at periosteum [27] through the proliferation of peripheral articular cartilage which subsequently undergoes endochondral calcification and ossification [28]. Changing weight mechanics and pressure forces as well as alterations in oxygen tension and dynamic fluid pressure appear to be influential factors in osteophyte formation [14]. Mesenchymal stem cells of the synovium or periostium are likely precursors, with synovial macrophages and a milieu of growth factors and extracellular matrix molecules acting as probable mediators in this process [29].

Clinical presentation

Pain within the axial spine at the site of these degenerate changes is not surprising as nociceptive pain generators have been identified within facet joints, intervertebral disks, sacroiliac joints, nerve root dura, and myofascial structures within the axial spine [9].

These degenerative anatomical changes may culminate in a clinical presentation of spinal stenosis, or narrowing within the spinal canal [30] through progressive ingrowth of osteophytes, hypertrophy of the inferior articular process [31], disk herniation, bulging of the ligamentum flavum [17], or spondylolisthesis. The clinical result: a constellation of pain symptoms encompassed in the term neurogenic claudication (NC). NC may include (to varying extents) lower back pain, leg pain, as well as numbness and motor weakness to lower extremities that worsen with upright stance and walking, and improve with sitting and supine positioning [30].

Clinical presentations of radiculopathy may emanate from many sources, all of which can be explained by the degenerative process. Disk bulging may affect descending rootlets of the cauda equina, nerve roots exiting at the next lower intervertebral canal, or the spinal nerve within its ventral ramus, if protruding centrally, posterolaterally, or laterally, respectively [32]. Osteophyte lipping along the posterior aspect of vertebral bodies, along upper or lower margins, may similarly impinge upon the same neural structures as the bulging disk just described [17, 33]. Hypertrophic changes to the superior articular process may intrude upon nerve roots within the upper nerve root canal, dural sac, or prior to exiting from next lower intervertebral canal, depending on their projection [34]. These theoretical forms of impingement have been substantiated through cadaver studies. A 70% reduction or 30% residual diameter of neuroforminal space is cited as the critical amount of occlusion to induce neural compromise [15]. Moreover, compression of the posterior disk to less than 4 mm height, or foraminal height to less than 15 mm has also been determined as critical dimensions for foraminal stenosis and nerve impingement [35].

Etiology/risk factors

What factors mediate this degenerative progression? What leads a large portion of the population to manifest spondylosis, even early on in their lives? Given the substantial variability in the number and degree of spine changes observed in individuals and the wide range of clinical presentations, answers to these questions hold promise to broaden treatment options.

The influence of age

Large studies of osteoarthritis have long recognized the aging process to be the strongest risk factor for bony degeneration, particularly within the spine [36]. An extensive autopsy study in 1926 reported evidence of spondylitis deformans to increase in a linear fashion from 0% to 72% between the ages of 39 and 70 years [37]. A subsequent autopsy study by Miller et al. [38] similarly noted an increase in disk degeneration from 16% at age 20 to about 98% at age 70 years based on macroscopic disk degeneration grades of 600 specimens. Other studies corroborate this finding [20, 39].

The associations are nevertheless imperfect. Kramer [40] found increasing age to be significantly associated with osteophyte formation but not predictive of the degree of disk space narrowing observed in a retrospective review of radiographs of women. She observed significant variability, noting “although few younger women have high average scores, some older women have no radiographic sign of OA, while others are severely affected.” Multiple studies have also demonstrated the presence of significant lumbar degeneration to be evident even within the first two decades [38, 39]. Such variability within members of the same age category suggests the influence of other contributing factors.

The impact of activity and occupation

Disk generation has long been associated with certain activities. Retrospective studies cite Body Mass Index (BMI), incident back trauma, daily spine loading (twisting, lifting, bending, and sustained nonneutral postures), and whole body vibration (such as vehicular driving) to be factors which increase both the likelihood and severity of spondylosis [20, 41]. While these correlations exist, a study following progressive radiographic changes in lumber DDD did not find significant associations with the extent of physical activity, noting only age, back pain, and associated hip OA to be predictive of DDD and osteophyte changes [42].

The role of heredity

Genetic factors likely influence the formation of osteophytes and disk degeneration. Spector and MacGregor [43] proposed that 50% of the variability found in osteoarthritis can be attributed to heritable factors. Similarly, twin studies evaluating the progression of degenerative changes in lumbar MRI imaging suggest that approximately half (47–66%) of the variance could be explained by genetic and environmental factors, attributing only 2–10% of variance to physical loading and resistance training [44]. Another twin study revealed a high degree of similarity in signal intensity, disk height narrowing, disk bulging, and end-plate changes [45]. A search for these underlying genetic factors has identified polymorphisms in genes regulating inflammatory pathways and a Vitamin D Receptor allele to correspond to radiographic progression of lumbar disk degeneration [46].

A functional adaptation?

Is osteophyte formation inherently pathological? van der Kraan and van den Berg question if osteophyte formation may represent a remodeling process, functionally adapting to the instability or the changes in the demands of the spine [14]. Likewise, Humzah and Soames [47] emphasize the dynamic and reparative qualities of the intervertebral disk, responding to variations in mechanical loading and influencing vertebral kinematics to extend this argument. Osteophytes may form in the absence of other degenerative processes, and cartilaginous damage may exist without corresponding osteophytes [14]. Although there remains a strong association between the presence of osteophytes and other degenerative spine changes, isolated instances of one without the other occur, in the absence of overt symptoms.

A diagnostic approach

The initial evaluation for patients with low back pain begins with an accurate history and thorough physical exam with appropriate provocative testing. These first steps are complicated by the subjectivity of patient experiences of chronic spinal pain and the inherent difficulty isolating the anatomic region of interest during provocative testing without the influence of neighboring structures.

Radiographic studies, whether plain film, CT, CT myelogram, or MRI, may provide useful confirmatory evidence to support an exam finding and localize a degenerative lesion or area of nerve compression. However, imaging is an imperfect science, identifying the underlying cause of LBP in only 15% of patients in the absence of clear disk herniation or neurological deficit [25]. Furthermore, there remains a frequent disconnection between the symptom severity and the degree of anatomical or radiographic changes [18]. While correlations between the number and severity of osteophytes and back pain exist [20, 22], the prevalence of degenerative changes among asymptomatic patients underlies the difficulty assigning clinical relevance to observed radiographic changes in patients with LBP.

Nerve compression symptoms by clinical history may also be confirmed by electromyographic studies demonstrating normal distal motor and sensory nerve conduction studies with abnormal needle exam. Diagnostic injections can facilitate localization by isolating and anesthetizing irritated nerve roots (via epidural), or by blocking suspected pain generators within facet joints, sacroiliac joints, or the disk space itself (via discography) [48].

Intervention and treatment options

Given our limited ability to isolate causative sources of chronic lower back pain, there is a little consensus with regard to a definitive treatment approach. Substantial variation in management by conservative and invasive approaches exists between practitioners throughout the country [8]. We will briefly describe these treatment options for the management of chronic low back pain syndromes within each of the four primary categories: physical therapy (and associated modalities and behavioral techniques), pharmacotherapy, injection therapy, and surgical intervention.

Exercise-based and behavioral interventions

Exercise therapy

Exercise therapy (ET) remains one of the conservative mainstays of treatment for chronic lumbar spine pain, and may be tailored to include aerobic exercise, muscle strengthening, and stretching exercises [49]. Significant variation in regimen, intensity, and frequency of prescribed programs presents challenges to assessing efficacy among patients [50]. One meta-analysis of the current literature exploring the role of ET in patients with varying duration of symptoms found a graded exercise program implemented within the occupational setting demonstrated some effectiveness in subacute LBP. Among those suffering chronic pain symptoms, small, but statistically significant improvements were observed among patients, with regard to pain reduction and functional improvement [49]. The optimal approach to exercise therapy in chronic low back pain sufferers appears to be those regimens involving an individually-designed exercise program emphasizing stretching and muscle strengthening, administered in a supervised fashion, with high frequency and close adherence. Such results are complemented by other conservative approaches, including NSAIDS, manual therapies, and daily physical activity [50].

Transcutaneous electrical nerve stimulation (TENS)

A “TENS” unit is a therapeutic modality involving skin surface electrodes which deliver electrical stimulation to peripheral nerves in an effort to relieve pain noninvasively. Such devices are frequently available in outpatient exercise therapy settings, with up to a third of patients experiencing mild skin irritation following treatment [51]. While one small study identified an immediate reduction in pain symptoms 1 h following TENS application, there remains little evidence of long-term relief. Another larger study did not discover significant improvement with TENS compared with placebo with regard to pain, functional status, or range of motion [52, 53].

Back school

Back School was introduced first in Sweden with the purpose of minimizing lower back pain symptoms and their reoccurrence through review with patients of lumbar anatomy, concepts of posture, ergonomics, and appropriate back exercises [54]. Two meta-analyses concluded that there is moderate evidence for improvement in both pain and functional status for chronic low back pain within short and intermediate time courses, when measured against other modalities such as exercise, joint manipulation, myofascial therapy, and/or other educational therapy [52, 54].

Lumbar supports

Lumbar back supports may provide benefit to patients suffering chronic LBP secondary to degenerative processes through several potential, debated mechanisms. Supports are designed to limit spine motion, stabilize, correct deformity, and reduce mechanical forces. They may further have effects by massaging painful areas and applying beneficial heat; however, they may also function as a placebo. There is moderate available evidence evaluating efficacy of lumbar supports within a mixed population of acute, subacute, and chronic LBP sufferers to suggest that lumbar supports are not more effective than other treatment forms; data is conflicting with regard to patient improvement and functional ability to return to work [52].

Traction

Lumbar traction applies a longitudinal force to the axial spine through use of a harness attached to the iliac crest and lower rib cage to relieve chronic low back pain. The forces, which open intervertebral space and decrease spine lordosis, are adjusted both with regard to level and duration and may closely be measured in motorized and bed rest devices. Temporary spine realignments are theorized to improve symptoms related to degenerative spine disease by relieving mechanical stress, nerve compression, and adhesions of the facet and annulus, as well as through disruption of nociceptive pain signals [52]. Nonetheless, patients with chronic symptoms and radicular pain have not found traction to provide significant improvement in pain nor daily functioning [55–57]. Little is known with regard to the risks associated with the applied forces. Isolated case reports cite nerve impingement with heavy forces, and the potential for respiratory constraints or blood pressure changes due to the harness placement and positioning [52].

Spine manipulation

Spine manipulation is a manual therapy approach involving low-velocity, long lever manipulation of a joint beyond the accustomed, but not anatomical range of motion. The precise mechanism for improvement in low back pain sufferers remains unclear. Manipulative therapy may function through: “(1) release for the entrapped synovial folds, (2) relaxation of hypertonic muscle, (3) disruption of articular or periarticular adhesion, (4) unbuckling of motion segments that have undergone disproportionate displacement, (5) reduction of disk bulge, (6) repositioning of miniscule structures within the articular surface, (7) mechanical stimulation of nociceptive joint fibers, (8) change in neurophysiological function, and (9) reduction of muscle spasm” [58].

Available research regarding its efficacy in the context of chronic LBP finds spinal manipulation to be “more effective” compared to sham manipulation with regard to both short- and long-term relief of pain, as well as short-term functional improvement [52]. Compared with other conventional, conservative treatment approaches such as exercise therapy, back school, and NSAID prescription, spinal manipulation appears comparable in its effectiveness both in short- and long-term benefits [52, 59]. Research exploring the safety of such therapy among trained therapists found a very low risk of complications, with clinically worsened disk herniation or cauda equina syndrome occurring in fewer than 1/3.7 million [60].

Massage therapy

Massage therapy for chronic LBP appears to provide some beneficial relief. Weighed against other interventions, it proved less efficacious than TENS and manipulation, comparable with corsets and exercise regimens, and superior to acupuncture and other relaxation therapies, when followed over a 1-year course. Such preliminary results need confirmation, and evaluation for cost-effectiveness, but nevertheless suggest a potential role in certain, interested patients [61].

Multidisciplinary back therapy: the bio-psychosocial approach

Psychopathology is well recognized for its association with chronic spinal pain, and, when untreated, its ability to compromise management efforts [25]. For this reason, patients may find relief through learned cognitive strategies, termed “behavioral”, or “bio-psychosocial” therapy. Strategies involving reinforcement, modified expectations, imagery/relaxation techniques, and learned control of physiological responses aim to reduce a patient’s perception of disability and pain symptoms. To date, evidence is limited with regard to the efficacy of operant, cognitive, and respondent treatment approaches [52].

Pharmacotherapy

Treatment efforts to control pain and swelling, minimize disability, and improve the quality of life with lumbar spondylosis often require medication to complement nonpharmacologic interventions. Extensive research efforts have explored the efficacy of different oral medications in the management of low back pain secondary to degenerative processes. Nonetheless, there remains no clear consensus regarding the gold-standard approach to pharmacologic management [62].

NSAIDS

NSAIDS are widely regarded as an appropriate first step in management, providing analgesic and anti-inflammatory effects. There is adequate data demonstrating efficacy in pain reduction in the context of chronic low back pain [63–66], with use most commonly limited by gastrointestinal (GI) complaints. COX2 inhibitors offer modest relief in chronic LBP and improved function in the long-term setting. While they elicit fewer GI complications, their utilization has been curbed due to evidence for increased cardiovascular risk with prolonged use [52].

Opioid medications

Opioid medications may be considered as an alternative or augmentive therapy for patients suffering from gastrointestinal effects or poor pain control on NSAID management. The practice of prescribing narcotics for chronic low back pain sufferers is extremely variable within practitioners, with a range of 3–66% of chronic LBP patients taking some form of opioid in various literature studies [67]. These patients tend to report greater distress/suffering and higher functional disability scores [68, 69]. Two meta-analyses suggest a modest short-term benefit of opioid use for treatment of chronic LBP while issuing a warning regarding the limited quality of available studies and the high rate of tolerance and abuse associated with long-term narcotic use within this patient population [62, 67].

