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1-(866)-298-7513 Spondylolisthesis
The mission of The Bonati Institute is to provide hope to people suffering with chronic pain from a back or neck condition. We believe that a well-informed patient is vital to restoring hope and finding answers to pain. We developed this web site primarily to help educate pain sufferers and their families. We’ve found that the more individuals in pain learn about their anatomy, their condition and the options available to them the more likely they will be to choose the advanced arthroscopic procedures offered by The Bonati Institute.
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Spondylolisthesis
Spondylolisthesis refers to the forward slippage of one vertebral body with respect to the one beneath it. This most commonly occurs at the lumbosacral junction with L5 slipping over S1, but it can occur at higher levels as well. It is classified based on etiology into 5 types: congenital or dysplastic, isthmic, degenerative, traumatic, and pathologic (Wiltse, 1976). Many cases can be managed conservatively. However, in persons with incapacitating symptoms, radiculopathy, neurogenic claudication, postural or gait abnormality resistant to nonoperative measures, and significant slip progression, surgery is indicated. The goal of surgery is to stabilize the spinal segment and decompress the neural elements if needed.
History of the Procedure
In 1854, Killian coined the term spondylolisthesis to describe the gradual slippage of the L5 vertebra due to gravity and posture. In 1858, Lambi demonstrated the neural arch defect (absence or elongation of pars interarticularis) in isthmic spondylolisthesis. Albee and Hibbs separately published their initial work on spinal fusion. Their methods were applied quickly to cases involving trauma, tumors, and, later, scoliosis. In the latter half of the 20th century, spinal fusion was used increasingly to treat degenerative disorders of the spine, including degenerative spondylolisthesis and degenerative scoliosis.
Problem
Spondylolisthesis is the forward slippage of one vertebra on another. This may or may not be associated with gross instability of the spine. Some individuals remain asymptomatic even with high-grade slips, but most complain of some discomfort. It may cause any degree of symptoms, from minimal symptoms of occasional low back pain to incapacitating mechanical pain, radiculopathy from nerve root compression, and neurogenic claudication.
What Is Spondylosis?
Spondylosis (spinal osteoarthritis) is a degenerative disorder that may cause loss of normal spinal structure and function. Although aging is the primary cause, the location and rate of degeneration is individual. The degenerative process of spondylosis may impact the cervical, thoracic, and/or lumbar regions of the spine affecting the intervertebral discs and facet joints.
Spondylosis often affects the following spinal elements
Intervertebral Discs and Spondylosis
As people age certain biochemical changes occur affecting tissue found throughout the body. In the spine, the structure of the intervertebral discs (anulus fibrosus, lamellae, nucleus pulposus) may be compromised. The anulus fibrosus (e.g. tire-like) is composed of 60 or more concentric bands of collagen fiber termed lamellae. The nucleus pulposus is a gel-like substance inside the intervertebral disc encased by the anulus fibrosus. Collagen fibers form the nucleus along with water, and proteoglycans.
The degenerative effects from aging may weaken the structure of the anulus fibrosus causing the 'tire tread' to wear or tear. The water content of the nucleus decreases with age affecting its ability to rebound following compression (e.g. shock absorbing quality). The structural alterations from degeneration may decrease disc height and increase the risk for disc herniation.
Facet Joints and Spondylosis
The facet joints are also termed zygapophyseal joints. Each vertebral body has four facet joints that work like hinges. These are the articulating (moving) joints of the spine enabling extension, flexion, and rotation. Like other joints, the bony articulating surfaces are coated with cartilage. Cartilage is a special type of connective tissue that provides a self-lubricating low-friction gliding surface. Facet joint degeneration causes loss of cartilage and formation of osteophytes (e.g. bone spurs). These changes may cause hypertrophy or osteoarthritis, also known as degenerative joint disease.
Bones and Ligaments
Osteophytes (e.g. bone spurs) may form adjacent to the end plates, which may compromise blood supply to the vertebra. Further, the end plates may stiffen due to sclerosis; a thickening/hardening of the bone under the end plates.
Ligaments are bands of fibrous tissue connecting spinal structures (e.g. vertebrae) and protect against the extremes of motion (e.g. hyperextension). However, degenerative changes may cause ligaments to lose some of their strength. The ligamentum flavum (a primary spinal ligament) may thicken and/or buckle posteriorly (behind) toward the dura mater (a spinal cord membrane).
