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Welcome to First Choice Physical Therapy’s patient resource about Sacral Insufficiency Fractures.

The sacrum is a wedge shaped bone that makes up part of the pelvis. It transmits the weight of the body to the pelvic girdle. As the name suggests, sacral insufficiency fractures occur when the quality of the sacral bone has become insufficient to handle the stress of weight bearing. The bone has lost some of its supporting structure and has become weak. Since this is usually because of osteoporosis, sacral insufficiency fractures occur most often in older women.

This guide will help you understand:

• what parts make up the sacrum
• what causes this condition
• how doctors diagnose this condition
• what treatment options are available

Anatomy

What makes up the sacrum?

The sacrum is the triangular bone just below the lumbar spine. The sacrum has five segments fused together into one large bone. The coccyx or tailbone attaches to the bottom of the sacrum.

The sacrum forms the base of the spine and the center of the pelvis. The sacrum transmits the weight of the body to the pelvic girdle. It is shorter and wider in the female than in the male. Its name means sacred bone.

At the top of the sacrum there are wings from each side called the sacral ala. At the ala, the sacrum fits between the two halves of the pelvis. These pelvic bones are called the iliac bones. This is where the sacroiliac joints are formed. Most everyone has two dimples in their low back where the sacroiliac joints form. These three bones of the pelvis, the sacrum and the two iliac bones, make a ring.

Each of the iliac bones has projections called the pubic rami. They meet together in the front of the pelvis, forming a joint called the symphysis pubis. The iliac bones also contain the cup or socket for the hip joint.

Nerves that leave the spine in the area of the sacrum help control the bowels and bladder and provide sensation to the crotch area.

There are three types of bone, woven bone, cortical bone, and cancellous bone. In adults, woven bone is found where there is a broken bone that is healing (callus formation). It can also be found with hyperparathyroidism and Paget’s disease. It is composed of randomly arranged collagen strands. It is normally remodeled by the body and replaced with cortical or cancellous bone.

Cortical bone is called compact or lamellar bone. It forms the inside and outside tables of flat bones and the outside surfaces of long bones. It is dense and makes up 80 percent of our bone mass. The radius (wrist bone), skull, and long bones are made of cortical bone.

Cancellous bone is also called trabecular bone. It lies between the cortical bone surfaces. It is the inner supporting structure and is spongy. It makes up 20 percent of our bone mass. Normal cancellous bone is always undergoing remodeling on the inside surfaces of bone. Cancellous bone is found in the hip, spine, and femur.

The three main cells that form and shape bones are osteoblasts, osteocytes, and osteoclasts. Osteoblasts are bone-forming cells. When calcium is deposited in the cells, they make bones strong and hard. Osteocytes are mature osteoblasts trapped within the bone. Osteoclasts are bone-resorbing cells. They dissolve bone surfaces by releasing a chemical called an enzyme. Their activity is in part controlled by hormones in the body.

It is normal for bones to have mini fractures from everyday wear and tear. They are healed by ongoing bone remodeling. Bone remodeling occurs in 120 day cycles. Normal bone has a balance of clearing away old bone and formation of new bone. Osteoclasts resorb or clear away the damaged bone for the first 20 days. Bone is then formed by osteoblasts over the last 100 days.

Sacral insufficiency fractures usually are parallel to the spine. They are most often in the ala, just beside the sacroiliac joint. At times there is also a transverse fracture that connects insufficiency fractures when they occur on both sides of the sacrum. The fracture lines then create an “H” pattern. Sacral fractures are classified into three zones, zone 1, zone 2, and zone 3. If the fracture involves just the ala, there is usually not a risk for nerve damage.

Lumbar Spine Anatomy

Causes

What causes sacral insufficiency fractures?

A physician named Lourie first described sacral insufficiency fractures in 1982. These fractures can cause severe pain in the buttock, back, hip, groin, and/or pelvis. Walking is typically slow and painful. Many daily activities become painful, difficult, and in some cases impossible.

Sacral insufficiency fractures occur when the quality of the sacral bone has become insufficient to handle the stress of weight bearing. The bone has lost some of its supporting structure and has become weak.

Osteoporosis is the leading cause of sacral insufficiency fractures. Osteoporosis is defined as low bone mass (weight). There is a decrease in bone tissue and minerals such as calcium. This can make the bones fragile. This means they can break more easily. Bone mineral density is measured by a DEXA scan. DEXA involves scanning the lumbar spine, the hip, and sometimes, the wrist. Osteoporosis affects 25 million people in the United States. Of these, 80 percent are females.

Other risk factors that can weaken bone include radiation to the pelvis, steroid use, rheumatoid arthritis, hyperparathyroidism, anorexia nervosa, liver transplantation, osteopenia, Paget’s disease, hip joint replacement, and lumbosacral fusion. Sacral insufficiency fractures can also occur in pregnant or breastfeeding women due to temporary osteoporosis.

Sacral insufficiency fractures can occur spontaneously, meaning there does not need to be any trauma such as a fall. The fracture can just simply happen when the bone becomes too weak to handle the stress of weight bearing. When the sacrum is fractured, 60 percent of the time the bone in front of the pelvis will also fracture. This bone is called the pubic ramus.

Symptoms

What does a sacral insufficiency fracture feel like ?

Unfortunately, sacral insufficiency fractures are often an unsuspected and undiagnosed cause of low back pain in elderly women. It was not until 1982 that they were described by a physician named Lourie.

Symptoms can include severe pain in the buttock, back, hip, groin, and/or pelvis. If the pubic ramus has fractured, there may be pain in the front of the pelvis. Walking is typically slow and painful. It can be difficult to do other necessary activities. Your back or pelvis may be tender to touch. You may find that you have limited range of motion of your low back.

Rarely there is nerve damage with sacral insufficiency fractures. When nerve damage does occur, the symptoms are usually problems with bowel or bladder function, or decreased sensation or strength of the leg(s).

Diagnosis

How do health care providers diagnose the problem?

When you visit First Choice Physical Therapy, we will ask questions about your general health, what your symptoms feel like, and if there was any trauma that could have caused your symptoms.

Our Physical Therapist will perform a physical exam. This will likely include checking your nerve and spinal cord function, checking your range of motion, and feeling or tapping your back and pelvis to check for tenderness.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

What treatment options are available?

Most of the time treatment for sacral insufficiency fractures is non-surgical.

Non-surgical Rehabilitation

At First Choice Physical Therapy, our Physical Therapy program will help to manage your pain. Our treatment consists of rest and gradually starting to walk again, with a walker or crutches. Bracing with a corset is also sometimes helpful. Patients may also want to consult with their doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication.

Our Physical Therapist may use heat, gentle massage, and electrical stimulation, or TENS units to reduce your pain. We may recommend use of water exercises done in a pool. The buoyancy of the water helps people walk and exercise safely without putting too much tension on the injured area.

Although recovery and rehabilitation times vary, as a general rule patients may see improvement of symptoms after one to two weeks of treatment. Most people are pain free in six to 12 months. Complete healing may occur after nine months. Most patients should have a full recovery.

Post-surgical Rehabilitation

Previously, bed rest was the recommended treatment for sacral insufficiency fractures. However there can be many complications of prolonged bed rest, especially in the elderly.

Before any weight bearing activities are allowed, you will likely have to remain non-weight bearing for a period of time. In this phase of your recovery, you may be able to do bed exercises under the supervision of a Physical Therapist. You will probably need assistance for daily activities initially and this may mean that you will have to have live-in help, or stay in an extended care facility.

Once you are ready to progress in Physical Therapy, the Physical Therapy program will begin to assist you with limited weight bearing activities during your recovery period. This can be tolerated with a walker or crutches in most cases. Limited weight bearing activity actually helps to stimulate new bone growth. As your Physical Therapy program continues, our Physical Therapist works with you on progressing weight bearing activities such as walking and lifting light weights. Avoiding too much caffeine, alcohol, and smoking is also important. Occupational therapy may also be recommended to help you with equipment that may be helpful for showering, dressing, and other daily activities.

At First Choice Physical Therapy, our goal is to help speed your recovery so that you can more quickly return to your everyday activities. When your recovery is well under way, regular visits to our office will end. We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Physician Review

Your doctor will want you to have imaging of your pelvis. Plain X-rays are often negative. However, a fracture will be seen on bone scan, Computed Tomography (CT), or Magnetic Resonance Imaging (MRI).

Your doctor may order a bone scan with technetium-99m medronate ethylene diphosphonate (MDP). The MDP is injected into your vein. This should be performed after a minimum of 48 to 72 hours after symptoms begin. Where there is a fracture, the MDP will be concentrated. Uptake patterns on the scan may include the “H”-shape, also called the Honda sign when there is a sacral insufficiency fracture.

 

Single Photon Emission Computed Tomography (SPECT) is a new, advanced diagnostic nuclear medicine procedure that uses the emission of a radioisotope that is carried in the blood to the tissues. SPECT imaging is often added to provide information that is not available on routine bone scan images. It provides three-dimensional (3-D) views of the area examined. Following a bone scan you will remain on the exam table and the camera will rotate around the table while it takes pictures. SPECT imaging adds 30 to 60 minutes to the time of the nuclear scan. Sedation may be needed.

CT scan may be used to confirm and complement a positive bone scan. The CT scan uses special Xrays.

MRI is the radiological examination of choice by some doctors. Bone marrow edema on an MRI suggests a fracture. The MRI machine uses magnetic waves, not X-rays to show the bone and soft tissues.

Your doctor may request that you give samples of blood for the laboratory. This is to see if there could be another cause for osteoporosis that can be treated.

Treating osteoporosis is crucial in an attempt to decrease the risk of another insufficiency fracture. Your surgeon will likely recommend additional calcium, vitamin D. A prescription medication to help prevent mineral loss from your bones is also commonly used.

Medications that are used to help the fracture heal include calcium (1200-1500mg) and Vitamin D (400-800 IU). Bisphoshonates such as Actonel, Fosamax and Boniva are used to treat osteoporosis. Calcitonin is also used to help with pain and healing of the bone when broken. Parathyroid hormone (PTH) replacement can also be beneficial. It increases both bone resorption and bone formation. Bone mineral density is increased, making the bone stronger. Patients may also want to consult with their doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication

For pain, narcotics or opioids can be helpful. Some doctors feel that nonsteroidal anti-inflammatories (NSAID) such as Aleve or Ibuprofen should not be used for at least three to four weeks after a new fracture. Some studies have shown that they can slow fracture healing.

Regular follow up with your doctor is important. DEXA scans are usually repeated to ensure that the treatments for your osteoporosis are working.

Your doctor may want you to have Physical Therapy to help with your pain. Heat, gentle massage, and electrical stimulation, or TENS units may improve pain.

Surgery

Surgical treatment is rare with sacral insufficiency fractures. A newer treatment that shows some promise in relieving pain and allowing more normal activity sooner is called a sacroplasty.