Antidepressants

The use of antidepressants for treatment of LBP symptoms has also been explored considerably given their proposed analgesic value at low doses, and dual role in treatment of commonly comorbid depression that accompanies LBP and may negatively impact both sleep and pain tolerance [52]. Two separate reviews of available literature found evidence for pain relief with antidepressants, but no significant impact on functioning [70, 71].

Muscle relaxants

Muscle relaxants, taking the form of either antispasmodic or antispasticity medications, may provide benefit in chronic low back pain attributed to degenerative conditions. There remains moderate to strong evidence through several trials comparing either a benzodiazepine, or non-benzodiazepine with placebo that muscle relaxants provide benefit with regard to short-term pain relief and overall functioning [52, 62, 72].

Injection therapy

Epidural steroid injections

Epidural steroid injections (ESI) have become a common interventional strategy in the management of chronic axial and radicular pain due to degeneration of the lumbar spine. These injections may be performed through interlaminar, transforaminal, or caudal approaches. Usually by way of needles guided under fluoroscopy, contrast, then local anesthetic and steroid are infused into the epidural space at the target vertebral level and bathe exiting nerve roots. Symptomatic relief is theorized to occur through complementary mechanisms. Local anesthetics provide quick diagnostic confirmation, and therapeutically may short circuit the “pain spasm cycle” and block pain signal transmission [73]. Corticosteroids are well recognized for their capacity to reduce inflammation through blockade of pro-inflammatory mediators.

Within the span of less than one decade (1998–2005), the number of ESI procedures performed has increased by 121% [73]. Despite this widespread utilization, controversy remains regarding the efficacy of these injections, fueled by the expense and the infrequent but potential risks related to needle placement and adverse medication reactions. Available published data cites wide ranges in reported success rates due to variation in study designs, distinct procedural techniques, small cohorts, and imperfect control groups [74]. For example, prior to the year 2000, few efficacy studies of lumbar ESI utilized fluoroscopy to establish appropriate needle position. Research suggests that without fluoroscopic guidance confirmation, needle position may be inappropriate in as frequently as 25% of cases, even with experienced providers [75]. Review articles and practicing clinicians alike must interpret such methodological differences between studies to assemble opinions on efficacy and utility of ESI for LBP treatment.

One such review exploring efficacy of interlaminar lumbar injections concluded strong evidence for short-term pain relief and limited benefit for long-term benefit [73] citing, among many, randomized controlled trials (RCT) by Arden and Carette of unilateral sciatic pain, finding statistically significant improvement in up to 75% of patients with steroid/anesthesia versus saline injections at 3 weeks, with benefit waning by 6 weeks and 3 months, respectively [76, 77].

The same review evaluating the transforaminal injection approach to unilateral sciatica found strong evidence for short-term, and moderate evidence for long-term symptom and functional improvement, based on the findings from several RCT. Vad et al. [78] studied 48 patients with herniated nucleus pulposus or radicular pain, treated with transforaminal ESI versus trigger point injections, citing an 84% improvement in functional scoring compared with 48% in the control group, extending for a follow-up period of 1 year. Lutz et al. [79] treated and followed a different cohort of 69 patients with the same underlying diagnoses, with transforaminal ESI for 80 weeks demonstrating 75% of patients with a successful long-term outcome, defined as >50% reduction in pain scores. In spinal stenosis, transforaminal ESI has achieved >50% pain reduction, improved walking, and improved standing tolerance in symptomatic patients extending through 1 year follow-up [80]. Furthermore, prospective trials by Yang and Riew found patients with severe lumbar radiculopathies and spinal stenosis treated with transforaminal injections experienced such sustained functional and symptomatic benefits so as to avoid intended surgical intervention [81–83].

Facet injections

Facet joints, also termed zygapophysial joints, are paired diarthrodial articulations between adjacent vertebrae. These joints are innervated from the medial branches of the dorsal rami and, through anatomical studies, possess free and encapsulated nerve endings, mechanoreceptors, and nociceptors. Inflammation to the joint creates pain signals which are implicated in 15–45% of patients with low back pain [25].

Diagnostic blocks of the joint inject anesthesia directly into the joint space or associated medial branch (MBB). Systematic reviews of both retrospective and prospective trials reveal single diagnostic facet blocks carry a false-positive rate of 22% to 47% [84] and medial branch blocks of 17–47% in the lumbar spine [85].

Subsequent therapeutic injections are similarly performed through either approach, with systematic reviews concluding moderate evidence available for short-term and long-term pain relief with facet blocks [86]. This evidence stems from studies such as Fuch’s RCT showing significant pain relief, functional improvement, and quality of life enhancement at 3 and 6 month intervals [87]. By contrast, Carette et al. [88] found no meaningful difference in perceived benefit between patients treated with steroid versus saline (control) injection at 3 and 6 month intervals. Available literature of MBB similarly show moderate evidence for short- and long-term relief [86] based on RCT of MBB under fluoroscopy, showing significant relief (by means of pain relief, physical health, psychological benefit, reduced narcotic intake, and employment status), with 1–3 injections in 100% patients at 3 months, 75–88% at 6 months, and 17–25% at 1 year [89].

SI joint injections

The sacroiliac joint space is a diarthrodial synovial joint with debated innervation patterns that involve both myelinated and unmyelinated axons. Injury or inflammation at the joint creates pain signals which are implicated in 10–27% of patients with low back pain [25] and may also refer to the buttocks, groin, thigh, and lower extremities.

There is moderate evidence to support the use of both diagnostic and therapeutic blocks of the SI joint [25]. Pereira treated 10 patients with MRI-guided bilateral SI joint injections of steroid, eight of whom reported “good to excellent” pain relief persisting through 13 months follow-up [90]. Maugers compared corticosteroid versus placebo injections under fluoroscopic guidance in SI joints of 10 symptomatic patients, reporting patient benefit only in the corticosteroid group. That benefit waned slowly over time, from 70% of patients at 1 month, to 62% at 3 months, and 58% at 6 months [91]. At this point, there is limited evidence to support radiofrequency neurotomy (ablation procedure) of the SI joint [92].

A recent meta-analysis provided the following guiding principles with regard to the frequency these procedures should be implemented in clinical practice. In cases of ESI, facet, and sacroiliac injections, diagnostic injections should be considered at intervals of no sooner than 1–2 weeks apart. Therapeutic injections may be performed at most every 2–3 months, provided the patient experiences greater than 50% relief within 6 weeks. Injections should be performed only as they are medically necessary given their associated risks and significant costs [25].

Intradiscal nonoperative therapies for discogenic pain

Discogenic pain has been identified as the source in 39% of patients with chronic low back pain. As described above, a cascade of effects induces the changes in the disk which generate pain. Discography seeks, when noninvasive imaging has failed, to identify damaged disks through injection of fluid into disk levels, in an attempt to reproduce patient symptoms. The technique’s utility remains controversial given significant potential for false positives. Provoked pain may be alternatively represent central hyperalgesia, reflect the patient’s chronic pain or psychological state, or result from technical difficulty due to the procedure itself [93].

If a diseased disk is identified, several treatment options exist. In addition to surgical correction, there are minimally invasive options. Both Intradiscal electrothermal therapy (IDET) and Radiofrequency posterior annuloplasty (RPA) involve electrode placement into the disk. Heat and electrical current coagulate the posterior anulus, and in doing so, strengthen collagen fibers, seal figures, denature inflammatory exudates, and coagulate nociceptors [25]. Current evidence provides moderate support for IDET in discogenic pain sufferers. Preliminary studies of RPA provide limited support for short term relief, with indeterminate long-term value. Both procedures have associated complications, including catheter malfunction, nerve root injuries, post-procedure disk herniation, and infection risk [25].

Surgical options

Surgical interventions are generally reserved for patients who have failed conservative options. Patients must be considered as appropriate “surgical candidates,” taking into consideration medical comorbidities as well as age, socioeconomic status, and projected activity level following a procedure [18]. Many surgical approaches have been developed to achieve one of the two primary goals: spinal fusion or spine decompression (or both).

Spinal fusion is considered in patients with malalignment or excessive motion of the spine, as seen with DDD and spondylolisthesis. Several surgical fusion approaches exist, all involving the addition of a bone graft to grow between vertebral elements to limit associated motion. Decompression surgery is indicated for patients with clear evidence of neural impingement, correcting the intrusion of bone or disk as might be seen in spinal or foraminal stenosis, disk herniation, osteophytosis, or degenerative spondylolisthesis. Despite dramatic increases in the number of procedures performed over the last several decades, there remains controversy as to the efficacy of these procedures in resolving chronic low back unresponsive to conservative management.

Controversy arises, in part, due to the inherent challenges of comparing the available research. Systematic reviews cite the heterogeneity of current trials which evaluate different surgical techniques with differing comparison groups and limited follow-up, frequently without patient-centered or pain outcomes included [18]. Some case series reveal promising results [94]. Nonetheless, a recent meta-analysis of 31 randomized controlled trials, concluded, “[there is] no clear evidence about the most effective technique of decompression for spinal stenosis or the extent of that decompression. There is limited evidence that adjunct fusion to supplement decompression for degenerative spondylolisthesis produces less progressive slip and better clinical outcomes than decompression alone.” Another review, noting no statistically significant improvement in patients undergoing fusion compared with nonsurgical interventions commented, “surgeons should recommend spinal fusion cautiously to patients with chronic low back pain. Further long-term follow-ups of the studies reviewed in this meta-analysis are required to provide more conclusive evidence in favor of either treatment” [95].

Conclusion

Lumbar spondylosis is a complicated diagnosis. We chose to define it broadly as degenerative conditions of the spine, but definitions vary widely within the literature. While it may not present a challenge to identify radiographically, its pervasiveness throughout all patient populations makes the exact diagnosis of symptomatic cases extremely difficult. Moreover, there is no current concrete, gold-standard treatment approach to the diverse range of patient presentations despite substantial research efforts to identify conservative and more invasive methods of managing symptoms and slowing progressive decline. Given the morbidity of low back pain within the population and its social and economic implications, this area will continue to be a critical research focus. Important clues are in place, from genetic studies, risk factor analysis, and explorative treatment approaches. These efforts, and future endeavors will no doubt fine-tune and present means to tackle not only symptoms, but confront progression, and ultimately prevention of disease in years to come.

Open Access

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What is It, Causes, Symptoms & Treatment

Overview

What is spondylolisthesis?

Spondylolisthesis is a condition involving spine instability, which means the vertebrae move more than they should. A vertebra slips out of place onto the vertebra below. It may put pressure on a nerve, which could cause lower back pain or leg pain.

The word spondylolisthesis (pronounced spohn-di-low-less-THEE-sis) comes from the Greek words spondylos, which means “spine” or “vertebra,” and listhesis, which means “slipping, sliding or movement.”

Is spondylolisthesis the same as spondylolysis?

Both spondylolysis and spondylolisthesis cause low back pain. They are related but not the same.

• Spondylolysis: This spine defect is a stress fractures or crack in spine bones. It’s common in young athletes.
• Spondylolisthesis: This condition is when a vertebra slips out of place, resting on the bone below it. Spondylolysis may cause spondylolisthesis when a stress fracture causes the slipping. Or the vertebra may slip out of place due to a degenerative condition. The disks between vertebrae and the facet joints (the two back parts of each vertebrae that link the vertebrae together) can wear down. Bone of the facet joints actually grows back and overgrows, causing an uneven and unstable surface area, which makes the vertebrae less able to stay in place. No matter what the cause, when the vertebra slips out of place, it puts pressure on the bone below it. Most cases of spondylolisthesis do not cause symptoms. If you feel leg pain, it can also be caused by compression or a “pinching” of the nerve roots that exit the spinal canal (the tunnel created by the interlocking vertebrae of the spine). The compression or pinching is due to the vertebrae slipping out of position and narrowing the needed space for the nerves.

What are the types of spondylolisthesis?

Types of spondylolisthesis include:

• Congenital spondylolisthesis occurs when a baby’s spine doesn’t form the way it should before birth. The misaligned vertebrae put the person at risk for slippage later in life.
• Isthmic spondylolisthesis happens as a result of spondylolysis. The crack or fracture weakens the bone.
• Degenerative spondylolisthesis, the most common type, happens due to aging. Over time, the disks that cushion the vertebrae lose water. As the disks thin, they are more likely to slip out of place.

Less common types of spondylolisthesis include:

• Traumatic spondylolisthesis happens when an injury causes vertebrae to slip.
• Pathological spondylolisthesis occurs when a disease — such as osteoporosis — or tumor causes the condition.
• Post-surgical spondylolisthesis is slippage as a result of spinal surgery.

How common is spondylolisthesis?

Spondylolisthesis and spondylolysis occur in about 4% to 6% of the adult population. It’s possible to live with spondylolisthesis for years and not know it, since you may not have symptoms.

Degenerative spondylolisthesis (which occurs due to aging and wear and tear on the spine), is more common after age 50 and more common in women than men.

When back pain occurs in teens, isthmic spondylolisthesis (usually caused by spondylolysis) is one of the most common causes.

Who is at risk for spondylolisthesis?

You may be more likely to develop spondylolisthesis due to:

• Athletics: Young athletes (children and teens) who participate in sports that stretch the lumbar spine, such as gymnastics and football, are more likely to develop spondylolisthesis. The vertebra slippage tends to occur during children’s growth spurts. Spondylolisthesis is one of the most common reasons for back pain in teens.
• Genetics: Some people with isthmic spondylolisthesis are born with thinner section of the vertebra called the pars interarticularis. This thin piece of bone connects the facet joints, which link the vertebrae directly above and below to form a working unit that permits movement of the spine. These thinner areas of vertebrae are more likely to fracture and slip. Degenerative spondylolisthesis also has a large genetic component.
• Age: As we age, degenerative spine conditions can develop, which is when wear and tear on the spine weakens the vertebrae. Older adults with degenerative spinal conditions may be at higher risk for spondylolisthesis. It becomes more common after age 50.