Cervical Spine and Spondylosis
The complexity of the cervical anatomy and its wide range of motion make this spinal segment susceptible to disorders associated with degenerative change. Neck pain from spondylosis is common. The pain may spread (radiate) into the shoulder or down the arm. When a bone spur (osteophyte) causes nerve root compression, extremity (e.g. arm) weakness may result. In rare cases, bone spurs that form at the front of the cervical spine, may cause difficult swallowing (dysphagia).
Thoracic Spine and Spondylosis
Pain associated with degenerative disease is often triggered by forward flexion and hyperextension. In the thoracic spine disc pain may be caused by flexion - facet pain by hyperextension.
Lumbar Spine and Spondylosis
Spondylosis often affects the lumbar spine in people over the age of 40. Pain and morning stiffness are common complaints. Usually multiple levels are involved (e.g. more than one vertebrae).
The lumbar spine carries most of the body's weight. Therefore, when degenerative forces compromise its structural integrity, symptoms including pain may accompany activity. Movement stimulates pain fibers in the anulus fibrosus and facet joints. Sitting for prolonged periods of time may cause pain and other symptoms due to pressure on the lumbar vertebrae. Repetitive movements such as lifting and bending (e.g. manual labor) may increase pain.
Spondylosis Diagnosis
Physical Examination
A thorough physical examination reveals a lot about the health and general fitness of the patient. The exam includes a review of the patient's medical and family history. Often laboratory tests such as complete blood count and urinalysis are ordered. The physical exam may include:
Palpation (exam by touch) determines spinal abnormalities, areas of tenderness, and muscle spasm.
Range of Motion measures the degree to which a patient can perform movement of flexion, extension, lateral bending, and spinal rotation.
Neurologic Evaluation
A neurologic evaluation assesses the patient's symptoms including pain, numbness, paresthesias (e.g. tingling), extremity sensation and motor function, muscle spasm, weakness, and bowel/bladder changes. Particular attention may be given to the extremities. Either a CT Scan or MRI study may be required if there is evidence of neurologic dysfunction.
X-Rays and Other Tests
Radiographs (x-rays) may indicate loss of vertebral disc height and the presence of osteophytes, but is not as useful as a CT Scan or MRI.
The CT Scan may be used to reveal the bony changes associated with spondylosis. An MRI is a sensitive imaging tool capable of revealing disc, ligament, and nerve abnormalities.
Discography seeks to reproduce the patient's symptoms to identify the anatomical source of pain. Facet blocks work in a similar manner. Both are considered controversial.
The physician compares the patient's symptoms to the findings to formulate a diagnosis and treatment plan. Further, the results from the examination provide a baseline from which the physician can monitor and measure the patient's progress.
Cervical spondylosis
Definition
Cervical spondylosis refers to common age-related changes in the area of the spine at the back of the neck. With age, the vertebrae (the component bones of the spine) gradually form bone spurs, and their shock-absorbing disks slowly shrink. These changes can alter the alignment and stability of the spine. They may go unnoticed, or they may produce problems related to pressure on the spine and associated nerves and blood vessels. This pressure can cause weakness, numbness, and pain in various areas of the body. In severe cases, walking and other activities may be compromised.
Description
As it runs from the brain down the back, the spinal cord is protected by ringlike bones, called vertebrae, stacked one upon the other. The vertebrae are not in direct contact with one another, however. The intervening spaces are filled with structures called disks. The disks are made up of a tough, fibrous outer tissue with an inner core of elastic or gel-like tissue.
One of the most important functions of disks is protecting the vertebrae and the nerves and blood vessels between the vertebrae. The disks also lend flexibility to the spinal cord, facilitating movements such as turning the head or bending the neck. As people age, disks gradually become tougher and more unyielding. Disks also shrink with age, which reduces the amount of padding between the vertebrae.
As the amount of padding shrinks, the spine loses stability. The vertebrae react by constructing osteophytes, commonly known as bone spurs. There are seven vertebrae in the neck; development of osteophytes on these bones is sometimes called cervical osteoarthritis. Osteophytes may help to stabilize the degenerating backbone and help protect the spinal cord.