During sacroplasty, a bone glue called polymethylmethacrylate (PMMA) is injected into the fracture. Serious complications can occur if it is not performed correctly.

Sacroplasty may be considered in those with a severe decrease in functional ability and quality of life. It may provide faster relief of pain than typical conservative care. It is usually done in a surgery suite.

The area that is to be injected is cleaned and sterilized. This helps to decrease the possibility of an infection. A needle is placed in the area over the fracture. This is monitored with an X-ray machine. Bone glue is then injected and hardens rather quickly. This stabilizes the fracture. You are usually allowed to go home the same day.

If there are neurological symptoms from the sacral fracture, the sacrum may need to be stabilized. Hardware such as screws and plates may be used.

Your surgeon will want you to follow up with him or her on a regular basis to check on how the fracture is healing. Imaging studies will be repeated. In six to nine months, you should be able to return to your previous activity level.

If you have sacroplasty, the fracture will be considered healed much more quickly. This allows you to return to your previous activity level sooner also. Your doctor will likely repeat imaging studies to check the progress of the healing fracture(s).

Welcome to First Choice Physical Therapy’s patient resource about Sacroiliac Joint Dysfunction.

A painful sacroiliac joint is one of the more common causes of mechanical low back pain. Sacroiliac (SI) joint dysfunction is a term that is used to describe the condition – because it is still unclear why this joint becomes painful and leads to low back pain. Sacroiliac joint dysfunction can be a nuisance but it is seldom dangerous and rarely leads to the need for surgery. Most people who suffer from this problem can reduce the pain and manage the problem with simple methods.

This article will help you understand:

• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What part of the back is involved?

At the lower end of the spine, just below the lumbar spine lies the sacrum. The sacrum is a triangular shaped bone that is actually formed by the fusion of several vertebrae during development. The sacroiliac (SI) joint sits between the sacrum and the iliac bone (thus the name “sacroiliac” joint). You can see these joints from the outside as two small dimples on each side of the lower back at the belt line.

The SI joint is one of the larger joints in the body. The surface of the joint is wavy and fits together similar to the way Legos fit together. Very little motion occurs in the SI joint. The motion that does occur is a combination of sliding, tilting and rotation. The most the joint moves in sliding is probably only a couple of millimeters, and may tilt and rotate two or three degrees.

Surface of Joint Fits Together

The SI joint is held together by several large, very strong ligaments. The strongest ligaments are in the back of the joint outside of the pelvis. Because the pelvis is a ring, these ligaments work somewhat like the hoops that hold a barrel together. If these ligaments are torn, the pelvis can become unstable. This sometimes happens when a fracture of the pelvis occurs and the ligaments are damaged. Generally, these ligaments are so strong that they are not completely torn with the usual injury to the SI joint.

Ligaments

The SI joint hardly moves in adults. During the end of pregnancy as delivery nears, the hormones that are produced causes the joint to relax. This allows the pelvis to be more flexible so that birth can occur more easily. Multiple pregnancies seem to increase the amount of arthritis that forms in the joint later in life. Other than the role the joint plays in pregnancy, it does not appear that motion is important to the function of the joint. The older one gets, the more likely that the joint is completely ankylosed, a term that means the joint has become completely stiffened with no movement at all. It appears that the primary function of the joint is to be a shock absorber and to provide just enough motion and flexibility to lessen the stress on the pelvis and spine.

Lumbar Spine Anatomy

Causes

What causes this problem?

There are many different causes of SI joint pain. Pregnancy may be a factor in the the development of SI joint problems later in life. Also, if a person has one leg is shorter that the other, the abnormal alignment may end up causing SI joint pain and problems. Often, an exact cause leading to a painful SI joint condition can’t be found. The joint simply gets painful, and the patient and provider don’t have an answer as to why the joint has become painful.

The SI joint is a synovial joint, similar to all joints such as the knee, hip and shoulder. Because of this, different types of arthritis that affect all the joints of the body will also affect the sacroiliac joint. This includes conditions such as rheumatoid arthritis, gout and psoriasis. The joint can be infected when bacteria that travel in the blood settle in the joint causing a condition called septic arthritis. This is perhaps the most worrisome cause of SI joint pain and may well require surgery to drain the infection.

Injury to the SI joint is thought to be a common cause of pain. Injury can occur during an automobile accident. One common pattern of injury occurs when the driver of a vehicle places one foot on the brake before a collision. The impact through the foot on the brake is transmitted to the pelvis causing a twisting motion to this side of the pelvis. This can injure the SI joint on that side resulting in pain. A similar mechanism occurs with a fall on one buttock. The force again causes a twisting motion to the pelvis and may injure the ligaments around the joint.

Impact

Symptoms

What does the condition feel like?

The most common symptoms from SI joint dysfunction are low back and buttock pain. The pain may affect one side or both SI joints. The pain can radiate down the leg all the way to the foot and may be confused with a herniated disc in the lumbar spine. The pain may radiate into the groin area. People often feel muscle spasm in one or both of their buttocks muscles.

Problems with the SI joint may make sitting difficult. Pain in one SI joint may cause a person to sit with that buttock tilted up. It is usually uncomfortable to sit flat in a chair.

Diagnosis

How do health care providers diagnose the problem?

Diagnosis begins with a complete history and physical exam. When you visit First Choice Physical Therapy, we will ask questions about your symptoms and how the pain is affecting your daily activities. Our Physical Therapist will also want to know what positions or activities make your symptoms worse or better. We will ask you about any past injuries and about any other medical problems you or your family members might have.

Our Physical Therapist then will examine you by checking your posture, how you walk and where your pain is located. We check to see which back movements cause pain or other symptoms. Your lower extremity skin sensation, muscle strength, and reflexes will also be tested.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Physical Therapy is often recommended for patients with SI joint dysfunction. At First Choice Physical Therapy, patients with this condition are normally seen a few times each week for four to six weeks, although recovery time varies for each patient. In severe and chronic cases, patients may need a few additional weeks of care.

Our Physical Therapist may first advise you to rest your back by limiting your activities. The purpose of this is to help decrease inflammation and calm any muscle spasm.

After evaluating your condition, your Physical Therapist at First Choice Physical Therapy can assign positions and exercises to ease your symptoms. Our Physical Therapist may design an exercise program to improve the strength and control of your back and abdominal muscles.

If You Have Limited SI Joint Motion

When movement of a joint is limited, the pain and symptoms of SI joint dysfunction may worsen. Getting more motion can give you the relief you need for daily activities. If you don’t have full range of motion, our Physical Therapist has several ways to help you get more movement including joint manipulation, stretching, and exercises.

Our Physical Therapists commonly prescribe a set of stretches to improve flexibility in the muscles of the trunk, buttocks, and thighs. In addition to the treatment you receive at First Choice Physical Therapy, you may be given ways to help your SI joint yourself if your pain returns. These exercises usually require that you position your hip and pelvis in a certain way and either stretch or contract and relax specific muscles. Follow the instructions of our Physical Therapist when doing these exercises at home. Active movement and stretching, as part of a home program, can also help restore movement and get you better faster.

If You Have Excess SI Joint Mobility

If the SI joint has too much mobility and problems keep coming back, you may need extra help to stabilize the SI joint. Some patients benefit from wearing a special brace called a sacroiliac belt. This belt wraps around the hips to hold the sacroiliac joint tightly together, which may ease your pain. A belt like this can often ease pain enough to let you exercise comfortably.

You’ll learn some exercises to help you build strength, muscle control, and endurance in the muscles that attach around the SI joint. Unfortunately, few muscles actually connect to both the sacrum and the pelvis. Key muscles to work are the gluteus maximus, as well as the abdominal and low back muscles.

Post-surgical Rehabilitation

You will normally need to wait at least six weeks before beginning a rehabilitation program after having SI joint fusion surgery. Although recovery and rehabilitation varies for each patient, as a guideline you should plan on attending Physical Therapy sessions for six to eight weeks. Expect full recovery to take up to six months.

When you visit First Choice Physical Therapy after SI joint surgery, our Physical Therapist may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm your pain and muscle spasm. Then we will instruct you how to move safely with the least strain on the healing area.

As your First Choice Physical Therapy rehabilitation program evolves, you’ll begin doing more challenging exercises. Our goal is to safely improve your strength and function.

As Physical Therapy sessions come to an end, our Physical Therapist will help you get back to the activities you enjoy. Ideally, you’ll be able to resume your normal activities. You may need guidance on which activities are safe or how to change the way you go about your activities.

When treatment is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you’ll be in charge of doing your exercises as part of an ongoing home program.

Physician Review

Doctors often begin by prescribing nonsurgical treatment for SI joint dysfunction. In some cases, doctors simply monitor the patient’s condition to see if symptoms improve.

Medications

Anti-inflammatory medications, such as ibuprofen and naproxen, are commonly used to treat the pain and inflammation in the joint. Acetominiphen (for example, Tylenol) can be used to treat the pain, but it will not control the inflammation. Doctors often recommend Physical Therapy for patients with SI joint dysfunction.

Laboratory Tests
Your doctor may order laboratory tests if there is any question whether you might have an infection or some type of arthritis affecting multiple joints. You may also need to have blood drawn and give a urine sample to send to the laboratory for special tests.

Radiological Tests

X-rays are commonly ordered of both the low back and pelvis. X-rays can give your doctor an idea about how much wear and tear has occurred in the SI joint. X- rays of the lumbar spine and hips are also helpful to rule out problems in these areas that may act and look like SI joint dysfunction.

Other radiological tests may be useful as well. The magnetic resonance imaging (MRI) scan can be used to look at the lumbar spine and pelvis in much more detail and to rule out other conditions in the area. The MRI scan uses magnetic waves rather than x-rays and shows a very detailed picture of the soft tissues of the body.

A computed tomography (CAT) scan may also be used to show a much more detailed look at the bone of the pelvis and the sacroiliac joint.

A bone scan is useful to see how the skeleton is reacting to any type of “stress,” such as an injury, an infection, or inflammation from arthritis. This test involves injecting chemical “tracers” into your blood stream. The tracers then show up on special spine X-rays. The tracers collect in areas where the bone tissue is reacting strongly to some type of stress to the skeleton, such as arthritis and infection of the SI joint.

The most accurate way of determining whether the SI joint is causing pain is to perform a diagnostic injection of the joint. Because the joint is so deep, this must be done using X-ray guidance with a fluoroscope (a type of realtime X-ray). Once the doctor places a needle in the joint, an anesthetic is injected into the joint to numb the joint. If your pain goes away while the anesthetic is in the joint, then your doctor can be reasonably sure that the pain you are experiencing is coming from the SI joint.