What is low-grade versus high-grade spondylolisthesis?

To determine how severe spondylolisthesis is, your healthcare provider gives it a grade:

• Low-grade (Grade I and Grade II) typically don’t require surgery. Low grade cases are usually seen in adolescents with isthmic spondylolisthesis and in almost all cases of degenerative spondylolisthesis.
• High-grade (Grade III and Grade IV) may require surgery if you’re in a lot of pain.

Will I need surgery for spondylolisthesis?

Your healthcare provider will start with nonsurgical options, such as rest and physical therapy. These treatments often relieve symptoms. Your healthcare provider may recommend surgery if you:

• Have high-grade spondylolisthesis.
• Experience severe pain.
• Tried nonsurgical treatments but still have symptoms.

Symptoms and Causes

What causes spondylolisthesis?

Overextending the spine is one of the main causes of spondylolisthesis in young athletes. Genetics may play a role, too. Some people are born with thinner vertebral bone. In older adults, wear and tear on the spine and disks (the cushions between vertebrae) can cause this condition.

What are the symptoms of spondylolisthesis?

You may not experience any symptoms of spondylolisthesis. Some people have the condition and don’t even know it. If you do have symptoms, lower back pain is typically the main one. The pain may extend to the buttocks and down the thighs. You may also experience:

• Muscle spasms in the hamstring (muscles in the back of the thighs).
• Back stiffness.
• Difficulty walking or standing for long periods.
• Pain when bending over.
• Numbness, weakness or tingling in the foot.

Diagnosis and Tests

How is spondylolisthesis diagnosed?

Your healthcare provider will do a physical exam and ask you about your symptoms. You will then likely need an imaging scan to confirm the diagnosis.

What imaging tests will I need?

• Spinal X-ray helps healthcare providers see if a vertebra is out of place.
• CT scan or MRI scan may be necessary to see the spine in more detail or to see soft tissue such as discs and nerves.

Management and Treatment

How do healthcare providers treat spondylolisthesis?

Treatment depends on the grade of the slippage, your symptoms, age and overall health. Your healthcare provider will discuss treatment options with you. You may need medication, physical therapy or surgery.

What nonsurgical treatments are available for spondylolisthesis?

Nonsurgical treatments include:

• Rest: Take a break from strenuous activities and sports.
• Medication: An over-the-counter nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Motrin®) or naproxen (Aleve®), can bring relief. If those don’t work, your healthcare provider may prescribe other medications.
• Injections: You receive an injection of steroid medications directly into the affected area.
• Physical therapy: A physical therapist can teach you targeted exercises to strengthen your abdomen (belly) and back. Daily exercises often relieve pain after a few weeks.
• Bracing: A brace can help stabilize your spine. The brace limits movement so that fractures can heal. Braces are not used in adults.

How do I know if I need surgery for spondylolisthesis?

You may need surgery if you have high-grade spondylolisthesis, the pain is severe or you’ve tried nonsurgical treatments without success. The goals of spondylolisthesis surgery are to:

• Relieve pain from the irritated nerve.
• Stabilize the spine where the vertebra has slipped.
• Restore your function.

What happens during surgery for spondylolisthesis?

Surgery for back pain due to spondylolisthesis typically involves spinal decompression, with or without fusion. Decompression alone is almost never done in isthmic spondylolisthesis. Studies show fusion with decompression may give better outcome than decompression alone. During a decompression surgery, your surgeon removes bone and disk from the spine. This procedure gives the nerves space inside the spinal canal, relieving pain.

For a fusion surgery, your surgeon fuses (connects) the two affected vertebrae. As they heal, they form into one bone, eliminating movement between the two vertebrae. You may experience some limited spinal flexibility as a result of the surgery.

Will spondylolisthesis come back?

Most of the time, pain is gone after you recover from spondylolisthesis surgery. You can gradually begin to resume your activities until you are back to full function and movement.

Prevention

How can I reduce my risk of spondylolisthesis?

You can take steps to reduce your risk of spondylolisthesis:

• Do regular exercises for strong back and abdominal muscles.
• Maintain a healthy weight. Excess weight puts added stress on your lower back.
• Eat a well-balanced diet to keep your bones well-nourished and strong.

After treatment, how can I prevent spondylolisthesis from returning?

Your healthcare provider may recommend exercises to strengthen the back and abdominal muscles, especially for children. Make sure to have regular checkups so your healthcare provider can detect any problems early on.

The chances of spondylolisthesis coming back, or recurring, are higher if the grade was higher. For people with a minor slippage, the condition may never come back.

Outlook / Prognosis

What is the outlook for people with spondylolisthesis?

Surgery has a high success rate. People who have surgery for spondylolisthesis often return to an active life within a few months of surgery. You will likely need rehabilitation after surgery to help you get back to full function.

Living With

Will spondylolisthesis go away on its own?

While the condition won’t go away on its own, you can often experience relief through rest, medication and physical therapy.

Can spondylolisthesis be reversed?

Nonsurgical treatments cannot undo the crack or slippage, but they can provide long-term pain relief. Surgery can relieve pressure on the nerves, stabilize the vertebrae and restore your spine’s strength.

What can I do about pain from spondylolisthesis?

First, take a break from strenuous activity and exercise. Try over-the-counter medications to relieve pain and inflammation. And make sure to see your healthcare provider, who can help you figure out next steps.

A note from Cleveland Clinic

Spondylolisthesis is a common cause of back pain, but it is not dangerous and doesn’t need to take over your life. Many treatments are available, from medication and physical therapy to spinal surgery. If you have low back pain or find it difficult to walk, stand or bend over, talk to your healthcare provider to find out how you can feel better.

What is It, Causes, Symptoms & Treatment

Overview

What is spondylolisthesis?

Spondylolisthesis is a condition involving spine instability, which means the vertebrae move more than they should. A vertebra slips out of place onto the vertebra below. It may put pressure on a nerve, which could cause lower back pain or leg pain.

The word spondylolisthesis (pronounced spohn-di-low-less-THEE-sis) comes from the Greek words spondylos, which means “spine” or “vertebra,” and listhesis, which means “slipping, sliding or movement.”

Is spondylolisthesis the same as spondylolysis?

Both spondylolysis and spondylolisthesis cause low back pain. They are related but not the same.

• Spondylolysis: This spine defect is a stress fractures or crack in spine bones. It’s common in young athletes.
• Spondylolisthesis: This condition is when a vertebra slips out of place, resting on the bone below it. Spondylolysis may cause spondylolisthesis when a stress fracture causes the slipping. Or the vertebra may slip out of place due to a degenerative condition. The disks between vertebrae and the facet joints (the two back parts of each vertebrae that link the vertebrae together) can wear down. Bone of the facet joints actually grows back and overgrows, causing an uneven and unstable surface area, which makes the vertebrae less able to stay in place. No matter what the cause, when the vertebra slips out of place, it puts pressure on the bone below it. Most cases of spondylolisthesis do not cause symptoms. If you feel leg pain, it can also be caused by compression or a “pinching” of the nerve roots that exit the spinal canal (the tunnel created by the interlocking vertebrae of the spine). The compression or pinching is due to the vertebrae slipping out of position and narrowing the needed space for the nerves.

What are the types of spondylolisthesis?

Types of spondylolisthesis include:

• Congenital spondylolisthesis occurs when a baby’s spine doesn’t form the way it should before birth. The misaligned vertebrae put the person at risk for slippage later in life.
• Isthmic spondylolisthesis happens as a result of spondylolysis. The crack or fracture weakens the bone.
• Degenerative spondylolisthesis, the most common type, happens due to aging. Over time, the disks that cushion the vertebrae lose water. As the disks thin, they are more likely to slip out of place.

Less common types of spondylolisthesis include:

• Traumatic spondylolisthesis happens when an injury causes vertebrae to slip.
• Pathological spondylolisthesis occurs when a disease — such as osteoporosis — or tumor causes the condition.
• Post-surgical spondylolisthesis is slippage as a result of spinal surgery.

How common is spondylolisthesis?

Spondylolisthesis and spondylolysis occur in about 4% to 6% of the adult population. It’s possible to live with spondylolisthesis for years and not know it, since you may not have symptoms.

Degenerative spondylolisthesis (which occurs due to aging and wear and tear on the spine), is more common after age 50 and more common in women than men.

When back pain occurs in teens, isthmic spondylolisthesis (usually caused by spondylolysis) is one of the most common causes.

Who is at risk for spondylolisthesis?

You may be more likely to develop spondylolisthesis due to:

• Athletics: Young athletes (children and teens) who participate in sports that stretch the lumbar spine, such as gymnastics and football, are more likely to develop spondylolisthesis. The vertebra slippage tends to occur during children’s growth spurts. Spondylolisthesis is one of the most common reasons for back pain in teens.
• Genetics: Some people with isthmic spondylolisthesis are born with thinner section of the vertebra called the pars interarticularis. This thin piece of bone connects the facet joints, which link the vertebrae directly above and below to form a working unit that permits movement of the spine. These thinner areas of vertebrae are more likely to fracture and slip. Degenerative spondylolisthesis also has a large genetic component.
• Age: As we age, degenerative spine conditions can develop, which is when wear and tear on the spine weakens the vertebrae. Older adults with degenerative spinal conditions may be at higher risk for spondylolisthesis. It becomes more common after age 50.

What is low-grade versus high-grade spondylolisthesis?

To determine how severe spondylolisthesis is, your healthcare provider gives it a grade:

• Low-grade (Grade I and Grade II) typically don’t require surgery. Low grade cases are usually seen in adolescents with isthmic spondylolisthesis and in almost all cases of degenerative spondylolisthesis.
• High-grade (Grade III and Grade IV) may require surgery if you’re in a lot of pain.

Will I need surgery for spondylolisthesis?

Your healthcare provider will start with nonsurgical options, such as rest and physical therapy. These treatments often relieve symptoms. Your healthcare provider may recommend surgery if you:

• Have high-grade spondylolisthesis.
• Experience severe pain.
• Tried nonsurgical treatments but still have symptoms.

Symptoms and Causes

What causes spondylolisthesis?

Overextending the spine is one of the main causes of spondylolisthesis in young athletes. Genetics may play a role, too. Some people are born with thinner vertebral bone. In older adults, wear and tear on the spine and disks (the cushions between vertebrae) can cause this condition.

What are the symptoms of spondylolisthesis?

You may not experience any symptoms of spondylolisthesis. Some people have the condition and don’t even know it. If you do have symptoms, lower back pain is typically the main one. The pain may extend to the buttocks and down the thighs. You may also experience:

• Muscle spasms in the hamstring (muscles in the back of the thighs).
• Back stiffness.
• Difficulty walking or standing for long periods.
• Pain when bending over.
• Numbness, weakness or tingling in the foot.

Diagnosis and Tests

How is spondylolisthesis diagnosed?

Your healthcare provider will do a physical exam and ask you about your symptoms. You will then likely need an imaging scan to confirm the diagnosis.

What imaging tests will I need?

• Spinal X-ray helps healthcare providers see if a vertebra is out of place.
• CT scan or MRI scan may be necessary to see the spine in more detail or to see soft tissue such as discs and nerves.

Management and Treatment

How do healthcare providers treat spondylolisthesis?

Treatment depends on the grade of the slippage, your symptoms, age and overall health. Your healthcare provider will discuss treatment options with you. You may need medication, physical therapy or surgery.

What nonsurgical treatments are available for spondylolisthesis?

Nonsurgical treatments include:

• Rest: Take a break from strenuous activities and sports.
• Medication: An over-the-counter nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Motrin®) or naproxen (Aleve®), can bring relief. If those don’t work, your healthcare provider may prescribe other medications.
• Injections: You receive an injection of steroid medications directly into the affected area.
• Physical therapy: A physical therapist can teach you targeted exercises to strengthen your abdomen (belly) and back. Daily exercises often relieve pain after a few weeks.
• Bracing: A brace can help stabilize your spine. The brace limits movement so that fractures can heal. Braces are not used in adults.

How do I know if I need surgery for spondylolisthesis?

You may need surgery if you have high-grade spondylolisthesis, the pain is severe or you’ve tried nonsurgical treatments without success. The goals of spondylolisthesis surgery are to:

• Relieve pain from the irritated nerve.
• Stabilize the spine where the vertebra has slipped.
• Restore your function.

What happens during surgery for spondylolisthesis?

Surgery for back pain due to spondylolisthesis typically involves spinal decompression, with or without fusion. Decompression alone is almost never done in isthmic spondylolisthesis. Studies show fusion with decompression may give better outcome than decompression alone. During a decompression surgery, your surgeon removes bone and disk from the spine. This procedure gives the nerves space inside the spinal canal, relieving pain.

For a fusion surgery, your surgeon fuses (connects) the two affected vertebrae. As they heal, they form into one bone, eliminating movement between the two vertebrae. You may experience some limited spinal flexibility as a result of the surgery.

Will spondylolisthesis come back?

Most of the time, pain is gone after you recover from spondylolisthesis surgery. You can gradually begin to resume your activities until you are back to full function and movement.

Prevention

How can I reduce my risk of spondylolisthesis?

You can take steps to reduce your risk of spondylolisthesis:

• Do regular exercises for strong back and abdominal muscles.
• Maintain a healthy weight. Excess weight puts added stress on your lower back.
• Eat a well-balanced diet to keep your bones well-nourished and strong.

After treatment, how can I prevent spondylolisthesis from returning?

Your healthcare provider may recommend exercises to strengthen the back and abdominal muscles, especially for children. Make sure to have regular checkups so your healthcare provider can detect any problems early on.

The chances of spondylolisthesis coming back, or recurring, are higher if the grade was higher. For people with a minor slippage, the condition may never come back.

Outlook / Prognosis

What is the outlook for people with spondylolisthesis?

Surgery has a high success rate. People who have surgery for spondylolisthesis often return to an active life within a few months of surgery. You will likely need rehabilitation after surgery to help you get back to full function.

