Spondylosis
Spondylosis is a general term referring to degenerative arthritic changes of the spine predominantly involving the vertebral bodies, and/or neuroforamina (where the nerve roots exit). Most degenerative changes of the spine are part of the normal process of aging (just like developing grey hair) and everyone is expected to have some evidence of spondylosis as they get older. In many instances there are no symptoms felt by patients who demonstrate evidence of spondylosis on imaging studies.
Muscle strain is the most common cause of back pain in teenagers and athletes and in most cases improves with rest. More serious causes of back pain need early identification and treatment or they may become worse. It is important to see a doctor if a young person’s back pain lasts for more than several days or progressively worsens.
Spondylolysis is a common cause of low back pain in adolescent athletes. Spondylolysis is a stress fracture in one of the vertebrae at the base of the spinal column (Figure 1). It most commonly affects the fifth lumbar vertebra and is the most common cause of back pain in adolescent athletes and can commonly be seen on x-ray.
Figure 1
If the pars "cracks" or fractures, the condition is called spondylolysis (Figure 2). If the fracture gap at the pars widens and the vertebra shifts forward, then the condition is called spondylolisthesis (Figure 3). If too much slippage occurs, the bones may begin to press on nerves and surgery may be necessary to correct the condition.
Figure 2:
Figure 3:
SYMPTOMS:
Many people with symptomatic spondylotic changes will describe stiffness or localized aching at the involved area. Symptoms may be exacerbated by specific movements, including physical activity and/or prolonged abnormal postures of the spine. In more severe cases, spondylotic changes may cause pressure on a nerve root that produces pain, sensory and/or motor disturbances in the distribution of the nerve root. Also, if the degenerative changes apply pressure on the spinal cord this may cause a wide variety of vague symptoms characterized by global weakness, gait dysfunction, loss of balance, sensory changes in the hands and feet, and loss of bowel and/or bladder control.
There are several symptoms that often accompany spondylolisthesis which include:
• Pain in the low back, especially after exercise
• Increased lordosis (i.e., swayback).
• Pain and/or weakness in one or both thighs or legs
• Reduced ability to control bowel and bladder functions
• Tight hamstring musculature
CAUSES:
Some sports, such as gymnastics, weight lifting, and football, put a great deal of stress on the bones in the lower back. These sports require that the athlete constantly hyperextend the spine, which may result is a stress fracture on one or both sides of the vertebra. In addition, slippage of one vertebra on another, or spondylolisthesis tends to progress during periods of rapid growth so adolescents are at some risk for progression of spondylolysis to spondylolisthesis.
Diagnosis
X-rays of the lumbar spine are used to evaluate the position of the vertebra and look for spondylolysis. When necessary, bone scan and CT scan can be used to detect a spondylolysis that is not visible on regular x-rays. If there is evidence of pressure on the lumbar nerves, then an MRI scan may be needed to further assess the abnormality (Figure 4).
Figure 4 Caption: X-ray and MRI of the lumbar spine in a patient with spondylolysis that has progressed to spondylolisthesis. Note the forward slippage (red arrow). The MRI scan (right) shows degeneration of the bottom disc and spondylolisthesis (open arrow).
TREATMENT OPTIONS:
Initial treatment for spondylolysis is always nonsurgical. The patient should take a break from sporting activities until symptoms resolve and guided physical therapy will be initiated to improve core strengthening and lumbar motion. Anti-inflammatory medications, such as ibuprofen, may be used to help reduce back pain.
Treatment is usually conservative in nature (especially if there is no evidence of spinal cord or nerve root compression). The most commonly used treatments are physical therapy, chiropractic, osteopathy, acupuncture and other manual medicine practices. Patient education on lifestyle modifications and nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be beneficial in managing symptoms. Occasionally, narcotic pain medicines may be needed for severe or chronic symptoms.
In most cases, activities can be resumed gradually and there will be few complications or recurrences. Stretching and strengthening exercises for the back and abdominal muscles can help prevent future recurrences of pain. Periodic X-rays may be needed to be sure the vertebra is not changing position.
OPERATIVE TREATMENT:
Surgery is used only if slippage progressively worsens or if back pain does not respond to nonsurgical treatment and begins to interfere with activities of daily living. In some cases, a repair of the pars interarticularis can be performed, in cases of progressive slippage, a spinal fusion may be required (Figure 5).
Figures 4 and 5: Spondylolisthesis Case Example:
This is a 21 year old woman with spondylolisthesis. She was diagnosed with spondylolisthesis in high school and she worked hard to manage her pain with physical therapy. She still able to play sports and even played lacrosse on her college team. Eventually she began to have worsening pain in her back radiating into her legs that therapy and medicines could not control and she decided to have surgery.
The surgeons at The Virginia Spine Institute were able to fix her spondylolisthesis through a small incision below her belly button. The fixation was strong enough that no brace was needed after surgery and she got out of bed the first day after surgery. She returned to college 1 week after her surgery and has now returned to all her activities including sports without any further pain. Her X-rays before and after surgery show correction of her spondylolisthesis with titanium cages and a plate.
Figure 4:
Figure 5:
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