Injections

If conservative treatment is unsuccessful, injections may be suggested by your doctor. As described above, injections are used primarily to confirm that the pain is coming from the SI joint. A series of cortisone injections may be recommended to try to reduce the inflammation in and around the SI joint. Cortisone is a powerful anti-inflammatory medication that is commonly used to control pain from arthritis and inflammation. Other medications have been injected into the joint as well. A chemical called hyaluronic acid has been used for years to treat osteoarthritis of the knee. This chemical is thought to reduce pain due to its lubricating qualities and the fact that it nourishes the articular cartilage in the synovial joints. The true mechanism of action remains unknown, but it has been used with some success in the SI joint. All of these injections are temporary and are expected to last several months at the most.

Radiofrequency Ablation

Another procedure that has been somewhat successful is called radiofrequency ablation. After a diagnostic injection has confirmed that the pain is coming from the SI joint, the small nerves that provide sensation to the joint can be “burned” with a special needle called a radiofrequency probe. In theory, this destroys any sensation coming from the joint, making the joint essentially numb. This procedure is not always successful. It is temporary but can last for up to two years. It can be repeated if needed.

Surgery

Surgery may be considered if other treatments don’t work. Surgery consists of fusing the painful SI joint. A fusion is an operation where the articular cartilage is removed from both ends of the bones forming the joint. The two bones are held together with plates and screws until the two bones grow together, or fuse, into one bone. This stops the motion between the two bones and theoretically eliminates the pain from the joint.

This is a big operation and is not always successful at relieving the pain. The operation is not commonly performed unless the pain is debilitating. SI joint pain is seldom this severe.

Anatomy

Causes

Symptoms

Diagnosis

Treatment

Physical Therapy

Anatomy

Rationale

Preparations

Procedure

Complications

After Care

Rehabilitation

Anatomy

Causes

Symptoms

Diagnosis

Physician�s Review

Treatment

Rehabilitation

Surgery

Welcome to First Choice Physical Therapy’s patient resource about Adult Degernative Scoliosis. 

 A normal healthy spine will be straight when seen from the front or the back. When seen from the side, the normal spine forms a gentle S curve.

Scoliosis is an abnormal or exaggerated curve of the spine from the side or from the front or back.  Adult degenerative scoliosis is different from the type of scoliosis that occurs in teenagers. Adult degenerative scoliosis occurs after the spine has stopped growing and results from wear and tear on the spine. The condition most often affects the lumbar spine.

This guide will help you understand:

• what parts make up the spine
• what causes adult degenerative scoliosis
• how your doctor will diagnose this condition
• what treatment options are available

Anatomy

What parts make up the spine?

The spine is made up of 24 moveable bone segments called vertebrae. The spine is divided into three distinct portions. There are seven cervical or neck vertebrae, 12 thoracic or mid-back vertebrae and five lumbar or low back vertebrae.

The spine is made up of three general parts.  The top portion is the cervical spine and connects with the skull or cranium.  The middle portion is the thoracic spine and is identified by the ribs that attach to each of the vertebrae.  The lower portion is the lumbar spine. It connects with the pelvis at the sacrum.

The vertebra stack on top of one another and are separated by discs. The spine has normal curves. When looking at the spine from the side, the spinal column is not straight up and down, but forms an S curve. The cervical spine has an inward curve called a lordosis. The thoracic spine curves outward. This curve is called a kyphosis.  The lumbar spine usually has an inward curve or a lordosis. The S curve seen in the side view allows for shock-absorption and acts as a spring when the spine is loaded with weight.  This S curve maintains balance of the spine in a forward and backward plane.

The spinal cord travels within a canal made by the vertebra.  Branching off of the spinal cord are nerve roots. These nerves then supply arm, trunk, and leg muscles for movement. They also supply muscles of organs such as the bladder.

Discs are fluid-filled cushions between the vertebrae.  Facet joints are small joints connecting each vertebra in the back that allow movement.  Facet joints are lined with cartilage. The cartilage is a covering of the joint surface that gives some cushion and protects the bone. It is also slippery which helps with motion.

Lumbar Spine Anatomy

Causes

What causes adult degenerative scoliosis?

Adult degenerative scoliosis can be a result of scoliosis from childhood. The curvature may increase during adulthood and become painful. Scoliosis that happens in childhood is usually idiopathic, meaning there is no known reason for it.

Any part of the spine can be affected by scoliosis including the cervical, thoracic, or lumbar vertebrae. Most often the lumbar spine is affected. The vertebrae curve to one side and may rotate, which makes the waist, hips, or shoulders appear uneven.

The most common cause of adult degenerative scoliosis is from degeneration, known as wear and tear. It usually occurs after the age of 40. In older women, it is often related to osteoporosis. Osteoporosis is the loss of calcium in the supporting bone. This makes the vertebrae weak.

In adult degenerative scoliosis, the spine loses its structural stability and becomes unbalanced. This imbalance of the spine causes changes in the way the forces of the spine are directed. The larger the scoliotic curve becomes, the faster these changes cause degeneration of the spine. This creates a vicious cycle where increasing deformity causes more imbalance, that in turn causes more deformity. While this process occurs very slowly, it usually continues to slowly progress until something is done to restore the balance in the spine.

When there is an S curve when viewing the spine from the front, the condition is called scoliosis. The scoliotic deformity may also affect the normal S curve that the spine has when viewed from the side. These curves are normal and required to maintain the proper balance of the spine. Many patients with scoliosis actually lose the normal curves of the spine.

Our body has a natural tendency to try to maintain a balance where the head is straight above the middle of the pelvis. If one leg is longer that the other, and the pelvis tilts, the spine will curve in the opposite direction to place the head above the center of the pelvis. If there is a curve in a portion of the spine, then the remainder of the spine will bend in the opposite direction to try and keep the head above the middle of the pelvis.

The scoliotic curve has a convex and concave side. The convex side is simply the outside of the curve where concave is the inside of the curve. The spine above and below the curve will tend to bend in the opposite direction in an attempt to balance the spine. Remember, the body will always try to place the head immediately above the middle of the pelvis. The concave side will tend to have more compression of the facet joints and possibly the nerve roots. This can lead to more pain from arthritis on the concave side of the curve and may lead to pain, weakness and numbness into the legs from the compressed nerve roots. These nerve changes are called radiculopathy.

In adult degenerative scoliosis, there is gradual narrowing of the discs that cushion between the vertebrae.  The cartilage and joint surfaces of the facet joints in the spine can wear out, causing arthritis. This can cause back pain.

Stenosis is a term meaning narrowing. There are times when the canal for the spinal cord is narrowed. The openings for the nerve roots may also be narrowed.  This will usually cause compression of the nerve structures.  When the spinal cord or spinal nerves are compressed, pain, changes in feeling and/or motor function of the muscles can happen.

Sometimes spondylolisthesis occurs. This is slippage of one vertebra on the other. This can happen in adult degenerative scoliosis when the vertebrae do not stack on top of one another like they are supposed to.  One vertebra may be shifted sideways or forward, not lining up as it should. The slippage is graded from I to IV, one being mild, IV often causing neurological symptoms.

In rare and severe cases, the chest may become deformed because of scoliosis. This may affect the lungs and heart. This can lead to breathing problems, fatigue, and even heart failure.

Degenerative scoliosis is more common the older we get. As our population ages, adult scoliosis will be even more common. It will be an increasing source of deformity, pain, and disability.

Symptoms

What does adult degenerative scoliosis feel like?

Most people who have scoliosis will notice the deformity it can cause. There is usually a hump (rib hump) in the back. One shoulder and/or side of the pelvis may be lower than the other. You may have noticed that you have shrunk in height. You may not be able to stand up straight. For many, there is no significant pain caused by the scoliosis. Other symptoms may include:

• Decreased range of motion or stiffness in the back
• Pain involving the spine
• Stiffness and pain after prolonged sitting or standing
• Pain when lifting and carrying
• Pain may travel along the nerve distribution and be felt in areas away from the spine itself.  It may cause pain in the buttocks or legs
• Spasm of the nearby muscles
• Difficulty walking
• Difficulty breathing

Diagnosis

When you first visit First Choice Physical Therapy, we will ask you several questions about your pain and function, what makes your pain better and worse, when it started, if there have been changes in bowel or bladder function, or changes in motor function, and whether you have had previous surgery.

Our Physical Therapist will perform a physical examination that will include observation of your posture in standing position both sideways and from the front and back to assess for scoliosis. Mobility of your spine and hips, as well as walking ability will be evaluated. A neurological exam that includes testing reflexes with a small rubber hammer, and testing of sensation will likely be included.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

What treatment options are available?

Most of the time treatment of adult degenerative scoliosis is conservative care, meaning non-surgical. Rarely is surgery necessary. Treatment decisions for adult degenerative scoliosis are based on how much pain you are experiencing, how much the condition is affecting your ability to function and whether or not you are having symptoms of nerve compression.

Non-surgical Rehabilitation

When you begin Physical Therapy at First Choice Physical Therapy, the first goal of our treatment is to ease pain and other symptoms so that you can resume and maintain normal activities as soon as possible.

Activity modification such as limited lifting or avoidance of prolonged sitting or standing can be helpful. Occasional use of a cane or walker to improve walking tolerance may be recommended.

Much of the pain from adult degenerative scoliosis is the result of muscle spasm. This spam occurs when the normal muscles must work harder than normal try to restore the balance to the spine. The muscles become fatigued and begin to spasm. This causes pain.

At home, use of ice or heat may prove beneficial, and our Physical Therapist can provide you with guidelines for the use of these therapies.

Physical Therapy is important for strengthening muscles of the spine, abdomen, hip girdle, and legs.  Our Physical Therapist may advise you to participate in weight bearing exercises to help strengthen your bones and muscles. These may include activities such as walking, toning with the use of weights or other resistance, and tai chi.

Stretching of certain muscles may also be recommended. Stretching or traction applied to the sides of the curve is sometimes used. Traction devices may also be tried, and are often available for home use. At First Choice Physical Therapy we will teach you exercises that you can do at home, on a regular, ongoing basis. It may be possible to improve posture and motion.

The goals of our exercise program will be to improve the flexibility of your tight muscles, strengthen your back and abdominal muscles, and to help you move safely and with less pain.  Specific abdominal, or “core” strengthening will be very important to increase the stability of your spine and prevent further degeneration.

Muscle stimulators may also be used to help train your muscles. These are battery-powered electrical devices that cause muscle contraction.  The electrodes or patches are placed over a muscle such as along the spine. There are wires that then attach the electrodes to the device. The current is given for a limited period of time, controlled by a timer. This can help train the muscles to contract on their own. For pain management, your Physical Therapist at First Choice Physical Therapy in Lynn Haven and Panama City Beach may place a battery operated electrical device (TENS unit) over the area of pain. This reduces painful input to the brain from your back.