Living With

Will spondylolisthesis go away on its own?

While the condition won’t go away on its own, you can often experience relief through rest, medication and physical therapy.

Can spondylolisthesis be reversed?

Nonsurgical treatments cannot undo the crack or slippage, but they can provide long-term pain relief. Surgery can relieve pressure on the nerves, stabilize the vertebrae and restore your spine’s strength.

What can I do about pain from spondylolisthesis?

First, take a break from strenuous activity and exercise. Try over-the-counter medications to relieve pain and inflammation. And make sure to see your healthcare provider, who can help you figure out next steps.

A note from Cleveland Clinic

Spondylolisthesis is a common cause of back pain, but it is not dangerous and doesn’t need to take over your life. Many treatments are available, from medication and physical therapy to spinal surgery. If you have low back pain or find it difficult to walk, stand or bend over, talk to your healthcare provider to find out how you can feel better.

What is It, Causes, Symptoms & Treatment

Overview

What is spondylolisthesis?

Spondylolisthesis is a condition involving spine instability, which means the vertebrae move more than they should. A vertebra slips out of place onto the vertebra below. It may put pressure on a nerve, which could cause lower back pain or leg pain.

The word spondylolisthesis (pronounced spohn-di-low-less-THEE-sis) comes from the Greek words spondylos, which means “spine” or “vertebra,” and listhesis, which means “slipping, sliding or movement.”

Is spondylolisthesis the same as spondylolysis?

Both spondylolysis and spondylolisthesis cause low back pain. They are related but not the same.

• Spondylolysis: This spine defect is a stress fractures or crack in spine bones. It’s common in young athletes.
• Spondylolisthesis: This condition is when a vertebra slips out of place, resting on the bone below it. Spondylolysis may cause spondylolisthesis when a stress fracture causes the slipping. Or the vertebra may slip out of place due to a degenerative condition. The disks between vertebrae and the facet joints (the two back parts of each vertebrae that link the vertebrae together) can wear down. Bone of the facet joints actually grows back and overgrows, causing an uneven and unstable surface area, which makes the vertebrae less able to stay in place. No matter what the cause, when the vertebra slips out of place, it puts pressure on the bone below it. Most cases of spondylolisthesis do not cause symptoms. If you feel leg pain, it can also be caused by compression or a “pinching” of the nerve roots that exit the spinal canal (the tunnel created by the interlocking vertebrae of the spine). The compression or pinching is due to the vertebrae slipping out of position and narrowing the needed space for the nerves.

What are the types of spondylolisthesis?

Types of spondylolisthesis include:

• Congenital spondylolisthesis occurs when a baby’s spine doesn’t form the way it should before birth. The misaligned vertebrae put the person at risk for slippage later in life.
• Isthmic spondylolisthesis happens as a result of spondylolysis. The crack or fracture weakens the bone.
• Degenerative spondylolisthesis, the most common type, happens due to aging. Over time, the disks that cushion the vertebrae lose water. As the disks thin, they are more likely to slip out of place.

Less common types of spondylolisthesis include:

• Traumatic spondylolisthesis happens when an injury causes vertebrae to slip.
• Pathological spondylolisthesis occurs when a disease — such as osteoporosis — or tumor causes the condition.
• Post-surgical spondylolisthesis is slippage as a result of spinal surgery.

How common is spondylolisthesis?

Spondylolisthesis and spondylolysis occur in about 4% to 6% of the adult population. It’s possible to live with spondylolisthesis for years and not know it, since you may not have symptoms.

Degenerative spondylolisthesis (which occurs due to aging and wear and tear on the spine), is more common after age 50 and more common in women than men.

When back pain occurs in teens, isthmic spondylolisthesis (usually caused by spondylolysis) is one of the most common causes.

Who is at risk for spondylolisthesis?

You may be more likely to develop spondylolisthesis due to:

• Athletics: Young athletes (children and teens) who participate in sports that stretch the lumbar spine, such as gymnastics and football, are more likely to develop spondylolisthesis. The vertebra slippage tends to occur during children’s growth spurts. Spondylolisthesis is one of the most common reasons for back pain in teens.
• Genetics: Some people with isthmic spondylolisthesis are born with thinner section of the vertebra called the pars interarticularis. This thin piece of bone connects the facet joints, which link the vertebrae directly above and below to form a working unit that permits movement of the spine. These thinner areas of vertebrae are more likely to fracture and slip. Degenerative spondylolisthesis also has a large genetic component.
• Age: As we age, degenerative spine conditions can develop, which is when wear and tear on the spine weakens the vertebrae. Older adults with degenerative spinal conditions may be at higher risk for spondylolisthesis. It becomes more common after age 50.

What is low-grade versus high-grade spondylolisthesis?

To determine how severe spondylolisthesis is, your healthcare provider gives it a grade:

• Low-grade (Grade I and Grade II) typically don’t require surgery. Low grade cases are usually seen in adolescents with isthmic spondylolisthesis and in almost all cases of degenerative spondylolisthesis.
• High-grade (Grade III and Grade IV) may require surgery if you’re in a lot of pain.

Will I need surgery for spondylolisthesis?

Your healthcare provider will start with nonsurgical options, such as rest and physical therapy. These treatments often relieve symptoms. Your healthcare provider may recommend surgery if you:

• Have high-grade spondylolisthesis.
• Experience severe pain.
• Tried nonsurgical treatments but still have symptoms.

Symptoms and Causes

What causes spondylolisthesis?

Overextending the spine is one of the main causes of spondylolisthesis in young athletes. Genetics may play a role, too. Some people are born with thinner vertebral bone. In older adults, wear and tear on the spine and disks (the cushions between vertebrae) can cause this condition.

What are the symptoms of spondylolisthesis?

You may not experience any symptoms of spondylolisthesis. Some people have the condition and don’t even know it. If you do have symptoms, lower back pain is typically the main one. The pain may extend to the buttocks and down the thighs. You may also experience:

• Muscle spasms in the hamstring (muscles in the back of the thighs).
• Back stiffness.
• Difficulty walking or standing for long periods.
• Pain when bending over.
• Numbness, weakness or tingling in the foot.

Diagnosis and Tests

How is spondylolisthesis diagnosed?

Your healthcare provider will do a physical exam and ask you about your symptoms. You will then likely need an imaging scan to confirm the diagnosis.

What imaging tests will I need?

• Spinal X-ray helps healthcare providers see if a vertebra is out of place.
• CT scan or MRI scan may be necessary to see the spine in more detail or to see soft tissue such as discs and nerves.

Management and Treatment

How do healthcare providers treat spondylolisthesis?

Treatment depends on the grade of the slippage, your symptoms, age and overall health. Your healthcare provider will discuss treatment options with you. You may need medication, physical therapy or surgery.

What nonsurgical treatments are available for spondylolisthesis?

Nonsurgical treatments include:

• Rest: Take a break from strenuous activities and sports.
• Medication: An over-the-counter nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Motrin®) or naproxen (Aleve®), can bring relief. If those don’t work, your healthcare provider may prescribe other medications.
• Injections: You receive an injection of steroid medications directly into the affected area.
• Physical therapy: A physical therapist can teach you targeted exercises to strengthen your abdomen (belly) and back. Daily exercises often relieve pain after a few weeks.
• Bracing: A brace can help stabilize your spine. The brace limits movement so that fractures can heal. Braces are not used in adults.

How do I know if I need surgery for spondylolisthesis?

You may need surgery if you have high-grade spondylolisthesis, the pain is severe or you’ve tried nonsurgical treatments without success. The goals of spondylolisthesis surgery are to:

• Relieve pain from the irritated nerve.
• Stabilize the spine where the vertebra has slipped.
• Restore your function.

What happens during surgery for spondylolisthesis?

Surgery for back pain due to spondylolisthesis typically involves spinal decompression, with or without fusion. Decompression alone is almost never done in isthmic spondylolisthesis. Studies show fusion with decompression may give better outcome than decompression alone. During a decompression surgery, your surgeon removes bone and disk from the spine. This procedure gives the nerves space inside the spinal canal, relieving pain.

For a fusion surgery, your surgeon fuses (connects) the two affected vertebrae. As they heal, they form into one bone, eliminating movement between the two vertebrae. You may experience some limited spinal flexibility as a result of the surgery.

Will spondylolisthesis come back?

Most of the time, pain is gone after you recover from spondylolisthesis surgery. You can gradually begin to resume your activities until you are back to full function and movement.

Prevention

How can I reduce my risk of spondylolisthesis?

You can take steps to reduce your risk of spondylolisthesis:

• Do regular exercises for strong back and abdominal muscles.
• Maintain a healthy weight. Excess weight puts added stress on your lower back.
• Eat a well-balanced diet to keep your bones well-nourished and strong.

After treatment, how can I prevent spondylolisthesis from returning?

Your healthcare provider may recommend exercises to strengthen the back and abdominal muscles, especially for children. Make sure to have regular checkups so your healthcare provider can detect any problems early on.

The chances of spondylolisthesis coming back, or recurring, are higher if the grade was higher. For people with a minor slippage, the condition may never come back.

Outlook / Prognosis

What is the outlook for people with spondylolisthesis?

Surgery has a high success rate. People who have surgery for spondylolisthesis often return to an active life within a few months of surgery. You will likely need rehabilitation after surgery to help you get back to full function.

Living With

Will spondylolisthesis go away on its own?

While the condition won’t go away on its own, you can often experience relief through rest, medication and physical therapy.

Can spondylolisthesis be reversed?

Nonsurgical treatments cannot undo the crack or slippage, but they can provide long-term pain relief. Surgery can relieve pressure on the nerves, stabilize the vertebrae and restore your spine’s strength.

What can I do about pain from spondylolisthesis?

First, take a break from strenuous activity and exercise. Try over-the-counter medications to relieve pain and inflammation. And make sure to see your healthcare provider, who can help you figure out next steps.

A note from Cleveland Clinic

Spondylolisthesis is a common cause of back pain, but it is not dangerous and doesn’t need to take over your life. Many treatments are available, from medication and physical therapy to spinal surgery. If you have low back pain or find it difficult to walk, stand or bend over, talk to your healthcare provider to find out how you can feel better.

What is It, Causes, Symptoms & Treatment

Overview

What is spondylolisthesis?

Spondylolisthesis is a condition involving spine instability, which means the vertebrae move more than they should. A vertebra slips out of place onto the vertebra below. It may put pressure on a nerve, which could cause lower back pain or leg pain.

The word spondylolisthesis (pronounced spohn-di-low-less-THEE-sis) comes from the Greek words spondylos, which means “spine” or “vertebra,” and listhesis, which means “slipping, sliding or movement.”

Is spondylolisthesis the same as spondylolysis?

Both spondylolysis and spondylolisthesis cause low back pain. They are related but not the same.

• Spondylolysis: This spine defect is a stress fractures or crack in spine bones. It’s common in young athletes.
• Spondylolisthesis: This condition is when a vertebra slips out of place, resting on the bone below it. Spondylolysis may cause spondylolisthesis when a stress fracture causes the slipping. Or the vertebra may slip out of place due to a degenerative condition. The disks between vertebrae and the facet joints (the two back parts of each vertebrae that link the vertebrae together) can wear down. Bone of the facet joints actually grows back and overgrows, causing an uneven and unstable surface area, which makes the vertebrae less able to stay in place. No matter what the cause, when the vertebra slips out of place, it puts pressure on the bone below it. Most cases of spondylolisthesis do not cause symptoms. If you feel leg pain, it can also be caused by compression or a “pinching” of the nerve roots that exit the spinal canal (the tunnel created by the interlocking vertebrae of the spine). The compression or pinching is due to the vertebrae slipping out of position and narrowing the needed space for the nerves.

What are the types of spondylolisthesis?

Types of spondylolisthesis include:

• Congenital spondylolisthesis occurs when a baby’s spine doesn’t form the way it should before birth. The misaligned vertebrae put the person at risk for slippage later in life.
• Isthmic spondylolisthesis happens as a result of spondylolysis. The crack or fracture weakens the bone.
• Degenerative spondylolisthesis, the most common type, happens due to aging. Over time, the disks that cushion the vertebrae lose water. As the disks thin, they are more likely to slip out of place.

Less common types of spondylolisthesis include:

• Traumatic spondylolisthesis happens when an injury causes vertebrae to slip.
• Pathological spondylolisthesis occurs when a disease — such as osteoporosis — or tumor causes the condition.
• Post-surgical spondylolisthesis is slippage as a result of spinal surgery.

How common is spondylolisthesis?

Spondylolisthesis and spondylolysis occur in about 4% to 6% of the adult population. It’s possible to live with spondylolisthesis for years and not know it, since you may not have symptoms.

Degenerative spondylolisthesis (which occurs due to aging and wear and tear on the spine), is more common after age 50 and more common in women than men.

When back pain occurs in teens, isthmic spondylolisthesis (usually caused by spondylolysis) is one of the most common causes.

Who is at risk for spondylolisthesis?

You may be more likely to develop spondylolisthesis due to:

• Athletics: Young athletes (children and teens) who participate in sports that stretch the lumbar spine, such as gymnastics and football, are more likely to develop spondylolisthesis. The vertebra slippage tends to occur during children’s growth spurts. Spondylolisthesis is one of the most common reasons for back pain in teens.
• Genetics: Some people with isthmic spondylolisthesis are born with thinner section of the vertebra called the pars interarticularis. This thin piece of bone connects the facet joints, which link the vertebrae directly above and below to form a working unit that permits movement of the spine. These thinner areas of vertebrae are more likely to fracture and slip. Degenerative spondylolisthesis also has a large genetic component.
• Age: As we age, degenerative spine conditions can develop, which is when wear and tear on the spine weakens the vertebrae. Older adults with degenerative spinal conditions may be at higher risk for spondylolisthesis. It becomes more common after age 50.

What is low-grade versus high-grade spondylolisthesis?