By age 50, 25-50% of people develop cervical spondylosis; by 75 years of age, it is seen in at least 70% of people. Although shrunken vertebral disks, osteophyte growth, and other changes in their cervical spine may exist, many of these people never develop significant problems.
However, about 50% of people over age 50 experience neck pain and stiffness due to cervical spondylosis. Of these people, 25-40% have at least one episode of cervical radiculopathy, a condition that arises when osteophytes compress nerves between the vertebrae. Another potential problem occurs if osteophytes, degenerating disks, or shifting vertebrae narrow the spinal canal. This pressure compresses the spinal cord and its blood vessels, causing cervical spondylitic myelopathy, a disorder in which large segments of the spinal cord are damaged. This disorder affects fewer than 5% of people with cervical spondylosis. Symptoms of both cervical spondylitic myelopathy and cervical radiculopathy may be present in some people.
Causes and Symptoms
As people age, shrinkage of the vertebral disks prompts the vertebrae to form osteophytes to stabilize the back bone. However, the position and alignment of the disks and vertebrae may shift despite the osteophytes. Symptoms may arise from problems with one or more disks or vertebrae.
Osteophyte formation and other changes do not necessarily lead to symptoms, but after age 50, half of the population experiences occasional neck pain and stiffness. As disks degenerate, the cervical spine becomes less stable, and the neck is more vulnerable to injuries, including muscle and ligament strains. Contact between the edges of the vertebrae can also cause pain. In some people, this pain may be referred--that is, perceived as occurring in the head, shoulders, or chest, rather than the neck. Other symptoms may include vertigo (a type of dizziness) or ringing in the ears.
The neck pain and stiffness can be intermittent, as can symptoms of radiculopathy. Radiculopathy refers to compression on the base, or root, of nerves that lead away from the spinal cord. Normally, these nerves fit comfortably through spaces between the vertebrae. These spaces are called intervertebral foramina. As the osteophytes form, they can impinge on this area and gradually make the fit between the vertebrae too snug.
The poor fit increases the chances that a minor incident, such as overdoing normal activities, may place excess pressure on the nerve root, sometimes referred to as a pinched nerve. Pressure may also accumulate as a direct consequence of osteophyte formation. The pressure on the nerve root causes severe shooting pain in the neck, arms, shoulder, and/or upper back, depending on which nerve roots of the cervical spine are affected. The pain is often aggravated by movement, but in most cases, symptoms resolve within 4-6 weeks.
Cervical spondylosis can cause cervical spondylitic myelopathy through stenosis- or osteophyte-related pressure on the spinal cord. Spinal stenosis is a narrowing of the spinal canal-- the area through the center of the vertebral column occupied by the spinal cord. Stenosis occurs because of misaligned vertebrae and out-of-place or degenerating disks. The problems created by spondylosis can be exacerbated if a person has a naturally narrow spinal canal. Pressure against the spinal cord can also be created by osteophytes forming on the inner surface of vertebrae and pushing against the spinal cord. Stenosis or osteophytes can compress the spinal cord and its blood vessels, impeding or choking off needed nutrients to the spinal cord cells; in effect, the cells starve to death.
With the death of these cells, the functions that they once performed are impaired. These functions may include conveying sensory information to the brain or transmitting the brain's commands to voluntary muscles. Pain is usually absent, but a person may experience leg numbness and an inability to make the legs move properly. Other symptoms can include clumsiness and weakness in the hands, stiffness and weakness in the legs, and spontaneous twitches in the legs. A person's ability to walk is affected, and a wide-legged, shuffling gait is sometimes adopted to compensate for the lack of sensation in the legs and the accompanying, realistic fear of falling. In very few cases, bladder control becomes a problem.
Diagnosis
Cervical spondylosis is often suspected based on the symptoms and their history. Careful neurological examination can help determine which nerve roots are involved, based on the location of the pain and numbness, and the pattern of weakness and changes in reflex responses. To confirm the suspected diagnosis, and to rule out other possibilities, imaging tests are ordered. The first test is an x ray. X rays reveal the presence of osteophytes, stenosis, constricted space between the vertebrae, and misalignment in the cervical spine--in short, an x ray confirms that a person has cervical spondylosis. To demonstrate that the condition is causing the symptoms, more details are needed. Other imaging tests, such as magnetic resonance imaging (MRI) and computed tomography myelography, help assess effects of cervical spondylosis on associated nerve tissue and blood vessels.