Bracing may also provide some help especially when the scoliosis is painful or unstable. Braces that are made to fit may be more comfortable and effective, but they are more expensive than off-the-shelf braces or supports. There are also unloading braces to help relieve pressure on the discs, nerves and joints of the spine.

Patients may also want to consult with their doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication to help you gain better control of your symptoms so you can resume normal activity swiftly. Over-the-counter anti-inflammatory medications such as Ibuprofen or Naproxenare often helpful. There are also many prescription anti-inflammatories available. In severe cases, narcotic medication may be considered by your doctor to make you more comfortable.

Post-surgical Rehabilitation

If surgery was necessary for your adult scoliosis you will likely be hospitalized for several days following surgery.  Some patients prefer to extend their stay in a transitional care unit in the hospital, or even a skilled nursing facility (nursing home).

Your surgeon may suggest a brace following surgery to support your spine and ensure that you do not bend too far.

You will be allowed to get in and out of bed and walk shortly after surgery.  Lifting is usually limited during the initial recovery period. You will gradually be allowed to resume your usual activities after several weeks or months.

It may be recommended that you have Physical Therapy after your surgery to help you regain strength and independence with daily activity. When you begin your First Choice Physical Therapy post-surgical program, we will help you with activity modification, and possibly recommend equipment for use in your home that may be helpful.

When you visit First Choice Physical Therapy for your post-surgical rehabilitation, we will first focus on reactivating the affected muscle systems. You will be trained in exercises that will increase your core stability and functional stability of the area. If your condition allows, we will eventually have you engage in training specifically designed to help you return to your previous daily activities or your sport.

Your surgeon will want to see you periodically to monitor your progress.  Repeat imaging with X-ray, MRI or CT scan is usually done to follow the progress of your spine as it heals.

Physician Review

Your doctor will want to start with x-rays to measure the degree of the scoliosis. X-rays provide pictures of the alignment of the vertebra. Using a device to measure angles held up to the x-ray image, the degree of curvature of the spine can be measured. These measurements are referred to as the Cobb angles. Diagnosis of scoliosis is made when a curve measures greater than 10 degrees. X-rays can also give your doctor information about how much degeneration has occurred in the spine. They show the amount of space between the vertebrae. They can also show the degree of fusion of the spine following surgery.

If you are having pain into your leg(s), or difficulty with bowel or bladder function, your doctor will likely order a magnetic resonance imaging (MRI) scan. The MRI scan provides a better image of the soft tissues such as discs, nerves, and the spinal cord. The MRI machine uses magnetic waves rather than x-rays to show the soft tissues of the spine. The pictures show slices of the area imaged. The test does not require a needle or dye.

A computed tomography (CT) scan may be ordered. It is best for evaluating problems with the vertebral bones.  It is a form of x-ray.  Sometimes, it may require dye into the spinal canal fluid so that the spinal cord and nerve root anatomy is identified better. When dye is injected for this purpose, the technique is called a myelogram.

SPECT stands for Single Photon Emission Computed Tomography. It is a nuclear scan because it uses a radioactive tracer, Technetium. Technetium is injected into your vein. Where there is increase in metabolic activity, such as in the case with inflammation (arthritis), fracture, infection, or tumor the Technetium will be more concentrated.

Electromyogram (EMG) and/or or nerve conduction velocity (NCV) tests are performed by the placement of small needles in extremities where there is concern about change in motor function, or sensation.  By using low-level electrical current, the device measures whether or not a motor nerve is being compressed. It can also help determine the source of changes in sensation. The EMG tests the muscles to see whether they are working properly. If they aren not, it may be because the nerve is not working well. The NCV test measures the speed of the impulses traveling along the nerve. Impulses are slowed when the nerve is compressed or constricted.

If symptoms limit your ability to function normally, your doctor may suggest an injection into the spine to help with pain. Your doctor may recommend facet injections into the joints of the spine. A procedure called radiofrequency ablation may provide more lasting benefit.  Epidural or transforaminal injections into the spine can also be helpful. A series of injections may be more helpful to provide temporary decrease in pain.

If you have osteoporosis, discuss with your doctor how you can optimize your treatment for this condition to slow the progression of osteoporosis. Adequately treating the osteoporosis can help reduce the progression of the scoliosis.

Surgery

Surgery is usually considered when non-surgical treatments have not provided enough relief from pain – or when the nerves of the spine are being damaged. Surgery is more common when the curvature is continuing to increase and the imbalance of the spine is clearly getting worse. Surgery to correct adult degenerative scoliosis is both complex and difficult. Most surgeons would not suggest surgical intervention except as a last resort when all conservative measures have failed and the pain is intolerable.

Adult degenerative scoliosis is a disease of older people. As a result, the overall health of the individual is important when making decisions about whether or not to consider surgery. Other illnesses, such as heart disease, lung disease or diabetes, may increase the risk of medical complications either during or after the operation and make surgery too risky.

Surgeons must consider the quality of the bone of the spine as well. Older individuals are more likely to have some degree of osteoporosis. This makes the bone weaker. Weaker bone may not be able to hold the instrumentation, the rods and screws necessary to correct the spine. If the bone weakened by osteoporosis cannot hold the screws necessary to hold the spine aligned as it fuses, this can lead to failure of the entire operation.

The goal of surgery is to improve the balance of the spine and remove pressure on any of the nerves of the spine. Surgery to relieve pressure on the nerves is called a decompression. Surgery to reinforce the area that is unstable is called a fusion. To accomplish the goals of the surgery requires several steps.

First, the surgeon must be able to adequately see the area of spine to be corrected. This is called the exposure. The surgery usually requires an incision in the back. In some cases, surgery will also need to be performed on the front of the spine. This may require an incision in the abdomen or from the side of the body to allow the surgeon to reach the front of the spine. Sometimes a combination of both is necessary.

Next, the surgeon must perform a decompression so that all nerves are free of any pressure. This is accomplished by removing any bone spurs or disc material that is causing pressure on the spinal nerves.

The surgeon must then mobilize the spine. Usually after the  decompression is finished, the spine is mobilized a great deal. Removing bone spurs and disc material also loosens the contracted scar tissue around the spine and allows the surgeon to straighten the spine back toward normal.

Finally, the surgeon must insert the screws and rods that will hold the spine in the new position while the fusion occurs. Two special screws called pedicle screws are inserted into each vertebra. These special screws are then attached to metal rods that hold the vertebrae in alignment.

Bone graft is placed between each vertebra. This bone graft will form a solid bone bridge between each vertebra and allow the spine to grow together – or fuse. The combination of the pedicle screws and the metal rods is called the instrumentation. This instrumentation forms the strut that will hold the spine in the correct alignment until the spine fuses.

Once the spine has fused, it will remain in the balanced position. The instrumentation is no longer really necessary, as the fused bone of the spine is now what is keeping the spine from collapsing again. The instrumentation is rarely removed and only removed when it is causing a problem. Restoring balance to the spine should decrease pain and reduce the risk of future problems.

Welcome to First Choice Physical Therapy’s patient resource about Lumbar Degenerative Disc Disease.

The intervertebral discs in the lower spine are commonly blamed for low back pain. Yet low back pain has many possible causes, and doctors aren’t always certain why symptoms occur.

During an office visit for low back pain, your doctor may describe how changes in the discs can lead to back pain. When talking about these changes, your doctor may use the terms degeneration or degenerative disc disease. Although the parts of the spine do change with time and in some sense degenerate, this does not mean the spine is deteriorating and that you are headed for future pain and problems. These terms are simply a starting point for describing what occurs in the spine over time, and how the changes may explain the symptoms people feel.

This guide will help you understand:

• how degenerative disc disease develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column gives the body its form. It is the body’s main upright support. The section of the spine in the lower back is known as the lumbar spine.

Lumbar Spine

An intervertebral disc sits between each pair of vertebrae. The intervertebral disc is made of connective tissue. Connective tissue is the material that holds the living cells of the body together. Most connective tissue is made of fibers of a material called collagen. These fibers help the disc withstand tension and pressure.

Lumbar Spine Anatomy

Intervertebral Disc

The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during strenuous activities that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are connective tissues that attach bones to other bones.

Two Parts of Intervertebral Disc

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

Facet Joints

Causes

Why do I have this problem?

Our intervertebral discs change with age, much like our hair turns gray. Conditions such as a major back injury or fracture can affect how the spine works, making the changes happen even faster. Daily wear and tear and certain types of vibration can also speed up degeneration in the spine. In addition, strong evidence suggests that smoking speeds up degeneration of the spine. Scientists have also found links among family members, showing that genetics play a role in how fast these changes occur.

Disc degeneration follows a predictable pattern. First, the nucleus in the center of the disc begins to lose its ability to absorb water. The disc becomes dehydrated. Then the nucleus becomes thick and fibrous, so that it looks much the same as the annulus. As a result, the nucleus isn’t able to absorb shock as well. Routine stress and strain begin to take a toll on the structures of the spine. Tears form around the annulus. The disc weakens. It starts to collapse, and the bones of the spine compress.

View animation of degeneration:

This degeneration does not always mean the disc becomes a source of pain. In fact, X-rays and MRI scans show that people with severe disc degeneration don’t always feel pain.

Pain caused by degenerative disc disease is mainly mechanical pain, meaning it comes from the parts of the spine that move during activity: the discs, ligaments, and facet joints. Movement within the weakened structures of the spine causes them to become irritated and painful.

Symptoms

What does the condition feel like?

Pain in the center of the low back is often the first symptom patients feel. It usually starts to affect patients in their twenties and thirties. Pain tends to worsen after heavy physical activity or staying in one posture for a long time. The back may also begin to feel stiff. Resting the back eases pain. At first, symptoms only last a few days.

This type of back pain often comes and goes over the years. Doctors call this recurring back pain. Each time it strikes, the pain may seem worse than the time before. Eventually the pain may spread into the buttocks or thighs, and it may take longer for the pain to subside.

Diagnosis

How do health care providers diagnose the problem?

Diagnosis begins with a complete history and physical exam. When you visit First Choice Physical Therapy, we will ask questions about your symptoms and how your problem is affecting your daily activities. Our Physical Therapist will also want to know what positions or activities make your symptoms worse or better.

Our Physical Therapist then does a physical examination by checking your posture and the amount of movement in your low back. We check to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Whenever possible, nonsurgical treatment of lumbar degenerative disc disease is preferred. The first goal of nonsurgical treatment is to ease pain and other symptoms so the patient can resume normal activities as soon as possible.

We rarely prescribe bed rest for patients with degenerative disc problems. Instead, patients are encouraged to do their normal activities using pain as a gauge for how much is too much. If symptoms are severe, a maximum of typically two days of bed rest may be prescribed.

After evaluating your condition, your Physical Therapist at First Choice Physical Therapy can assign positions and exercises to ease symptoms. Our Physical Therapist can design a personalized exercise program to improve flexibility of tight muscles, to strengthen the back and abdominal muscles, and to help you move safely and with less pain. Although recovery time varies among patients, as a guideline you may expect to work with our Physical Therapist a few times each week for four to six weeks. In some cases, patients may need a few additional weeks of care.