To determine how severe spondylolisthesis is, your healthcare provider gives it a grade:

• Low-grade (Grade I and Grade II) typically don’t require surgery. Low grade cases are usually seen in adolescents with isthmic spondylolisthesis and in almost all cases of degenerative spondylolisthesis.
• High-grade (Grade III and Grade IV) may require surgery if you’re in a lot of pain.

Will I need surgery for spondylolisthesis?

Your healthcare provider will start with nonsurgical options, such as rest and physical therapy. These treatments often relieve symptoms. Your healthcare provider may recommend surgery if you:

• Have high-grade spondylolisthesis.
• Experience severe pain.
• Tried nonsurgical treatments but still have symptoms.

Symptoms and Causes

What causes spondylolisthesis?

Overextending the spine is one of the main causes of spondylolisthesis in young athletes. Genetics may play a role, too. Some people are born with thinner vertebral bone. In older adults, wear and tear on the spine and disks (the cushions between vertebrae) can cause this condition.

What are the symptoms of spondylolisthesis?

You may not experience any symptoms of spondylolisthesis. Some people have the condition and don’t even know it. If you do have symptoms, lower back pain is typically the main one. The pain may extend to the buttocks and down the thighs. You may also experience:

• Muscle spasms in the hamstring (muscles in the back of the thighs).
• Back stiffness.
• Difficulty walking or standing for long periods.
• Pain when bending over.
• Numbness, weakness or tingling in the foot.

Diagnosis and Tests

How is spondylolisthesis diagnosed?

Your healthcare provider will do a physical exam and ask you about your symptoms. You will then likely need an imaging scan to confirm the diagnosis.

What imaging tests will I need?

• Spinal X-ray helps healthcare providers see if a vertebra is out of place.
• CT scan or MRI scan may be necessary to see the spine in more detail or to see soft tissue such as discs and nerves.

Management and Treatment

How do healthcare providers treat spondylolisthesis?

Treatment depends on the grade of the slippage, your symptoms, age and overall health. Your healthcare provider will discuss treatment options with you. You may need medication, physical therapy or surgery.

What nonsurgical treatments are available for spondylolisthesis?

Nonsurgical treatments include:

• Rest: Take a break from strenuous activities and sports.
• Medication: An over-the-counter nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Motrin®) or naproxen (Aleve®), can bring relief. If those don’t work, your healthcare provider may prescribe other medications.
• Injections: You receive an injection of steroid medications directly into the affected area.
• Physical therapy: A physical therapist can teach you targeted exercises to strengthen your abdomen (belly) and back. Daily exercises often relieve pain after a few weeks.
• Bracing: A brace can help stabilize your spine. The brace limits movement so that fractures can heal. Braces are not used in adults.

How do I know if I need surgery for spondylolisthesis?

You may need surgery if you have high-grade spondylolisthesis, the pain is severe or you’ve tried nonsurgical treatments without success. The goals of spondylolisthesis surgery are to:

• Relieve pain from the irritated nerve.
• Stabilize the spine where the vertebra has slipped.
• Restore your function.

What happens during surgery for spondylolisthesis?

Surgery for back pain due to spondylolisthesis typically involves spinal decompression, with or without fusion. Decompression alone is almost never done in isthmic spondylolisthesis. Studies show fusion with decompression may give better outcome than decompression alone. During a decompression surgery, your surgeon removes bone and disk from the spine. This procedure gives the nerves space inside the spinal canal, relieving pain.

For a fusion surgery, your surgeon fuses (connects) the two affected vertebrae. As they heal, they form into one bone, eliminating movement between the two vertebrae. You may experience some limited spinal flexibility as a result of the surgery.

Will spondylolisthesis come back?

Most of the time, pain is gone after you recover from spondylolisthesis surgery. You can gradually begin to resume your activities until you are back to full function and movement.

Prevention

How can I reduce my risk of spondylolisthesis?

You can take steps to reduce your risk of spondylolisthesis:

• Do regular exercises for strong back and abdominal muscles.
• Maintain a healthy weight. Excess weight puts added stress on your lower back.
• Eat a well-balanced diet to keep your bones well-nourished and strong.

After treatment, how can I prevent spondylolisthesis from returning?

Your healthcare provider may recommend exercises to strengthen the back and abdominal muscles, especially for children. Make sure to have regular checkups so your healthcare provider can detect any problems early on.

The chances of spondylolisthesis coming back, or recurring, are higher if the grade was higher. For people with a minor slippage, the condition may never come back.

Outlook / Prognosis

What is the outlook for people with spondylolisthesis?

Surgery has a high success rate. People who have surgery for spondylolisthesis often return to an active life within a few months of surgery. You will likely need rehabilitation after surgery to help you get back to full function.

Living With

Will spondylolisthesis go away on its own?

While the condition won’t go away on its own, you can often experience relief through rest, medication and physical therapy.

Can spondylolisthesis be reversed?

Nonsurgical treatments cannot undo the crack or slippage, but they can provide long-term pain relief. Surgery can relieve pressure on the nerves, stabilize the vertebrae and restore your spine’s strength.

What can I do about pain from spondylolisthesis?

First, take a break from strenuous activity and exercise. Try over-the-counter medications to relieve pain and inflammation. And make sure to see your healthcare provider, who can help you figure out next steps.

A note from Cleveland Clinic

Spondylolisthesis is a common cause of back pain, but it is not dangerous and doesn’t need to take over your life. Many treatments are available, from medication and physical therapy to spinal surgery. If you have low back pain or find it difficult to walk, stand or bend over, talk to your healthcare provider to find out how you can feel better.

90,000 Inflammatory diseases of the spine – operations and treatment in Moscow, prices on the website of N.N. Burdenko

Inflammatory diseases of the spine (spondylitis) can occur after any common infectious disease. Spondylitis are primary and secondary, and can be acute and chronic. In the clinical picture of spondylitis, there are significant differences due to the localization of the inflammatory process in the spine and the prevalence of bone destruction.The most common symptom is pain and fever, later neurological and septic complications join.

Spondylitis can be nonspecific (purulent), caused by various bacteria and specific (tuberculosis, syphilis, gonorrhea, actinomycosis, brucellosis).

Hematogenous osteomyelitis of the spine (spondylitis) is a serious disease that is difficult to recognize, often at a later date, when destruction (destruction) of the vertebral bodies is already taking place.Most often, the lesion is located in the thoracic and lumbar spine, rarely in the cervical. Damage to the vertebral bodies, and sometimes the arches, can occur as a metastasis in furunculosis, angina, dental caries, after operations on the abdominal cavity, kidneys and pelvic organs. Local infection has been observed during lumbar spinal block, lumbar puncture, anesthesia, and disc surgery.

Nonspecific spondylitis

To diagnose spondylitis, radiography, computed tomography, magnetic resonance imaging, scintigraphy, and laboratory data are used.

For radical treatment, a surgical operation is required – posterior internal fixation of the spine, and in case of pronounced destruction of the vertebrae and the formation of purulent streaks, anterior operations with resection of the vertebral bodies and sanitation of the pathological focus. In the future, antibiotic therapy and dynamic observation are carried out. Unfortunately, refusal from active surgical tactics of treatment sometimes leads to irreparable complications.

Radiographs after surgical treatment of spondylitis.90,000 Ankylosing spondylitis (ankylosing spondylitis) – ME “Grodno University Clinic”

This is an inflammatory disease with damage to the spine and joints, in which there is a gradual fusion of bones with each other, which leads to ossification of the ligaments of the spine, the formation of so-called ankylosis and, as a result, a significant limitation of mobility.

Usually, ankylosing spondylitis begins with minor pain in the lumbar spine, and given that this symptom is typical for a dozen other diseases of the spine, at the first stage of spondylitis, the diagnosis causes certain difficulties.Complicating the situation is the fact that pains can disappear very quickly. Meanwhile, the disease continues to develop, preparing to inflict a new, already more serious blow to its carrier. So, after a while, back pain reappears. This time they are much more noticeable than they were before, and sleep and rest do not lead to their disappearance. Having affected the lumbar spine, spondylitis tends to the upper levels of the spine, reaching all the way to the neck. At the middle stage of the development of the disease, neither morning exercises nor even pain relievers help a person.Under the influence of the pills, the pain may go away for a while, but the stiffness remains.

One thing is clear for doctors – spondylitis occurs as a result of disorders of the immune system and affects autogenous cells. So, immune cells mistakenly attack healthy cells of the body, and first of all – the cells of bone tissue and joints, as a result of which the skeleton undergoes deformations.

Symptoms of spondylitis:

• Morning lower back stiffness. During the day, the feeling of stiffness will surely pass, but such a sign should definitely not be left without attention.
• Pain in the buttocks and lower back.
• Increased pain in the lower back and spine during rest. For many other diseases of the skeleton, their decrease is characteristic, but in the case of spondylitis, the opposite is true.
• Moderate and gradually increasing pain in the hip joint. If there are any, there is a possibility that it is spondylitis, and not at all in its initial stage.
• Problems with forward bending of the trunk.Spondylitis, as it develops, deprives the human spine of its natural flexibility, and the easiest way to identify the disease is to lean forward. Pain and sensations as if something is preventing you from bending over are symptoms characteristic of spondylitis.
• Limitation of the flexibility of the cervical spine. The cervical spine can lose flexibility for a variety of reasons, but as an option – the development of spondylitis.
• Joint inflammation. Joint inflammation (swelling, redness, pain) is a very common symptom of spondylitis.
• Breathing problems. Affecting the costal-vertebral joints, spondylitis restricts the mobility of the chest, as a result of which it becomes more difficult to breathe than before. With such a symptom, it is urgent to go to the doctor, and the point here is not only the likely development of ankylosing spondylitis, but also the risk of developing inflammatory processes in the lungs.
• Pain and redness of the eyes without deterioration of vision is another symptom of spondylitis.
• The abatement of the once regular pain in the spine with the preservation of limitations in flexibility and mobility is a symptom of the last stage of spondylitis.

Spondylitis is one of those diseases for which there is no age limit. But more often men are sick.

Many doctors openly admit: the diagnosis of spondylitis in the initial stage is extremely difficult, because ankylosing spondylitis is perfectly disguised as other diseases. An experienced doctor at first glance will be able to recognize the presence of the disease and almost immediately, confirming the fears, begin to solve the problem.

Methods for the treatment of spondylitis

The main principle of the treatment of spondylitis is to maintain a healthy lifestyle.Move more, monitor the correct body position when walking, sitting at a table, and so on. If you regularly engage in therapeutic exercises, you can stop the progression of the disease. At the same time, there is one “BUT” here: this method applies only to the initial stage of spondylitis.

Effective methods of treating spondylitis are:

• Taking non-steroidal anti-inflammatory drugs.
• Ankylosing spondylitis can also be treated with physical therapy.Physiotherapy is usually prescribed as an adjunct to medication, which ensures that a positive result is achieved in a fairly short time.
• In the remission stage of spondylitis, massage and manual therapy are used. At the same time, doctors say: during massage, it is important not to overdo it with intensity.

Material prepared by rheumatologist
polyclinics GOKB Pavlovich N.P.

Spondylitis of the spine

Spondylitis – what is this disease

Spondylitis is a chronic inflammatory disease of the spinal column.Spondylosis refers to a form of spondylopathy, during which the destruction of the vertebral body occurs, and this is fraught with multiple deformities. Spondylitis is rare in the population and is associated with a bacterial or autoimmune complication. The prevalence does not exceed 0.6% of cases in the world. The disease can occur at any age and its course does not depend on gender. Spondylitis are specific, associated with other chronic diseases and nonspecific – which are an independent failure in the body.

Types of spondylitis

How is the disease classified:

1. Specific type. This category includes diseases provoked by a bacterial pathogen. Most often, specific spondylitis develops against the background of tuberculosis, syphilis, gonorrhea, typhoid fever, and brucellosis.
2. Nonspecific type. This form of the disease can be provoked by opportunistic microorganisms that live in the body or a malfunction of the immune system. This type of spondylitis does not occur immediately, it develops in response to a stressful situation for the body – hypothermia, physical or nervous exhaustion, hormonal disorders, trauma.An example is ankylosing spondylitis.

According to the localization of inflammation, the following is isolated:

1. Cervical spondylopathy.
2. Lesion of the thoracic region.
3. Inflammation in the lumbar spine.

There are also differences in the course of the disease. The pathology progresses slowly and is characterized by a chronic course or is greatly exacerbated and significantly reduces the patient’s quality of life. The most common types of spondylitis encountered in medical practice will be described below.

Tuberculous spondylitis

The second name of the pathology is Pott’s disease. The thoracic region is most often affected in adolescents and children, since their spine is not yet fully developed. The mechanism of development of the complication is associated with the penetration of mycobacterium tuberculosis into the vertebral body, where they begin to release toxic substances, which triggers the processes of necrotization. Without therapy, tuberculous spondylitis begins to affect the adjacent parts of the spine, affecting all the new vertebrae.This is fraught with the development of abscesses and severe inflammation. Patients express nonspecific complaints – increased fatigue, back pain and poor quality of night sleep.

What is spondylitis

Tuberculous spondylitis does not debut immediately, but within a few months or even years after infection. Complication triggers are trauma, decreased immunity, stress. The disease is characterized by a severe course, since large areas of the spine are affected. The selection of antibiotic therapy is difficult, since tuberculous spondylitis is very resistant to pharmacological treatment.

Aseptic spondylitis

The second name of the pathology is Kummel-Verneuil disease. It usually develops after a back injury. Several months pass between the first episode of illness and trauma, so patients do not always associate these conditions with each other. After the appearance of foci of necrosis in the ridge, the patient’s condition worsens, he feels weakness and back pain, which forces him to seek medical help.

Due to improperly redistributed load, signs of compression and fractures appear.Nerve roots also suffer from inflammation. Initially, with aseptic spondylitis, the thoracic region is affected, less often the lumbar region suffers. Most often, the pathology makes its debut in men aged 40 – 45 years.