An MRI may be preferred, because it is a noninvasive procedure and does not require injecting a contrast medium as does computed tomography myelography. MRIs also have greater sensitivity for detecting disk problems and spinal cord involvement, and they test allows the physician to create permit creating images of a larger area from various angles. However, these images may not show enough detail about the vertebrae themselves. Computed tomography myelography yields a superior image of the bones involved in cervical spondylosis. Added benefits include that it takes less time to perform and tends to be less expensive than an MRI. A good diagnosis may be reached with either a computed tomography myelography or an MRI, but sometimes complementary information from both tests is necessary. Nerve conduction velocity, electromyogram (EMG), and/or somatosensory evoked potential testing may help to confirm which nerve roots are involved.
Treatment
Pain can sometimes be treated with nonsteroidal anti-inflammatory drugs, such as aspirin or ibuprofen. If these drugs are ineffective, a short-term prescription for corticosteroids or muscle relaxants may be given. For chronic pain, tricyclic antidepressants can be prescribed. Although these drugs were developed to treat depression, they are also effective in treating pain. Once any pain is resolved, exercises to strengthen neck muscle and preserve flexibility are prescribed.
If the pain is severe, a short treatment of epidural corticosteroids may be prescribed with discretion. A corticosteroid such as prednisone can be combined with an anaesthetic and injected with a long needle into the space between the damaged disk and the covering of the nerve and spinal cord. Injection into the cervical epidural space relieves severe pain that is not managed with conventional treatment. Frequent use of this treatment is not medically recommended and is used only if the more conservative therapy is not effective.
If pain is continuous and does not respond to conservative treatment, surgery may be suggested. Surgery is usually not recommended for neck pain, but it may be necessary to address radiculopathy and myelopathy. Surgery is particularly recommended for people who have already developed moderate to severe symptoms of myelopathy, although age or poor health may prohibit that recommendation. The specific details of the surgery depend on the structures involved, but the overall goal is to relieve pressure on the nerve root, spinal cord, or blood vessels and to stabilize the spine.
Since cervical spondylosis is part of the normal aging process, not much can be done to prevent it. It may be possible to ward off some or all of the symptoms by engaging in regular physical exercise and limiting occupational or recreational activities that place pressure on the head, neck, and shoulders. The best exercises for the health of the cervical spine are non-contact activities, such as swimming, walking, or yoga. Once symptoms have already developed, the emphasis is on symptom management rather than prevention.
Terms
Alexander technique
A technique developed by Frederick Alexander that focuses on the variations in body posture, muscles, the breathing, Defects in these functions can lead to stress, nervous tension or possible loss of function.
Bone spur
Also called an osteophyte, it is an outgrowth or ridge that forms on a bone.
Cervical
Referring to structures within the neck.
Computed tomography myelography
This medical procedure combines aspects of computed tomography scanning and plain-film myelography. A CT scan is an imaging technique in which cross-sectional x rays of the body are compiled to create a three-dimensional image of the body's internal structures. Myelography involves injecting a water-soluble substance into the area around the spine to make it visible on x rays. In computed tomography myelography or CT myelography, the water-soluble substance is injected, but the imaging is done with a CT scan.
Disk
A ringlike structure that fits between the vertebrae in the spine to protect the bones, nerves, and blood vessels. The outer layer is a tough, fibrous tissue, and the inner core is composed of more elastic tissue.
movements.
Magnetic resonance imaging (MRI)
An imaging technique that uses a large circular magnet and radio waves to generate signals from atoms in the body. These signals are used to construct images of internal structures.
Myelopathy
A disorder in which the tissue of the spinal cord is diseased or damaged.
Osteophyte
Also referred to as bone spur, it is an outgrowth or ridge that forms on a bone.
Radiculopathy
Sometimes referred to as a pinched nerve, it refers to compression of the nerve root--the part of a nerve between vertebrae. This compression causes pain to be perceived in areas to which the nerve leads.
Spine
A term for the backbone that includes the vertebrae, disks, and spinal cord as a whole.
Stenosis
A condition in which a canal or other passageway in the body is constricted.
Vertebrae
The ringlike component bones of the spine.
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