Our first goal of treatment is to control symptoms. Your Physical Therapist will work with you to find positions and movements that ease pain. We may use heat, cold, ultrasound, and electrical stimulation to calm pain and muscle spasm.

Our Physical Therapist may perform hands-on treatments such as massage and specialized forms of soft-tissue mobilization. These can help a patient begin moving with less pain and greater ease. Traction is also a common treatment for degenerative disc problems. Traction gently stretches the low back joints and muscles. Our Physical Therapist will instruct you on stretches that will help you move easier and with less pain.

As you recover, we will gradually advance you in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps patients move more easily and lessens the chances of future pain and problems.

A primary purpose of Physical Therapy is to help you learn how to take care of your symptoms and prevent future problems. We’ll give you a home program of exercises to continue improve flexibility, posture, endurance, and low back and abdominal strength. Our Physical Therapist will also discuss strategies you can use if your symptoms flare up.

Post-surgical Rehabilitation

Rehabilitation after surgery is more complex. Some patients leave the hospital shortly after surgery. However, some surgeries require patients to stay in the hospital for a few days.

During recovery from surgery, patients should follow their surgeon’s instructions about wearing a back brace or support belt. You should be cautious about overdoing activities in the first few weeks after surgery.

Many surgical patients need Physical Therapy outside of the hospital. Patients who’ve had lumbar fusion surgery normally need to wait up to three months before beginning a rehabilitation program. Our treatment sessions help patients build strength and learn to move and do routine activities without putting extra strain on their backs.

Although the length of First Choice Physical Therapy rehabilitation programs vary based on an individual patient’s rate of recovery, as a guideline you can expect to attend Physical Therapy sessions for eight to 12 weeks and should expect full recovery to take up to six months.

As your Physical Therapy sessions come to an end, our Physical Therapist will help you get back to the activities you enjoy.  You may need guidance on which activities are safe or how to change the way you go about your activities. Ideally, patients are able to resume normal activities.

When recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will be are in charge of doing your exercises as part of an ongoing home program.

Physician Review

Doctors rely on the history and physical exam to determine which treatments will help the most. X-rays are rarely ordered on the first doctor visit for this problem. This is because over 30 percent of low back X-rays show abnormalities from degeneration, even in people who aren’t having symptoms.

However, if symptoms are severe and aren’t going away, the doctor may order an X-ray. The test can show if one or more discs has started to collapse. It can also show if there are bone spurs in the vertebrae and facet joints. Bone spurs are small points of bone that form with degeneration.

When more information is needed, your doctor may order a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It is helpful for showing if the tissues in the disc are able to absorb water and whether there are cracks inside the disc. It can also show if there are problems in other soft tissues, such as the spinal nerves.

Discography can help with the diagnosis. This is a specialized X-ray test in which dye is injected into one or more discs. The dye is seen on X-ray and can give some information about the health of the disc or discs. This test may be done when the surgeon is considering surgery, since it can help determine which disc is causing the symptoms.

Back braces are sometimes prescribed. Keeping the moving parts of the low back still can help calm mechanical pain. When a doctor issues a brace, he or she normally asks that the patient only wear it for two to four days. This lessens the chance that the trunk muscles will shrink (atrophy) from relying on the belt.

Patients may also be prescribed medication by their physician to help them gain control of their symptoms so they can resume normal activity swiftly.

If symptoms continue to limit a person’s ability to function normally, the doctor may suggest an epidural steriod injection (ESI). Steroids are powerful anti-inflammatories, meaning they help reduce pain and swelling. In an ESI, medication is injected into the space around the lumbar nerve roots. This area is called the epidural space. Some doctors inject only a steroid. Most doctors, however, combine a steroid with a long-lasting numbing medication. Generally, an ESI is given only when other treatments aren’t working. But ESIs are not always successful in relieving pain. If they do work, they often only provide temporary relief.

Surgery

People with degenerative disc problems tend to gradually improve over time. Most do not need surgery. In fact, only one to three percent of patients with degenerative disc problems typically require surgery.

Doctors prefer to try nonsurgical treatment for a minimum of three months before considering surgery. If, after this period, nonsurgical treatment hasn’t improved symptoms, the doctor may recommend surgery. The main types of surgery for degenerative disc problems include

• lumbar laminectomy
• discectomy
• fusion

Lumbar Laminectomy

The lamina forms a roof-like structure over the back of the spinal column. When the nerves in the spinal canal are squeezed by a degenerated disc or by bone spurs pushing into the canal, a laminectomy removes most, or all of the lamina to release pressure on the spinal nerves.

Discectomy

Surgery to take out part or all of a problem disc in the low back is called discectomy. Discectomy is done when the degenerated disc has ruptured (herniated) into the spinal canal, putting pressure on the spinal nerves. Surgeons commonly perform this operation through an incision in the low back. Before the disc material can be removed, the surgeon must first remove part of the lamina. Generally, only a small piece of the lamina is chipped away to expose the problem disc. This is called laminotomy. It usually creates enough room for the surgeon to remove the disc. If more room is needed, the surgeon may need to take out a larger section of the lamina by doing a laminectomy (described above).

Many surgeons now do minimally invasive surgeries that require only small incisions in the low back. These procedures are used to remove damaged portions of the problem disc. Advocates believe that this type of surgery is easier to perform. They also believe it prevents scarring around the nerves and joints and helps patients recover more quickly. Minimally invasive surgeries include percutaneous lumbar discectomy, laser discectomy, and microdiscectomy.

Fusion

Fusion surgery joins two or more bones into one solid bone. This prevents the bones and joints from moving. The procedure is sometimes done with a discectomy. Mechanical pain is eased because the fusion holds the moving parts steady, so they can’t cause irritation and inflammation.

The main types of fusion for degenerative disc problems include

• anterior lumbar interbody fusion
• posterior lumbar fusion
• combined fusion

Anterior Lumbar Interbody Fusion

Anterior lumbar interbody fusion surgery is done through the abdomen, allowing the surgeon to work on the anterior (front) of the lumbar spine. Removing the disc (discectomy) leaves a space between the pair of vertebrae. This interbody space is filled with a bone graft. One method is to take a graft from the pelvic bone and tamp it into place. Another method involves inserting two hollow titanium screws packed with bone, called fusion cages, into the place where the disc was taken out. The bone graft inside the cages fuses with the adjacent vertebrae, forming one solid bone.

Bone Graft

Posterior Lumbar Fusion

A posterior lumbar fusion is done though an incision in the back. In this procedure, the surgeon lays small grafts of bone over the problem vertebrae. Most surgeons will also apply metal plates and screws to hold the vertebrae in place while they heal. This protects the graft so it can heal better and faster.

Metal Plates and Screws

Combined Fusion

A combined fusion involves fusing the anterior (front) and posterior (back) surfaces of the problem vertebrae. By locking the vertebrae from the front and back, some surgeons believe the graft stays solid and is prevented from collapsing. Results do show improved fusion of the graft, though patients seem to fare equally well with other methods of fusion.

Welcome to First Choice Physical Therapy’s patient resource about Lumbar Disc Herniation.

Although people often refer to a disc herniation as a slipped disc, the disc doesn’t actually slip out of place. Rather, the term herniation means that the material at the center of the disc has squeezed out of its normal space. This condition mainly affects people between 30 and 40 years old.

This guide will help you understand:

• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is formed by 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column gives the body its form. It is the body’s main upright support. The section of the spine in the lower back is known as the lumbar spine.

Vertebrae

Lumbar Spine

The lumbar spine is made up of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. These five vertebrae line up to give the low back a slight inward curve. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones. Some people have an extra, or sixth, lumbar vertebra. This condition doesn’t usually cause any particular problems.

Lumbar Spine Anatomy

Intervertebral discs separate the vertebrae. The discs are made of connective tissue. Connective tissue is the material that holds the living cells of the body together. Most connective tissue is made of fibers of a material called collagen. These fibers help the disc withstand tension and pressure.

A disc is made of  two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are connective tissues that attach bones to other bones.

Healthy discs work like shock absorbers to cushion the spine. They protect the spine against the daily pull of gravity. They also protect it during strenuous activities that put strong force on the spine, such as jumping, running, and lifting.

Causes

Why do I have this problem?

Herniation occurs when the nucleus in the center of the disc pushes out of its normal space. The nucleus presses against the annulus, causing the disc to bulge outward. Sometimes the nucleus herniates completely through the annulus and squeezes out of the disc.

Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand this pressure. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. This process is known as degeneration. Over time, the annulus weakens, and the nucleus may begin to herniate (squeeze) through the damaged annulus. At first, the pressure bulges the annulus outward. Eventually, the nucleus may herniate completely through the outer ring of the disc.

Vigorous, repetitive bending, twisting, and lifting can place abnormal pressure on the shock-absorbing nucleus of the disc. If great enough, this increased pressure can injure the annulus, leading to herniation.

A lumbar disc can also become herniated during an acute (sudden) injury. Lifting with the trunk bent forward and twisted can cause a disc herniation. A disc can also herniate from a heavy impact on the spine, such as falling from a ladder and landing in a sitting position.

Herniation causes pain from a variety of sources. It can cause mechanical pain. This is pain that comes from the parts of the spine that move during activity, such as the discs and ligaments. Pain from inflammation occurs when the nucleus squeezes through the annulus. The nucleus normally does not come in contact with the body’s blood supply. However, a tear in the annulus puts the nucleus at risk for contacting this blood supply. When the nucleus herniates into the torn annulus, the nucleus and blood supply meet, causing a reaction of the chemicals inside the nucleus. This produces inflammation and pain. A disc herniation may also put pressure against a spinal nerve. Pressure on an irritated or damaged nerve can produce pain that radiates along the nerve. This is called neurogenic pain.

Symptoms

Many cases of lumbar disc herniation result from degenerative changes in the spine. The changes that eventually lead to a disc herniation produce symptoms gradually. At first, complaints may only be dull pain centered in the low back, pain that comes and goes over a period of a few years. Doctors think this is mainly from small tears in the annulus. Larger cracks in the annulus may spread pain into the buttocks or lower limbs.

When the disc herniates completely through the annulus, it generally causes immediate symptoms, with sharp pain that starts in one hip and shoots down part or all of the leg. Commonly, patients no longer feel their usual back pain, only leg pain. This is likely because painful tension on the annulus releases when the nucleus pushes completely through.

Disc herniations produce inflammation when the nucleus comes in contact with the body’s blood supply (mentioned earlier). The inflammation can be a source of throbbing pain in the low back and may spread into one or both hips and buttocks.

A herniated disc can press against a spinal nerve, producing symptoms of nerve compression. Nerve pain follows known patterns in the lower limbs. It can be felt on the side of the upper thigh, in the calf, or even in the foot and toes.