Ankylosing spondylitis or spondyloarthritis

The second name is ankylosing spondylitis. This is an autoimmune pathology associated with damage to the axial, less often the peripheral skeleton by its own immunity. For unknown reasons, triggered by stress, injury and hypothermia, the body triggers a cascade of autoimmune reactions, during which the joints become inflamed.An important diagnostic criterion is that ankylosing spondylitis always begins with inflammation in the ileosacral joints.

Without treatment, inflammation is chronic and destroys bones and cartilage. To protect itself, the body begins to build around the foci of inflammation “protective shell”, consisting of a bone structure, which creates a fixed frame of the ridge. As a result, the patient loses mobility in the back. It is noteworthy that after the completion of the ossification process, the inflammation disappears. Ankylosis patient has trouble breathing if the chest is affected, and with back pain it becomes difficult to physically maintain normal activity.

To slow down the growth of bone ankylosis, you need to do daily breathing exercises and train your back flexibility, because this is 50% of success in treatment. In most cases, genetically predisposed men, aged 20 to 30, face the disease. If the pathology makes its debut in childhood or adolescence, then this is an unfavorable prognostic sign. In women, pathology occurs approximately 10 times less often than in men.

Reasons for the debut of spondylitis

Usually, pathology is associated with neglect of the main infectious diseases that arise due to delayed access to a doctor.Complications on the spine are caused by chronic infections that constantly circulate in the body. The list of common pathogenic microorganisms includes Staphylococcus aureus, streptococcus, actinomycosis. Often complications provoke sexually transmitted diseases – gonorrhea, chlamydia, syphilis. Even angina can provoke a complication in the form of spondylitis.

Common causes of spondylitis are:

1. Severe immunosuppression associated with chronic illness and unhealthy lifestyles.
2. Hormonal disorders in the body, endocrine pathologies.
3. Severe physical and mental stress.
4. Spinal injuries.
5. Genetic predisposition.
6. Long-term use of immunosuppressants against the background of bacterial complications.
7. Presence of a focus of chronic infection.
8. Severe hypothermia or overheating.

Signs of spondylitis

Symptoms of spondylitis usually increase or worsen as the decrease in bone mineral density in the spine progresses.The second name of the pathology is secondary osteoporosis.

Early manifestations of spondylitis include:

1. Slight pain in the chest or lumbar region, which only occasionally bother the patient.
2. Decreased daily energy, fatigue.
3. Reception of unconsciously characteristic poses that reduce the load on the affected spine.

As the pathology develops, the following disturbing symptoms are connected:

1. Shortness of breath, feeling of suffocation when inhaling, chest pain.
2. Spread of pain to other parts of the spine and its intensification.
3. Pain bothers even in a motionless position of the body.
4. There are shooting and sharp pains in the back, discomfort in the sacral region during prolonged sitting.
5. There are pressure surges, headaches, if the thoracic or cervical regions are affected.
6. There is pain in the abdomen, a sign of irradiation of discomfort from the lumbar region.
7. There is redness and external signs of inflammation of the skin of the back, where the vertebrae are affected.There is slight swelling.
8. The quality of sleep is reduced due to pain.
9. The patient begins to move carefully so as not to provoke an aggravation of pain.
10. The patient has mood changes – irritability, depression and emotional instability appear.

Over time, persistent deformities develop, including the following pathological changes:

1. Kyphosis provoked by persistent deformational changes in the vertebrae.In most cases, the natural curves are disturbed and the abdomen is pulled strongly forward. There is hypertonicity of the lower back and weakness of the gluteal muscles.
2. A hump appears associated with a shortening of the length of the spinal column.
3. The mobility of the ridge is significantly reduced, which is especially noticeable when turning the back to the sides. There is chronic pain and stiffness in the sacroiliac joint.
4. Over time, there is a loss of the ability to self-service.
5. Numbness of the upper or lower extremities associated with pinching of the nerve roots.
6. Paralysis.
7. Violation of the pelvic organs – urinary or fecal incontinence.
8. The appearance of fistulas.

If a patient has purulent spondylitis, symptoms appear rapidly. The patient’s body temperature is increased to 40 degrees, chills, signs of intoxication.

Diagnosis of spondylitis

To determine this disease, a thorough differential diagnosis is required, because the symptoms are not always obvious in chronic course and often resemble the more common signs of ridge pathology – osteochondrosis, osteoporosis, neurological disorders.A number of laboratory analyzes and instrumental studies are being carried out.

What analyzes and types of instrumental studies need to be carried out:

1. Radiography. This is a basic research method that allows you to identify such pathological changes – narrowing of the inter-articular gap, subchondral sclerosis, bone erosion, ankylosis, osteoporosis, degeneration of the vertebral bodies. If such signs are visible on the X-ray image and the patient presents complaints associated with stiffness and pain, then additional studies should be carried out further.
2. CT or MRI are more modern and accurate methods for diagnosing pathological changes in the ridge. With the help of magnetic resonance imaging, the smallest changes in bone and soft tissues are visible, and CT scans well hard tissues. Usually, with the help of these diagnostic methods, it is possible to finally clarify the pathological picture. An important diagnostic criterion – in persons with ankylosing spondyloarthritis, unilateral or, more often, bilateral sacroiliitis is observed on MRI of the ileosacral joints.
3. Blood tests. To clarify the overall diagnostic picture, you need to pass the UAC. If they are looking for an infectious or autoimmune cause of spondylitis, then such patients have a KLA characteristic changes – a shift in the leukocyte formula to the left is observed, hemoglobin is reduced and the erythrocyte sedimentation rate is increased, leukocytosis is observed. Such test results allow you to get closer to the possible cause of the disease.
4. Biochemical parameters of blood. It is important to assess the state of work of the internal organs.Often, specialists are interested in renal indicators, the level of liver enzymes.
5. Genetic markers. The most relevant in the diagnosis of ankylosing spondylitis. If a patient has an HLA-B27 antigen, then this indicates a high probability of developing this disease.
6. Analyzes for the presence of antibodies to viral and bacterial pathogens – yersinia, chlamydia, herpes virus, cytomegalovirus. If antibodies are present to these pathogens, then this may indicate a possible reason for the activation of the immune failure, which caused spondylitis of an autoimmune origin.

If infectious spondylitis is suspected, differential diagnosis of STDs is performed. It is also important to determine the level of C-reactive protein in the blood.

Complications

Spondylitis often turns into ankylosis – a motionless formation consisting of bone and fibrous tissue. Ankylosis leads to complete immobility of the spine. Pathology is more common in rheumatic inflammation, including the course of ankylosing spondylitis. With a prolonged and chronic inflammatory process, a pillar of bone tissue forms in the ridge, completely covering the vertebrae.In this zone, the inflammation passes, because it is a defensive reaction to the pathological course of the disease, but the vertebra completely loses its flexibility.

Spondylitis on MRI

If the entire spine is covered with bone tissue, then it becomes like a bamboo stick and the patient takes the forced pose of “proud” or “supplicant” (the head is always raised up or bent down). If the bone growth is not removed surgically, then the patient will not be able to take a different body position. The second formidable complication is compression fracture.To create the outer skeleton, calcium is pulled out of the spine, resulting in osteoporosis. As a result, the patient often suffers compression fractures, which are dangerous to health and life.

Important! There are no conservative methods for eliminating ankylosis. It is necessary to carry out a complex surgical operation to remove bone growths by doctors manually. In order to agree to such an operation, it is necessary to have serious indications, including a strong fusion that interferes with life.

Treatment of spondylitis of the spine

Therapy depends on the cause of the course of spondylitis. If the pathology is associated with a complication of tuberculosis or STDs, powerful antibiotic therapy is required. If the pathology is a complication of rheumatic disease, it is recommended to use immunosuppressants. With aseptic spondylitis, only symptomatic drugs are effective – muscle relaxants, NSAIDs, corticosteroids, vitamins of group B. Preventive drugs include calcium and D3, chondroprotectors.

During the recovery period, non-drug correction plays an important role. With the help of exercise, physiotherapy and gymnastics, it is possible to strengthen muscles, remove chronic non-inflammatory pain, strengthen the spine and bones, and improve blood circulation. Important! Non-drug methods of support are mandatory and should be used under the supervision of a physician and only during the recovery period, when acute symptoms are completely eliminated. Surgical intervention is rarely required, in exceptional situations.

Methods for treating the pathological process provoked by spondylitis depend on the clinical picture and stage of development of the disease and include the following items:

1. Medication support. The choice of drugs depends on the exact diagnosis.
2. Non-drug treatment of the spine. Physiotherapy procedures, spa treatment, correction with exercise therapy and rehabilitation measures are shown.
3. Elimination of pathogenic microorganisms, if they are the cause of the disease.This type of spinal lesion, unlike autoimmune disease, can be completely cured, but it will take time.
4. If spinal lesions are of an autoimmune nature, then the treatment of spinal spondylitis is aimed at suppressing immune aggression. Previously, it was not always possible to achieve a stable remission of the disease in patients, but with the advent of genetically engineered drugs, as a rule, now it is possible to significantly improve the quality of life. Early detection of pathology is the key to a better clinical response to therapy.
5. In the treatment of nonspecific spondylitis, it is important to use symptomatic and rehabilitative therapy, since this pathology is one of the post-traumatic complications. If there are no deep deformational changes in the spine, then the prognosis for treatment is favorable.

Treatment regimens are selected individually by the leading physician.

Antibiotics

If the disease is caused by an infection, then a long-term regimen of antibacterial drugs is prescribed, often consisting of several drugs in shock doses.This approach is due to the fact that the active substances poorly penetrate into the articular membranes, and mycobacterium tuberculosis does not respond well to antibiotic therapy. The most effective drugs are Isoniazid and Rifampicin. Usually, the course of treatment is based on their use. Other broad-spectrum antibacterial agents are less commonly used. The duration of treatment and the dose is prescribed by the doctor.

Immunosuppressants – basic antirheumatic drugs

Spondylitis usually manifests itself in several types of rheumatic diseases – reactive and psoriatic arthritis, ankylosing spondylitis.All rheumatic conditions are the result of an autoimmune malfunction, resulting in a powerful inflammatory reaction that affects the joints, including the ridge. This is how spondylitis is formed. Basic anti-rheumatic drugs, pain relievers, and genetically engineered drugs must be used to reduce inflammation.

What basic antirheumatic drugs can help:

1. Sulfasalazine. It is the only basic medicine that is effective in the presence of peripheral-type ankylosing spondylitis.The drug has a mild immunosuppressive effect, affecting the intestinal microflora. It is a mixture of an antibiotic and acetylsalicylic acid. Sulfasalazine is usually well tolerated, but liver and kidney performance should be monitored with long-term medication. The dosage range ranges from 1.5 to 3 g per day, depending on the severity of the condition.
2. Methotrexate. This drug is effective in the treatment of psoriatic arthritis. It is one of the most powerful basic antirheumatic agents in the world practice of treating autoimmune diseases.It is a cytostatic agent with low hematotoxicity, which allows it to be used in small doses without side effects. The range of working doses in rheumatology is 5 mg – 25 mg of the drug. Methotrexate is available as a shot or oral tablet. The drug not only suppresses the rate of cell division, but also reduces the amount of secreted pro-inflammatory cytokines of all types. A valuable property of Methotrexate is to enhance the effectiveness of genetically engineered drugs, which is also useful in the treatment of ankylosing spondylitis.
3. Leflunomide. It is a basic antirheumatic agent effective in the treatment of psoriatic and rheumatoid arthritis. The drug is effective in that it suppresses active proliferation processes in the joints, therefore it is often prescribed for such diseases, including spondylopathy. The dose range is 10 – 20 mg per day. During therapy, it is important to carefully monitor the parameters of the liver and kidneys, a complete blood count. Among all basic agents, Leflunomide has the greatest potential for hepatotoxicity.
4. Plaquenil. Basic antirheumatic agent that can be used for rheumatoid and psoriatic arthritis. It is a mild drug, the degree of effectiveness is comparable to Sulfasalazine. Plaquenil is usually well tolerated and rarely causes severe liver and kidney side effects. The range of working doses ranges from 200 to 400 mg. The duration of therapy is determined by the doctor individually.

Other types of basic antirheumatic drugs are prescribed less often for spondylopathy of autoimmune origin.

Bioengineering drugs

In advanced cases or in severe ankylosing spondyloarthritis, it is appropriate to prescribe genetically engineered monoclonal antibodies. Often there are difficult cases when traditional treatment does not help and you have to resort to radical therapy. Before using such drugs, the patient undergoes a full screening with an examination of the state of health – it is required to pass a general analysis of blood and urine, biochemical parameters. It is important to make sure that the person is not sick with hepatitis B or C, does not have latent tuberculosis, oncology.If the health indicators are normal, then therapy is started under the strict supervision of a rheumatologist.

What types of genetically engineered drugs exist:

1. Tumor necrosis factor alpha inhibitors. These are the drugs recommended as the first line of choice. According to modern research, in the presence of autoimmune processes, suppression of tumor necrosis factor is most effective in treating signs of inflammatory processes in the spine. Medicines that can suppress TNF include 5 drugs – Remicade (infliximab), Humira (adalimumab), Enbrel (etanercept), Simzia (certolizumab pegol), Simponi (golimumab).Each of these drugs, despite a similar mechanism of action, has its own peculiarities of use, nuances of use and dosage. Therefore, a leading rheumatologist must prescribe a specific drug.
2. Interleukin inhibitors. This is a relatively new class of genetically engineered biological preparations. After the discovery of sensational data that interleukins play a significant role in the autoimmune reaction, drugs were created that suppress a specific type of IL. In the context of spondyloarthropathies, IL-17a inhibitors turned out to be the most effective class of BAIs.Examples of drugs are Efleira (netakimab), Cosentix (secukinumab). Less commonly used inhibitors IL6, IL1.

There are also monoclonal antibodies that selectively suppress other links of the immune system, but they are usually not used in the treatment of autoimmune lesions of the spine.