Pressure on the nerve can also cause sensations of pins, needles, and numbness where the nerve travels down the lower limbs. If this happens, a person’s reflexes slow. The muscles controlled by the nerve weaken, and sensation in the skin where the nerve goes is impaired.

Pins, Needles, and Numbness

 

Rarely, symptoms involve changes in bowel and bladder function. A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder. The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure on the nerves can cause a loss of control in the bowels or bladder. This is an emergency. If the pressure isn’t relieved, it can lead to permanent paralysis of the bowels and bladder. This condition is called cauda equina syndrome. Doctors recommend immediate surgery to remove pressure from the nerves.

Cauda Equina Syndrome

Diagnosis

How do health care providers diagnose the problem?

Diagnosis begins with a complete history and physical exam. When you first visit First Choice Physical Therapy, we will ask questions about your symptoms and how your problem is affecting your daily activities. These will include questions about where you feel pain and whether you have numbness or weakness in your legs. Our Physical Therapist will also want to know what positions or activities make your symptoms worse or better. We rely on your report of pain to get an idea about which disc is causing problems and if a nerve is being squeezed.

Then our Physical Therapist will physically examine you to determine which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Unless your condition is causing significant problems or is rapidly getting worse, treatment for lumbar disc herniation usually begins with nonsurgical treatment. Most people with a herniated lumbar disc get better without surgery. As a result, it is usually recommended that patients try nonoperative treatments for at least six weeks before considering surgery.

At first, your Physical Therapist at First Choice Physical Therapy may want your low back immobilized. Keeping the back still for a short time can calm inflammation and pain. This might include a period of bed rest. Lying on your back can take pressure off sore discs and nerves. However, our Physical Therapists usually advise against strict bed rest and prefer their patients to do ordinary activities using pain to gauge how much is too much. In rare cases in which bed rest is prescribed, it is usually used for a maximum of two days.

A back support belt is sometimes used for patients with lumbar disc herniation. The belt can help lower pressure inside the problem disc. Our patients are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, their trunk muscles begin to rely on the belt and start to weaken and atrophy (shrink).

Our Physical Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. The first goal of our treatment is to control symptoms. Your Physical Therapist will help you find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulation may be used in the first few sessions. Lumbar traction may also be used at first to ease symptoms of lumbar disc herniation. In addition, our Physical Therapist may use hands-on treatments such as massage or spinal manipulation. These forms of treatment are mainly used to help reduce pain and inflammation so you can resume normal activity as soon as possible.

Your Physical Therapist will show you how to keep your spine safe during routine activities. You’ll learn about healthy posture and how posture relates to the future health of your spine. We will teach you about body mechanics, how the body moves and functions during activity. Our Physical Therapists teach safe body mechanics to help you protect the low back as you go about your day. This includes the use of safe positions and movements while lifting and carrying, standing and walking, and performing work duties.

The next part of our program will include a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps our patients begin moving easier and lessens the chances of future pain and problems. Aerobic exercises such as walking or swimming are used for easing pain and improving endurance.

We will work closely with your doctor and employer to help you get back on the job as quickly as reasonably possible. You may be required to do lighter duties at first, but as soon as you are able, you’ll begin doing your normal work activities. Our therapist can do a work assessment to make sure you’ll be safe to do your job. We may suggest changes that could help you work safely, with less chance of re-injuring your back.

A primary purpose of your Physical Therapy is to help you learn how to take care of your symptoms yourself and prevent future problems. We’ll provide you with a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. Our Physical Therapist will also discuss strategies you can use if your symptoms flare up.

When patients simply aren’t getting better during their therapy program, or if the problem is becoming more severe, surgery may be suggested.

Post-surgical Rehabilitation

Rehabilitation after surgery is more complex. Some patients leave the hospital shortly after surgery. However, some surgeries require patients to stay in the hospital for a few days.

During recovery from surgery, patients should follow their surgeon’s instructions about wearing a back brace or support belt, and should be cautious about overdoing activities in the first few weeks after surgery.

Although recovery time varies for each patient, as a guideline you may expect to see our therapist for one to three months, depending on the type of surgery. At first, your Physical Therapists may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm pain and muscle spasm. We provide reassurance to help you deal with fear and apprehension about pain. Then our therapist will teach you how to move safely while putting the least strain on your healing back. Exercises are used to improve flexibility, strength, and endurance.

When your recovery is well under way, your regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

X-rays are of minor help in diagnosing disc herniations. The discs don’t actually show up on X-rays. However, doctors can tell if the space between the vertebrae is smaller than normal. This can be an indication that wear and tear on one or more discs is causing problems. However, many peoples’ X-rays show degeneration of the discs. This is because degeneration in the discs is part of aging, like skin that wrinkles with time.

X-rays

Computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets doctors see slices of the body’s tissue. The image can show if a herniated disc is putting pressure on a spinal nerve.

Doctors may combine the CT scan with myelography. To do this, a special dye is injected into the space around the spinal canal, called the the subarachnoid space. When the CT scan is performed, the dye highlights the spinal cord and nerves. The dye can improve the accuracy of a standard CT scan for diagnosing a herniated disc.

When more information is needed, your doctor may order magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It gives a clear picture of the discs and whether a herniation is present. Like the CT scan, this machine creates pictures that look like slices of the area your doctor is interested in. The test does not require special dye or a needle.

Magnetic Resonance Imaging (MRI)

Doctors sometimes order a specialized X-ray test called discography. In this test, dye is injected into one or more discs. The dye is seen on X-ray and can give some information about the health of one or more discs. This test may be used when surgery is being considered to determine which disc is causing problems.

Discography

Doctors may also order electrical tests to locate more precisely which spinal nerve is being squeezed. Several tests are available to see how well the nerves are functioning, including the electromyography (EMG) test. This test measures how long it takes a muscle to work once a nerve signals it to move. The time it takes will be slower if a herniated disc has put pressure on a spinal nerve. Another test is the somatosensory evoked potential (SSEP) test. The SSEP is used to measure nerve sensations. These sensory impulses travel up the nerve, informing the body about sensations such as pain, temperature, and touch. The function of a nerve is recorded by an electrode placed over the skin in the area where the nerve travels. Doctors will often run these tests before performing surgery for a lumbar disc herniation.

Some patients who continue to have symptoms are given an epidural steriod injection (ESI). Steroids are powerful anti-inflammatories. In an ESI, medication is injected into the space around the lumbar spinal nerves where they branch off of the spinal cord. This area is called the epidural space. Some doctors inject only a steroid. Most doctors, however, combine a steroid with a long-lasting numbing medication. Generally, an ESI is given only when other treatments aren’t working. But ESIs are not always successful in relieving pain. If they do work, they often provide only temporary relief.

Epidural Steriod Injection (ESI)

Surgery

If the symptoms you feel are mild and there is no danger they’ll get worse, surgery is not usually recommended. However, if signs appear that pressure is building on the spinal nerves, surgery may be required, sometimes right away. The signs doctors watch for when reaching this decision include weakening in the leg muscles, pain that won’t ease up, and problems with the bowels or bladder.

Surgical treatment for lumbar disc herniation includes:

• laminotomy and discectomy
• microdiscectomy
• posterior lumbar fusion

Laminotomy and Discectomy

The lamina forms a roof-like structure over the back of the spinal canal. In this procedure, a thumbnail-sized piece of the lamina is removed (laminotomy) so the surgeon can more easily take out the problem disc (discectomy). This procedure is mainly used when the herniated disc is putting pressure on a nerve and causing pain to spread down one leg.

Microdiscectomy

Microdiscectomy is becoming the standard surgery for lumbar disc herniation. The procedure is used when a herniated disc is putting pressure on a nerve root. It involves carefully taking out part of the problem disc (discectomy). By performing the operation with a surgical microscope, the surgeon only needs to make a very small incision in the low back. Categorized as minimally invasive surgery, this surgery is thought to be less taxing on patients. Advocates also believe that this type of surgery is easier to perform, that it prevents scarring around the nerves and joints, and that it helps patients recover more quickly.

Posterior Lumbar Fusion

Lumbar disc herniation causes mechanical pain, the type of pain caused by wear and tear in the parts of the lumbar spine. Fusion surgery is mainly used to stop movement of the painful area by joining two or more vertebrae into one solid bone. This keeps the bones and joints from moving, easing mechanical pain.

In posterior lumbar fusion, the surgeon lays small grafts of bone over the problem area on the back of the spinal column. Most surgeons will also apply metal plates and screws to prevent the problem vertebrae from moving. This protects the graft so it can heal better and faster.

 

Welcome to First Choice Physical Therapy’s patient resource about Lumbar Facet Joint Arthritis.

Arthritis of the lumbar facet joints can be a source of significant low back pain. Aligned on the back of the spinal column, the facet joints link each vertebra together. Articular cartilage covers the surfaces where these joints meet. Like other joints in the body that are covered with articular cartilage, the lumbar facet joints can be affected by arthritis.

This article will help you understand:

• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What part of the back is involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support.

Human Spine

The back portion of the spinal column forms a bony ring. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

Facet Joints

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the bone ends to move against each other smoothly, without friction.

Articular Cartilage

Lumbar Spine Anatomy

Causes

Why do I have this problem?

Normally, the facet joints fit together snugly and glide smoothly, without pressure. If pressure builds where the joint meets, the cartilage on the joint surfaces wears off, or erodes.

Each segment in the spine has three main points of movement, the intervertebral disc and the two facet joints. Injury or problems in any one of these structures affects the other two. As a disc thins with aging and from daily wear and tear, the space between two spinal vertebrae shrinks. This causes the facet joints to press together.

Facet joints can also become arthritic due to a back injury earlier in life. Fractures, torn ligaments, and disc problems can all cause abnormal movement and alignment, putting extra stress on the surfaces of the facet joints.

The body responds to this extra pressure by developing bone spurs. As the spurs form around the edges of the facet joints, the joints become enlarged. This is called hypertrophy. Eventually, the joint surfaces become arthritic. When the articular cartilage degenerates, or wears away, the bone underneath is uncovered and rubs against bone. The joint becomes inflamed, swollen, and painful.

Animation of facet arthritis

Facet joint arthritis develops slowly over a long period of time. This is partly because spinal degeneration in later life is the main cause of facet joint arthritis. Symptoms rarely develop immediately when degeneration is causing the problems. However, rapid movements, heavy twisting, or backward motions in the low back can injure a facet joint, leading to immediate symptoms.

Symptoms

What does the condition feel like?

Pain from facet joint arthritis is usually worse after resting or sleeping. Also, bending the trunk sideways or backward usually produces pain on the same side as the arthritic facet joint. For example, if you lie on your stomach on a flat surface and raise your upper body, you hyperextend the spine. This increases pressure on the facet joints and can cause pain if there is facet joint arthritis.

Pain may be felt in the center of the low back and can spread into one or both buttocks. Sometimes the pain spreads into the thighs, but it rarely goes below the knee. Numbness and tingling, the symptoms of nerve compression, are usually not felt because facet arthritis generally causes only mechanical pain. Mechanical pain comes from abnormal movement in the spine.

However, symptoms of nerve compression can sometimes occur at the same time as the facet joint pain. The arthritis can cause bone spurs at the edges of the facet joint. These bone spurs may form in the opening where the nerve root leaves the spinal canal. This opening is called the neural foramen. If the bone spurs rub against the nerve root, the nerve can become inflamed and irritated. This nerve irritation can cause symptoms where the nerve travels. These symptoms may include numbness, tingling, slowed reflexes, and muscle weakness.

Diagnosis

How do health care providers diagnose the problem?

Diagnosis begins with a complete history and physical examination. When you visit First Choice Physical Therapy, we will ask questions about your symptoms and how your problem is affecting your daily activities. This will include questions about where you feel pain and if you have numbness or weakness in your legs. We will also want to know what positions or activities make your symptoms worse or better.

Our Physical Therapist then performs a physical exam to determine which back movements cause you pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Facet joint arthritis is mainly treated nonsurgically. At first, your Physical Therapist at First Choice Physical Therapy may prescribe a short period of rest to calm inflammation and pain. Patients may find added relief by curling up to sleep on a firm mattress or by lying on their back with their knees bent and supported. These positions take pressure off the facet joints.

By evaluating your condition, our Physical Therapist can assign positions and exercises to ease symptoms. Our Physical Therapist may recommend traction. Traction is a common treatment for this condition. It gently stretches the low back and takes pressure off the facet joints.

Although recovery time is different for each individual, as a general rule, our lumbar joint arthritis patients are normally seen a few times each week for four to six weeks. In severe and chronic cases, patients may need a few additional weeks of care.

The Physical Therapists at First Choice Physical Therapy create a personalized program to help each patient regain back movement, strength, endurance, and function. Hands-on treatments such as massage and specialized forms of soft-tissue mobilization may be used initially. We use these treatments to help patients begin moving with less pain and greater ease.

Our Physical Therapist may also prescribe strengthening and aerobic exercises. Strengthening exercises focus on improving the strength and control of the back and abdominal muscles. Aerobic exercises are used to improve heart and lung health and increase endurance in the spinal muscles. Stationary biking offers a good aerobic treatment and keeps the spine bent slightly forward, a position that gives relief to many patients with lumbar facet joint arthritis.

We will show you how to improve strength and coordination in the abdominal and low back muscles. Our Physical Therapist will also evaluate your workstation and the way you use your body when you do your activities.

Post-surgical Rehabilitaiton

Outpatient Physical Therapy, such as the programs offered at First Choice Physical Therapy, is usually prescribed only for post-surgical patients who have extra pain or show significant muscle weakness and deconditioning.

Patients usually don’t require Physical Therapy after facet rhizotomy. We may prescribe a short period of therapy when patients have lost muscle tone in their back and abdominal muscles, when they have problems controlling pain, or when they need guidance about returning to work.

Although recovery time varies, as a general rule, patients who require formal rehabilitation after facet rhizotomy will probably only need to attend sessions for two to four weeks and should expect full recovery to take up to three months.

Patients who have had lumbar fusion surgery normally need to wait at least six weeks before beginning a rehabilitation program. Again, although individuals recover at different rates, lumbar fusion patients typically need to attend therapy sessions for six to eight weeks and should expect full recovery to take up to six months.

During Physical Therapy after surgery, our therapist may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm pain and muscle spasm. Then we will teach you how to move safely with the least amount of strain on the healing back. As your First Choice Physical Therapy rehabilitation program evolves, you will do increasingly challenging exercises. Our goal is to safely improve strength and function.

As your Physical Therapy sessions contine, our therapist will help you get back to the activities you enjoy.  You may need guidance on how to change the way you go about your activities and which activities are safe. Ideally, patients are able to resume their normal activities.

When recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will be are in charge of doing your exercises as part of an ongoing home program.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

Your doctor may order X-rays to reveal if there are problems in the bone tissue in and near the facet joints. The images can show if degeneration has caused the space between the vertebrae to collapse and may show if bone spurs have developed near the facet joints.

Degeneration

When more information is needed, your doctor may order magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the facet joints to see whether they are enlarged or swollen. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require dye or a needle.

A computed tomography (CT) scan may be ordered. This is a detailed X-ray that lets your doctor see slices of bone tissue. The image can show whether the surface of the joint has eroded and whether bone spurs have developed.

A diagnostic injection may be used to locate the source of pain. The doctor uses a long needle to inject a local anesthetic (numbing medication) into either the joint or into the nerve that goes to the joint. The doctor watches the needle on a fluoroscope to make sure it reaches the correct spot. A fluoroscope is a special X-ray television that allows the doctor to see your spine and the needle as it moves. Once the doctor is sure the needle is in the right place, the medicine and a special dye are injected. The doctor watches the dye to make sure the medication is correctly placed. The results from the injection help the doctor make the diagnosis. If pain goes away, it helps confirm the source of pain.

Your doctor may prescribe anti-inflammatory medication, such as a nonsteroidal anti-inflammatory drug (NSAID) or aspirin. Muscle relaxants are occasionally used to calm muscles that are in spasm. Oral steroid medicine in tapering dosages may also be prescribed for pain.

Patients who still have pain after trying various treatments may require injections into the facet joint or the small nerves that go to the joint. An anesthetic is used to block pain coming from the facet joint. The procedure to inject the medication into the joint is similar to the diagnostic injection described earlier. A steroid medication is occasionally used instead of the anesthetic. There is no strong evidence that these injections work. However, they seem to have some good short-term results with few side effects, so they shouldn’t be abandoned completely. Doctors often have their patients resume Physical Therapy treatments following an injection.

Surgery

People with facet joint arthritis rarely need surgery. However, facet joint arthritis is a primary source of chronic low back pain about 15 percent of the time. After trying other types of treatment, some of these patients may eventually require surgery. There are several types of surgery for facet joint arthritis. The two primary operations are:

• facet rhizotomy
• posterior lumbar fusion

Facet Rhizotomy

Rhizotomy describes a surgical procedure in which a nerve is purposely cut or destroyed. Facet rhizotomy involves severing one of the small nerves that goes to the facet joint. The intent of the procedure is to stop the transmission of pain impulses along this nerve. The nerve is identified using a diagnostic injection (described earlier). Then the surgeon inserts a large, hollow needle through the tissues in the low back. A special probe is inserted through the needle, and a fluoroscope is used to guide the probe toward the nerve. The probe is slowly heated until the nerve is severed.

Posterior Lumbar Fusion

Facet joint arthritis mainly causes mechanical pain, the type of pain caused by wear and tear in the parts of the lumbar spine. Posterior lumbar fusion for facet joint arthritis is mainly used to stop movement of the painful joints by joining two or more vertebrae into one solid bone (fusion). This keeps the bones and painful facet joints from moving.

In this procedure, the surgeon lays small grafts of bone over the back of the spine. Most surgeons will also apply metal plates and screws to prevent the two vertebrae from moving. This protects the graft so it can heal better and faster.

Welcome to First Choice Physical Therapy’s patient resource about Lumbar Spinal Stenosis.

According to the North American Spine Society (NASS), spinal stenosis describes a clinical syndrome of buttock or leg pain. These symptoms may occur with or without back pain. It is a condition in which the nerves in the spinal canal are closed in, or compressed. The spinal canal is the hollow tube formed by the bones of the spinal column. Anything that causes this bony tube to shrink can squeeze the nerves inside. As a result of many years of wear and tear on the parts of the spine, the tissues nearest the spinal canal sometimes press against the nerves. This helps explain why lumbar spinal stenosis (stenosis of the low back) is a common cause of back problems in adults over 55 years old.

This guide will help you understand:

• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What part of the back is involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support.

Spinal Column

The back portion of the spinal column forms a bony ring. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This bony tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Bony Ring

Spinal Cord

The spinal cord only extends to the second lumbar (low back) vertebra. Below this level, the spinal canal encloses a bundle of nerves that go to the lower limbs and pelvic organs. The Latin term for this bundle of nerves is cauda equina, meaning horse’s tail.

Cauda Equina

An intervertebral disc fits between each vertebral body and provides a space between the spine bones. The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during heavy activities that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Two Parts of Intervertebral Disc

Lumbar Spine Anatomy

Causes

Why do I have this problem?

In the lumbar spine, the spinal canal usually has more than enough room for the spinal nerves. The canal is normally 17 to 18 millimeters around, slightly smaller than a penny. Spinal stenosis develops when the canal shrinks to 12 millimeters or less. When the size drops below 10 millimeters, severe symptoms of lumbar spinal stenosis occur.

There are many reasons why symptoms of spinal stenosis develop. Some of the more common reasons include:

• congenital stenosis (being born with a small spinal canal)
• spinal degeneration
• spinal instability
• disc herniation

Congenital stenosis: Some people are born with (congenital) a spinal canal that is narrower than normal. They may not feel problems early in life. However, having a narrow spinal canal puts them at risk for stenosis. Even a minor back injury can cause pressure against the spinal cord. People born with a narrow spinal canal often have problems later in life, because the canal tends to become narrower due to the effects of aging.

Degeneration: Degeneration is the most common cause of spinal stenosis. Wear and tear on the spine from aging and from repeated stresses and strains can cause many problems in the lumbar spine. The intervertebral disc can begin to collapse, and the space between each vertebrae shrinks. Bone spurs may form that stick into the spinal canal and reduce the space available to the spinal nerves. The ligaments that hold the vertebrae together may thicken and also push into the spinal canal. All of these conditions cause the spinal canal to narrow.

View animation of degeneration:

 

 

Spinal instability: Spinal instability can cause spinal stenosis. Spinal instability means that the bones of the spine move more than they should. Instability in the lumbar spine can develop if the supporting ligaments have been stretched or torn from a severe back injury. People with diseases that loosen their connective tissues may also have spinal instability. Whatever the cause, extra movement in the bones of the spine can lead to spinal stenosis.

Spinal Instability

 

Disc herniation: Spinal stenosis can occur when an intervertebral disc in the low back herniates (ruptures). Normally, the shock-absorbing disc is able to handle the downward pressure of gravity and the strain from daily activities. However, if the pressure on the disc is too strong, such as landing from a fall in a sitting position, the nucleus inside the disc may rupture through the outer annulus and squeeze out of the disc. This is called a disc herniation. If an intervertebral disc herniates straight backward, it can press against the nerves in the spinal canal, causing symptoms of spinal stenosis.

Disc Herniation

Symptoms

What does the spinal stenosis feel like?