Corticosteroids

These drugs are effectively used for aseptic and autoimmune lesions of the spine. Important! They cannot be prescribed for infectious forms of spondylopathy, otherwise the course of the disease will greatly worsen.Corticosteroids are synthetic hormonal derivatives with immunosuppressive effects, resulting in a powerful indiscriminate inhibition of pro-inflammatory cytokines, therefore, pain associated with inflammation goes away.

Treatment of spondylitis

With autoimmune, as well as aseptic spondyloarthropathies, long-term and constant use of corticosteroids is not recommended, since the abuse of such drugs is fraught with serious consequences for the body in the future.With prolonged use of GCS, steroid diabetes, osteoporosis, myopia, arterial hypertension, hypercortisolism and dyslipidemia can develop. To reduce the risk of possible complications, patients are prescribed GCS in the form of intra-articular injections, and drugs with prolonged action are selected.

What corticosteroids are used in the form of intra-articular injections, paravertebral blocks:

1. Diprospan. This is a corticosteroid based on betamethasone – a drug with a prolonged and short ether in the composition.The drug begins to act immediately, and the anti-inflammatory effect of the drug is revealed within a month, due to the long etheric component. To completely remove the pain of an inflammatory nature, it is enough to make 1-2 injections.
2. Depo-Medrol. The active ingredient is methylprednisolone. Depo-Medrol is used in less advanced cases, since the drug acts after administration for a week. The medicine rarely causes serious side effects, as it is considered a relatively mild medicine.

Less commonly, short-acting corticosteroids are used as part of blockades – Dexamethasone, Hydrocortisone. Blocks are always performed with an anesthetic. The anesthetic is injected subcutaneously to temporarily lower the patient’s pain threshold so that he does not feel pain from the intra-articular blockade. Usually Novocaine or Lidocaine are used. The first drug has a weak and short effect, but has the lowest risk of side effects from the cardiovascular system.Lidocaine is more effective in relieving pain, but it should not be prescribed to persons with individual intolerance and the presence of serious cardiovascular diseases.

Nonsteroidal anti-inflammatory drugs

NSAIDs are used for the symptomatic elimination of pain and inflammation in various diseases. NSAIDs occupy a special niche in the treatment of spinal pain associated with rheumatic or dystrophic lesions. The mechanism of action of NSAIDs is simple – they selectively or indiscriminately suppress cyclooxygenase, which reduces the release of prostaglandins, which makes a person no longer feel severe discomfort.If you do not overuse non-steroidal pain relievers, you can quickly and effectively get rid of pain without the risk of serious side effects.

If the patient is forced to drink such drugs for a long time, then he needs to carefully monitor the indicators of the kidneys, liver and undergo FGS annually. In parallel, gastroprotective drugs are prescribed, which reduce the risk of complications from the gastrointestinal tract. Usually, proton pump inhibitors are used (Omeprazole, Rabeprazole, etc.)) and choose highly selective modern drugs that have a low risk of possible side effects from the stomach and other vital internal organs.

Which NSAIDs are most often recommended by doctors, given the efficacy and safety profile:

1. Meloxicam. A modern selective NSAID intended for long-term use in the presence of rheumatic diseases. In high doses, Meloxicam partially loses its selectivity, but does not cause such side effects as NSAIDs of the old generation.The therapeutic dosage range of the drug ranges from 7.5 mg to 15 mg per day. The medication is good because it has a long half-life, so you can drink it once a day. It is safe to take meloxicam without gastroprotective cover for 3 consecutive weeks, after which, if possible, the patient should take a break or start using a proton pump inhibitor. Meloxicam is available in tablets, capsules, rectal suppositories and injectable solution. It is the first line of choice for the treatment of chronic and acute pain.
2. Nimesulide. Also applies to selective agents with a high safety profile. Nimesulide is taken in a short course, up to two weeks without a break, no more, since the drug has moderate hepatotoxicity. In some countries (for example, Finland), due to the possible risk of drug damage to the liver, its import and sale is prohibited. Nimesulide usually rarely causes severe liver side effects, so it is freely available over the counter in pharmacies. The range of therapeutic dosages ranges from 100 to 200 mg per day.The drug is available in tablets, granules and a gel for external use.
3. Celecoxib. Highly selective NSAID with a low risk of complications for the liver, kidneys and cardiovascular system. High selectivity means that even if the maximum recommended therapeutic dosages are exceeded, the drug does not inhibit other types of cyclooxygenase, except for COX-2. The drug is safe, suitable for a long course of administration of 2 months without interruption. The range of working daily dosages ranges from 200 mg to 400 mg.Release form – capsules, tablets.
4. Etoricoxib. The drug is marketed under the Arkoksia trademark. Release form – tablets. Like the previous agent, Etoricoxib is a highly selective NSAID. The duration of taking the medicine should not exceed 2 months. Arcoxia is contraindicated for use by persons with cardiovascular disorders. With prolonged use, hypertension and arrhythmia may occur. The range of working dosages of the drug ranges from 30 mg to 120 mg. The drug can be drunk once a day, as it has a long half-life.
5. Diclofenac. Non-selective NSAID with a powerful analgesic and anti-inflammatory effect. Diclofenac belongs to the gold standard of rheumatology in the treatment of severe and chronic inflammatory conditions associated with exacerbation of spondyloatritis. The medicine works quickly and effectively, relieves the most severe pain syndrome, therefore it is used in emergency cases. Diclofenac is best used for no more than 2-3 days, after which they switch to milder drugs. The range of therapeutic dosages is 50-200 mg per day.If long-term use is required, it is better not to exceed the dose of 75 mg. Forms of release – gel, ointment, capsules, retard capsules, tablets, suppositories, injection solution, transdermal patch. In the price range, Diclofenac is also the most affordable.
6. Indomethacin. Non-selective NSAID with the most pronounced anti-inflammatory effect. The analgesic effect of Indomethacin is also pronounced. The drug must be used with caution and always under the cover of proton pump inhibitors, since the drug more often than other NSAIDs causes gastrointestinal bleeding.The duration of admission should not exceed 2-3 days, after which they switch to safer medicines. Release forms – ointment, tablets and suppositories.

Less commonly, other NSAIDs are prescribed, including Naproxen, Ketoprofen, Ketanov, or Ibuprofen.

Muscle relaxants, antidepressants, B vitamins

Muscle stiffness and spasticity are common in patients with spinal disorders. This leads to chronic pain syndromes, fibromyalgia. Muscle relaxants, antidepressants and GABA derivatives are drugs widely used in neurology, because they can relieve chronic muscle pain.

Treatment of pain in spondylitis

Muscle relaxants selectively act on skeletal muscles, suppress the conduction of nerve impulses to segmented muscles, thereby relieving pain, and with prolonged use of medications, the muscles relax. For the effect to be more pronounced, you need to additionally do a back massage, if there are no contraindications. Muscle relaxants are also effective in treating chronic spondyloarthritis pain. Examples of medicines are Baclofen, Sirdalud (tizanidine), Midocalm (tolperisone), Thiocolchicoside.

GABA derivatives are also effective in the treatment of spinal pain caused by muscle spasms. These medicines effectively relax the skeletal muscles, reduce nervous tension, and give a sound and deep sleep. You can take them in a short course, no more than a month, otherwise their effectiveness will decrease and addiction may develop. Examples of funds are Gabapentin, Pregabalin.

Antidepressants are medicines widely used in modern psychiatric and neurological practice.Medicines have a powerful analgesic effect, stabilize the emotional background, and remove neurological symptoms. The most pronounced effect in this regard is possessed by SNRIs – selective serotonin and norepinephrine reuptake inhibitors (Example – Venlafaxine, Mirtazapine). These drugs are comparable in effectiveness to tricyclic antidepressants, but they have a significantly reduced risk of severe side effects. Less commonly, SSRIs (selective serotonin reuptake inhibitors) are used, they have a lower analgesic potential, but the body’s tolerance is significantly higher.Examples of funds – Tsipralex, Zoloft, Paxil, Prozac.

Vitamins of group B – affordable and effective means used in neurology. B1, B6 and B12 in large doses have an analgesic effect, have a positive effect on metabolism and hematopoietic function. With a lack of them, signs of depression, anemia appear, and the general well-being worsens. The doctor prescribes medicines in large doses, in a course of several weeks. Examples of medicines are Neurorubin, Milgamma.

Calcium and vitamin D supplements, chondroprotectors

In case of damage to cartilage tissue, a patient with a diseased spine is shown chondroprotectors based on glucosamine and chondroitin.These components are normally synthesized in the body in sufficient quantities, but if the cartilaginous tissue is affected, then their synthesis in the sore spot is insufficient, therefore, it is necessary to replace it from the outside. For a long time, supplements are prescribed based on these components. In acute situations, injections are prescribed, and then the patient switches to tablet forms of release. Duration of admission is at least 4-6 months with subsequent breaks. Less commonly, topical gels with chondroitin are prescribed. Examples of medicines are Dona, Hondrogard, Mucosat.

Calcium and vitamin D are taken to reduce the risk of osteoporosis if present in the patient. It is recommended to adhere to a balanced diet, but if the patient cannot cover the calcium norm with one meal, then he needs to periodically take a macronutrient in tablets. In order for its assimilation to improve, it is required to additionally use vitamin D. Persons living in northern latitudes, in the autumn-winter period, often suffer from a deficiency of this element, which is synthesized after exposure to sunlight.This is manifested by frequent acute respiratory viral infections and a decrease in mood. Additional supplementation is required for at-risk individuals.

Editorial Opinion

The treatment regimen for spondylopathy of the spine depends on the specified diagnosis. The main emphasis in treatment is placed on medication and conservative non-drug support. It is important to fully follow the recommendations of the attending physician.

90,000 Spondyloarthrosis and spondylosis, treatment with modern methods

About the disease

This ailment has several names, therefore, if you come across the terms spondylosis , spondyloarthrosis and facet arthropathy – know that we are talking about one diagnosis.Spondyloarthrosis is a disease that occurs as a result of the destruction of the joints of the spine, as a result of which growths are formed, which are called osteophytes.

Spondyloarthrosis is the next stage of osteochondrosis, this is exactly what the doctors came to. Most often, the elderly suffer from this ailment, in the younger generation it occurs mainly due to injuries. Spondylosis usually develops in cervical , thoracic or lumbar .

Reasons

Spondyloarthrosis develops at a high rate, it is caused either by frequent trauma in the past or by a genetic predisposition. The main reasons for the onset of spondylosis include metabolic disorders, as well as age and changes in the body that it carries with it. Spondyloarthrosis is diagnosed in people who work in a seated position for a long time, because not every person has the correct posture when working in a static position.
This disease, as a rule, is not independent and arises as a result of other existing diseases, these include osteochondrosis, scoliosis, displacement of the vertebrae, as well as a previous infection, trauma or obesity.

It is also worth noting that women suffer from spondylosis much less frequently than men. Spondyloarthrosis cannot be completely cured, but pain can be blocked and the destruction process stopped.

Symptoms

At the first stages, this ailment is almost asymptomatic and without any pain.At the moment when a person begins to feel a certain stiffness in movements, we can say that the spondylosis has acquired a chronic character. It also happens that the disease is discovered by chance on an x-ray, and the patient does not feel any inconvenience.

The arising painful sensations during spondylosis gradually increase and already interfere with the patient’s sleep or disturb even in a motionless state. It also happens that the pain intensifies during weather changes.

Spondyloarthrosis of the lumbar spine is manifested by the following symptoms: a feeling of heaviness, pain when bending over, stretching, and pain that bothers while sitting.

Spondylosis of the cervical spine , in turn, manifests itself in stiffness in the neck, difficulty and soreness when turning, as well as pain in the back of the head, radiating to the shoulder. As a result, sleep disturbance occurs.

Spondyloarthrosis of the thoracic region occurs less frequently than the first two variants of the disease. Of the main symptoms, one can single out a violation of the work of internal organs: heart, lungs, gastrointestinal tract.

Treatment

First of all, when diagnosing a disease, measures are taken to prevent inflammation and pain.Treatment of spondyloarthrosis, like many diseases of the spine, should be comprehensive and include:

• Chondroprotector, which restores the cartilaginous base
• Reception of anti-inflammatory and analgesic medications and massage (strictly according to the doctor’s prescription, taking into account all the features and only during remission)
• Kinesitherapy, manual therapy;
• Physiotherapy, reflexology, laser therapy;

Surgical intervention is a last resort for the treatment of spondylosis.As a result, people who have undergone this disease should monitor their posture: correctly distribute weight when walking, do not lift weights.

At the Institute of Physical Rehabilitation you can get expert advice from experienced doctors. If the diagnosis is confirmed on the basis of our clinic, it will be possible to undergo a course of treatment and rehabilitation.

90,000 symptoms, treatment and operations, exercises for the prevention of lumbosacral stenosis, prognosis – Department of Vertebrology, Central Clinical Hospital of the Russian Academy of Sciences

Lumbar spinal stenosis is a chronic condition in which a narrowed spinal canal puts pressure on the structures within it.Pathology progresses slowly, there can be no improvement without treatment. With the passage of time and the aggravation of the situation, patients need surgery. Basically, aged patients suffer from stenosis, its most frequent localization is the lower back. Without treatment, stenosis develops steadily, resulting in disability.

Types of stenosis

The classification is based on the nature of the disorder, location and severity:

• Lateral – narrowing the lumen to four mm.
• Central – narrowing outward with a decrease in the anteroposterior size of the lumen.
• Combined – a violation occurs once in several directions with combined symptoms.
• With relative stenosis, the inner diameter of the canal is 10-12 mm. In such a condition, it is advisable to use a therapeutic treatment, which, as a rule, gives a good result. If treatment is not started on time, the progress of the pathology is inevitable.
• Absolute – clearance is one centimeter or less. With such a diagnosis, we are not talking about conservative therapy. Compression provokes neurological symptoms and requires surgical correction.
• Lateral stenosis is an extreme lesion with severe narrowing of the canal (diameter about 3 mm). Treatment is just an operation.

Why is there

The occurrence of spinal stenosis can be due to both congenital and acquired features.Congenital stenosis appears as a result of thickening or reduction in the length of the vertebral arch, shortening of the spine or leg. Such changes are rare, much more often patients are faced with acquired stenosis of the spinal canal. The reasons for the appearance of acquired stenosis are as follows:

• Change in the normal position of the vertebrae, hernia, osteochondrosis, other damage to the tissues.
• Injuries, surgical operations and their consequences in the form of adhesions and scars.
• Diseases – rheumatoid arthritis, oncological formations, acromegaly.
• Changes in the structure of the yellow ligament of the spine.

Manifestations of pathology

Spinal stenosis of the lumbar spine has a number of characteristic features, including:

• Decreased leg tone, intermittent claudication, decreased sensitivity of the limbs, pain when walking. The localization of pain is usually difficult to determine, and it can occur in different places.The patient wants to stop and lie down. With a decrease in the load on the spine – bending the body forward, bending the legs at the knees, discomfort decreases. For this reason, a forced pose arises. When performing physical work in a sitting position, pain is not felt.
• Distribution of pain along the legs.
• Feeling of tension.
• Sensory impairment in which the patient is unable to indicate exactly how his limbs are now located.
• Burning, tingling sensation.

There are several signs that determine the last stage of stenosis:

• Violation of the body’s excretory functions – urinary and fecal incontinence.
• Violation of reflexes.
• Paresis.
• Dystrophy of the legs.
• Convulsions after physical activity.

Making a diagnosis

The diagnosis is made after questioning, examination and examination. As additional diagnostic methods are used:

• Computed tomography of the spine.
• MRI of the spine.
• X-ray of the spine.
• Myelography, scintigraphy and electroneuromyography are used as needed.

Treatment of stenosis without surgery

If no neurological changes are noted, the disease can be treated conservatively without surgery. When the patient only complains of pain and his visit to the doctor was timely, the following techniques can be used:

• Taking medications to relieve inflammation, pain, edema.
• Taking muscle relaxants to help relax the muscles of the lower back.
• Massage, exercise therapy exercises.
• Reception of vascular drugs to ensure normal blood flow.
• The use of blockages with hormonal and anesthetic drugs.
• Physiotherapy – currents, electrophoresis, dirt, magnetic effects.

With an integrated approach and a competent combination of techniques, the required result is achieved.The choice of methods is carried out strictly individually, considering the characteristics of the patient, contraindications and other factors.

Operation to correct narrowing

The operation is necessary to stop the compression of the nerve roots and resume the normal functioning of tissues. Both closed or endoscopic and full-scale open interventions can be performed. The most commonly used techniques are:

• Stabilizing operation.It involves the expansion of the space of the spinal canal with the subsequent strengthening of the support function due to the installation of braces.
• Decompression laminectomy. Expands the canal by removing some parts of the bone process, the arch of the spine, ligaments. This method is considered one of the most traumatic.
• Microsurgical decompression. The operation involves the use of a fixation system after the stenosis has been eliminated. It is important that the function and flexibility of the spine are preserved.
• Microdiscectomy or laser vaporization is performed, sometimes in conjunction with laminectomy, in cases where the stenosis is caused by a hernia.
• The use of a particular method of intervention depends on the clinical picture. In most cases, the patient fully recovers after the operation. An important role in rehabilitation is played by the patient’s behavior, compliance with all restrictions and rules established by the doctor.

Potential consequences of spinal stenosis

With untimely or completely absent treatment, pathology can give serious complications:

• Stable paresis, paralysis of the lower limbs.
• Violation of the pelvic organs, sexual dysfunction.
• Decrease or complete loss of sensitivity in the lower body.
• Severe pain in the legs and back.

Preventive measures

Some simple steps can help prevent the development of spinal stenosis of the lumbar spine or quickly get rid of the problem if it has already arisen:

• Visit a specialist’s office if you have any anxiety symptoms, pain or discomfort.
• Weight should remain within normal limits so as not to provoke excessive stress on the spine and other body systems.
• It is important to ensure that healthy physical activity is maintained – frequent walks, morning exercises, warm-ups during the day with sedentary work.

Stenosis reduces the patient’s quality of life and inevitably brings discomfort. If you consult a doctor on time, when the pathology has not developed into a serious stage, it can be eliminated by conservative methods, without surgery.Surgical intervention is required when the situation is running, the stenosis progresses and incapacitates the entire body.

Patients who underwent surgery note that timely seeking qualified help could significantly simplify the situation. For a complete recovery, it is important to follow a healthy lifestyle and see a doctor on time.

90,000 Spondylitis of the lumbar spine | Neurosurgery

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Contents:

Spondylitis symptoms

A few words about what spondylitis is (already mentioned in the blog).

Spondylitis is a very serious disease and usually begins with a lesion of the intervertebral disc with subsequent spread to adjacent vertebrae. This is osteomyelitis of the spine. As noted, it can be specific and non-specific.

Patients with weakened immunity (diabetes mellitus, HIV, heart failure, intravenous drug addicts, patients with bacterial endocarditis, etc.) are more likely to suffer from spondylitis. At the onset of the disease, a patient with spondylitis develops pain in the spine , which is often mistaken for an exacerbation of osteochondrosis, but this is not surprising, it is not so easy to suspect spondylitis in outpatient practice, but spondylitis is also characterized by intoxication syndrome , manifested by hyperthermia , aches, sweating, asthenia.Then, after the formation of pus, which can spread into the spinal canal, severe neurological manifestations can occur in the form of spinal cord compression syndrome, conduction disorders, radicular syndrome, dysfunction of the pelvic organs or abdominal pain, dyspepsia, lumbar plexus lesion syndrome, if pus spreads as a leak into the retroperitoneal space along the soleus muscle.

Spondylitis of the spine: treatment

In this article, I would like to highlight a clinical case of the treatment of a patient with congestion and spondylodiscitis in the lumbar spine.

MRI on admission:

He complained of general weakness, pain in the spine and in the left leg, which he constantly pressed to his stomach, but said that after a stroke. From the anamnesis – he suffers from cirrhosis of the liver, ascites. He was treated for a long time by a therapist, examined by a urologist, diagnosed with a perinephric abscess, etc.

All without success. We went to the neurosurgeon without permission. Almost everywhere in the Russian Federation, they have not yet decided who treats such patients – a doctor of osteoarticular tuberculosis? purulent surgeon (most logical)? vertebrologist (where can I get one in an ordinary medical facility?), neurosurgeon?

Answer – he heals the one who can and has already tried or agreed to heal! (Although this is not correct, i.e.because arbitrariness). This requires an operation on the retroperitoneal space, which is somehow not typical for neurosurgery, knowledge of the principles of purulent and general surgery.

Explanations for MRI.

1-left kidney

2-abscess on the psoas

3-psoas-abscess, to the left of the number 3, the causal place is discitis, from which it all began.

On the right soleus muscle, there are also fluid formations, possibly small abscesses?

Under anesthesia, transrectally on the left, access to the retroperitoneal space, from where 750 ml of odorless pus and flora growth were removed.2 silicone drains.

Control MRI after surgery.

No pus.

After the operation and against the background of massive antibiotic therapy, the pain and intoxication disappeared. The patient began to walk independently even without a cane. Discharged.

Such patients should be consulted by a phthisiatrician to exclude a specific tube. spondylitis.

The author of the article: neurosurgeon Vorobyev Anton Viktorovich

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Why choose us:

• we will offer the most optimal method of treatment;
• we have extensive experience in the treatment of major neurosurgical diseases;
• we have a polite and helpful staff;
• get expert advice on your problem.

Lumbago: symptoms, treatment, diagnosis of the disease

Lumbago is the name of a separate form of osteochondrosis, localized in the lumbosacral region of the spine and accompanied by paroxysmal acute pain in the lower back. An attack usually occurs when you try to sharply tilt or straighten your back, as well as when lifting a heavy load. The popular name for pathology is “backache”. Most often, the disease occurs in people at a young or middle age, from 25 to 45 years, less often in the elderly, in many cases it is accompanied by sciatica.Men suffer from lumbago more often than women.

Symptoms

The most pronounced symptom of lumbago is intense pain that “shoots” the lower back and back muscles. The pain is jerky, pulsating and, when it appears, makes the patient freeze in an inclined position, since straightening the back is fraught with increased pain. During an attack, a person cannot move, feeling helpless and stiff. Whenever you try to change your posture, move your arm or leg, the pain becomes even more severe.In some cases, it is accompanied by a headache.

The pain is accompanied by tension in the dorsal muscles in the lumbar region. The spasm causes a reflex reaction of the body to pain, but muscle contraction leads to compression of the nerve endings, due to which the sensations intensify.

Often, patients have a combination of lumbago with sciatica, that is, pain is felt not only in the lower back, but also in the buttock and the back of the thigh, possibly along the entire length of the leg.

The duration of the pain is different: in some people the attack lasts only a few minutes, in others – several hours or even days.With prolonged pain, as a rule, the first half hour is the most painful, then the sensations dull. A person feels best when lying on their back with their legs bent at the knees on several pillows or rolled blankets, or in a knee-elbow position with pillows placed under the stomach.

Do you have lumbago symptoms?

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Causes of the disease

Currently, the main causes of lumbago are:

• Excessive muscle tension in the lumbar region associated with dynamic (for example, when lifting weights) or static (long standing in an uncomfortable position) loads;
• lumbar disc herniation;
• congenital deformities of the spine;

90,025 arthritis;

• hypothermia;

90,025 back injuries and bruises;

90,025 tumors of the tissues of the spine;

• spondylitis is an inflammatory process in the spine.

As concomitant factors that increase the risk of developing the disease, one should name:

• Incorrect posture with a habit of constantly hunching over and a poorly developed muscle corset;
• hard physical labor for a long time;
• sedentary lifestyle;
• Age-related changes associated with the loss of healthy flexibility in the spine.

Heavy physical exertion, sharp turns or bends of the torso, as a rule, provoke attacks of lumbago.The most common situation leading to a “lumbago” in the lower back is overheating of the muscles due to active physical work or sports, followed by sudden hypothermia.

Diagnostics

The clinical diagnosis of lumbago, in addition to examining the patient and collecting complaints about his condition, includes:

• X-ray of the spine, allowing to establish the presence or absence of a tumor;
• biomechanical tests – the patient performs certain movements that allow to establish the nature of pain and differentiate the disease;
• MRI or CT scan to detect abnormalities in the spine;
• general analysis of urine and blood to detect the inflammatory process;
• spinal scintigraphy to study the condition of the blood vessels feeding this organ;
• Electroneuromyography for the study of nerve conduction in the muscles of the back.

Additional information is often provided by the patient’s history, in which, as a rule, there is osteochondrosis, herniated disc, spinal injury, and other problems.

Therapy

Depending on the severity of the symptoms characteristic of lumbago, treatment in the acute period requires an appointment:

• analgesics for pain relief;

90,025 non-steroidal anti-inflammatory drugs;

90,025 antispasmodics to relax tense muscles;

• vitamin preparations to strengthen the immune system.

With especially severe pain, intradermal novocaine blockades, sedatives and hypnotics can be prescribed. A good effect is given by local medicines – ointments with a warming effect, applications of Dimexidum, as well as a pepper patch. The therapeutic effect is achieved by increasing capillary blood circulation in the spasmodic muscles of the back.

During the treatment of lumbago in the period of exacerbation, the patient was prescribed strict bed rest and a state of complete rest.It is necessary to lie on a flat, moderately hard surface on the back, with legs bent at the knee and hip joint, under which folded blankets are placed. Compliance with bed rest continues for two weeks. At this time, it is necessary to give up spicy and fatty foods, pickles and smoked foods. It is especially important to follow the clinical guidelines for lumbago with sciatica.

As the pain decreases, the patient has the opportunity to attend physiotherapy procedures.A good effect is given by:

• acupuncture;
• manual therapy;
• classical massage;
• amplipulse therapy;
• laser therapy;
• magnetic therapy;
• medicinal mud applications.

Often the patient is prescribed a complex of several procedures. In addition, after the removal of acute pain, it is necessary to take care of strengthening the back muscles, developing ligaments and joints, for which special therapeutic exercises are the best remedy.Exercise has a complex effect: in addition to strengthening muscle tissue, it activates the metabolism in the tissues of the back and spine, accelerates self-healing processes and reduces the risk of relapses.

Prevention

To avoid relapses, the patient must avoid hypothermia, do not make sudden movements, do not lift weights, and give up heavy physical labor. However, moderate exercise is not only not harmful, but also beneficial to health.Walking, stretching exercises, cycling, performing a special set of exercises can strengthen the muscles of the back and avoid the recurrence of pain attacks for a long time.

Diagnostics and treatment of lumbago in Moscow

Clinic Professor Roitberg “Medicine” offers services of modern diagnostics and qualified treatment of lumbago and sciatica. We have neurologists, vertebrologists, orthopedists of the highest category, doctors with many years of experience.For diagnostic studies, advanced technology from the best manufacturers is used. Make an appointment with us online or call us for more information about our clinic.

Questions and answers

Which doctor treats lumbago?

For a consultation with a lumbago specialist, make an appointment with an experienced vertebrologist or neurologist. If there are no such doctors in your clinic, consult an orthopedist or surgeon.

The part of the body that is affected by lumbago

Lumbago affects the nerve roots in the lumbosacral spine with a simultaneous spasm of muscle tissue adjacent to the area of ​​nerve damage.

How to treat lumbago at home?

Traditional medicine has an additional effect on the affected area.Compresses made from garlic crushed into gruel, mixed with internal fat, or black radish juice help well – these agents have an excellent warming effect. Grated horseradish gruel acts similarly. It is recommended to rub a tincture of lilac flowers on kerosene into a sore spot 3-4 times a day until relief comes.