Spinal stenosis usually develops slowly over a long period of time. This is because the main cause of spinal stenosis is spinal degeneration in later life. Symptoms rarely develop quickly when degeneration is the source of the problem. A severe injury or a herniated disc may cause symptoms to develop immediately.

Patients with stenosis don’t always feel back pain. Primarily, they have severe pain and weakness in their legs, usually in both legs at the same time. Some people say they feel that their legs are going to give out on them.

Symptoms mainly affect sensation in the lower limbs. Nerve pressure from stenosis can cause a feeling of pins and needles in the skin where the spinal nerves travel. Reflexes become slowed. Some patients report charley horses in their leg muscles. Others report strange sensations like water trickling down their legs.

Symptoms change with the position of the low back. Flexion (bending forward) widens the spinal canal and usually eases symptoms. That’s why people with stenosis tend to get relief when they sit down or curl up to sleep. Activities such as reaching up, standing, and walking require the spine to straighten or even extend (bend back slightly). This position of the low back makes the spinal canal smaller and often worsens symptoms.

Diagnosis

How do health care providers diagnose the problem?

Diagnosis begins with a complete history and physical examination. When you visit First Choice Physical Therapy, our Physical Therapist will ask questions about your symptoms and how your problem is affecting your daily activities. This will include questions about your pain or if you have feelings of numbness or weakness in your legs. We will also want to know whether your symptoms are worse when you’re standing up or walking and if they go away when you sit down, as this helps us to rule in or our other conditions.

Our Physical Therapist will do a physical examination to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes will also be tested. Gait analysis and other special clinical tests can also be done.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Unless your condition is causing significant problems or is rapidly getting worse, spinal stenosis is first addressed with nonsurgical treatments. Up to one-half of all patients with mild-to-moderate lumbar spinal stenosis can manage their symptoms with conservative (nonsurgical) care. Neurologic decline and paralysis in this group is rare.

When you begin Physical Therapy at First Choice Physical Therapy, we may prescribe ways to immobilize the spine. Keeping the back still for a short time can calm inflammation and pain. Patients may find that curling up to sleep or lying back with their knees bent and supported gives the greatest relief. These positions flex the spine forward, which widens the spinal canal and can ease symptoms.

We may recommend a lumbar support belt or corset, though their benefits are controversial. Lumbosacral corsets do not appear to offer any long-term benefits. The support provides symptom relief only while you are wearing it. The support can limit pressure in the discs and prevent extra movement in the spine. But it can also cause the back and abdominal muscles to weaken. Some Physical Therapists have their patients wear a rigid brace that holds the spine in a slightly flexed position, widening the spinal canal. When its use is appropriate, we may have patients wear a corset for one to two weeks.

Our Physical Therapist may also suggest using traction. Traction is a common treatment for stenosis. It gently stretches the low back, taking pressure off the spinal nerves. Hands-on treatments such as massage and specialized forms of soft-tissue mobilization may be used initially. They are used to help you begin moving with less pain and greater ease.

 

The Physical Therapists at First Choice Physical Therapy also guide patients in a program of exercise designed to widen the spinal canal and take pressure off the spinal nerves. After evaluating your condition, we can assign positions and exercises to ease your symptoms.

It is important to improve the strength and coordination in the abdominal and low back muscles. Our Physical Therapist will create a program to help you regain back movement, strength, endurance, and function. We may also suggest strengthening and aerobic exercises. Strengthening exercises focus on improving the strength and control of the back and abdominal muscles. Aerobic exercises are used to improve heart and lung health and increase endurance in the spinal muscles. Stationary biking offers a good aerobic treatment and keeps the spine bent slightly forward, a position affording relief to many patients with lumbar stenosis.

Our therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems. Although each individual recovers as a different rate, as a guideline, our lumbar stenosis patients are normally seen a few times each week for one to two months. In severe cases, patients may need a few additional weeks of care.

Post-surgical Rehabilitation

After surgery, surgeons may have their patients work with a Physical Therapist or occupational therapist. Patients who’ve had fusion surgery normally need to wait two to three months before beginning a rehabilitation program. Although recovery time is different for each person, you will probably need to attend post-surgical Physical Therapy sessions for six to eight weeks and should expect full recovery to take up to six months.

When you begin your Physical Therapy program after surgery, our Physical Therapist may use treatments such as heat or ice, electrical stimulation, and massage to help calm pain and muscle spasm. We will also instruct you in how to move safely with the least strain on your healing back.

As your rehabilitation program evolves, we will suggest increasingly challenging exercises. Our goal is to safely improve strength and function. As your Physical Therapy sessions continue, we will focus on helping you get back to the activities you enjoy. We will provide guidance on how to change the way you go about certain activities and which activities are safe. Ideally, you will be able to resume your normal activities.

When recovery is well under way, your regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Physician Review

Your physician may first order X-rays to pinpoint the cause of your discomfort. X-rays can show if the problems are from changes in the bones of the spine. The images can show if degeneration has caused the space between the vertebrae to collapse. X-rays may also reveal any bone spurs sticking into the spinal canal.

The best way to see the effects and extent of lumbar spinal stenosis is with a magnetic resonance imaging  (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the spinal canal and whether the nerves inside are being squeezed. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require dye or a needle.

Computed tomography (a CT scan) may be ordered for those patients who can’t have an MRI for some reason, when the results of the MRI are unclear, or symptoms don’t match the MRI findings. The CT scan is a detailed X-ray that lets your doctor see slices of bone tissue. The image can show any bone spurs that may be sticking into the spinal column and taking up space around the spinal nerves.

When there is a concern about neurologic problems, doctors may recommend electrodiagnostic tests of the nerves that go to the legs and feet. An electromyogram (EMG) checks whether the motor pathway of a nerve is working correctly. Motor impulses travel down the nerve and work to energize muscles.

Doctors may also order a somatosensory evoked potential (SSEP) test to locate more precisely where the spinal nerves are being squeezed. The SSEP is used to measure nerve sensations. These sensory impulses travel up the nerve, informing the body about sensations such as pain, temperature, and touch. The function of a nerve is recorded by an electrode placed over the skin in the area where the nerve travels.

Not all causes of spinal stenosis are from degenerative conditions. Doctors use blood tests to determine whether symptoms are coming from other conditions, such as arthritis or infection.

Some patients are given an epidural steroid injection (ESI). The spinal cord is covered by a material called dura. The space between the dura and the spinal column is called the epidural space. It is thought that injecting steroid medication into this space fights inflammation around the nerves, the discs, and the facet joints. This can reduce swelling and give the nerves more room inside the spinal canal.

Research shows that a single steroid injection offers only short-term relief. Multiple injections can produce long-term, lasting pain relief. Epidural injections should be given using contrast-enhanced fluoroscopy. Fluoroscopy is an imaging technique used by the surgeon to guide the needle to the right spot during the procedure. This type of imaging improves the accuracy of medication delivery.

Doctors sometimes prescribe medication for patients with spinal stenosis. Patients may be prescribed anti-inflammatory medication such as nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin. These medications can cause side effects in the kidneys and gastrointestinal tract. Also, because most stenosis patients are elderly, doctors closely monitor patients who are using these medications to avoid complications.

Narcotic drugs, such as codeine or morphine, are generally not prescribed for stenosis patients. They are addictive when used too much or improperly. Muscle relaxants are occasionally used to calm muscles in spasm.

Symptoms of stenosis can lead to mood changes. As a result, doctors sometimes prescribe anti-depressant medication, called tricyclics. Tricyclics help steady peoples’ moods, and some tricyclics even improve sleep by helping the body make an important hormone called serotonin. These medications also seem to calm back pain by affecting the membranes around pain nerves.

Surgery

If the symptoms you feel are mild and there is no danger they’ll get worse, surgery is not usually recommended. Some patients may benefit from the use of a device called the X-STOP. The X-STOP is a metal implant made of titanium. The implant is inserted through a small incision in the skin of your back. It is designed to fit between the spinous processes of the vertebrae in your lower back. It stays in place permanently without attaching to the bone or ligaments in your back.

There are several advantages of the X-STOP. It can be inserted using local anesthesia on an outpatient basis. A small incision is made so the procedure is minimally invasive and no bone or soft tissue is removed. The implant is not close to nerves or the spinal cord. With the implant in place, you won’t have to bend forward to relieve your symptoms. The X-STOP keeps the space between your spinous processes open. With the implant in place, you stand upright without pinching the nerves in your back.

But for anyone with severe symptoms of lumbar spinal stenosis, surgery may be needed. When there are signs that pressure is building on the spinal nerves, decompressive surgery may be required, sometimes right away. Decompression means that bone and/or soft tissue are removed from around the spinal nerves to take the pressure off. The signs doctors watch for when reaching this decision include weakening in the leg muscles, pain that won’t ease up, and problems with the bowels or bladder.

Pressure on the spinal nerves can cause a loss of control in the bowels or bladder. This is an emergency. If the pressure isn’t relieved, it can lead to permanent paralysis of the bowels and bladder. Surgery is recommended to remove pressure from the nerves.

The main surgical procedure used to treat spinal stenosis is lumbar laminectomy. Some patients also require fusion surgery immediately after the laminectomy procedure if spinal instability is present.

Lumbar Laminectomy

The lamina is the covering layer of the bony ring of the spinal column. It forms a roof-like structure over the back of the spinal canal. When the nerves in the spinal canal are being squeezed by a herniated disc or bone spurs, a lumbar laminectomy removes the entire lamina to release pressure on the spinal nerves. This is the primary type of surgery used for lumbar spinal stenosis.

Posterior Lumbar Fusion

A posterior lumbar fusion may be needed after a surgeon performs a lumbar laminectomy. The fusion procedure is recommended when a spinal segment has become loose or unstable.

A fusion surgery joins two or more bones into one solid bone. This keeps the bones and joints from moving. In this procedure, the surgeon lays small grafts of bone over the back of the spine. Most surgeons also apply metal plates and screws to prevent the two vertebrae from moving. This protects the graft so it can heal better and faster.

Welcome to First Choice Physical Therapy’s patient resource about Lumbar Spondylolisthesis.

Normally, the bones of the spine (the vertebrae) stand neatly stacked on top of one another. Ligaments and joints support the spine. Spondylolisthesis alters the alignment of the spine. In this condition, one of the spine bones slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful.

This article will help you understand:

• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support. The section of the spine in the lower back is called the lumbar spine.

Spinal Column

The lumbar spine is made of the lower five vertebrae. Doctors often refer to these vertebrae as L1 to L5. These five vertebrae line up to give the low back a slight inward curve. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones.

Lowest Vertebra

Each vertebra is formed by a round block of bone, called a vertebral body. A circle of bone attaches to the back of the vertebral body. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Circle of Bone Attaches to Vertebral Body

Spinal Cord

The spinal cord only extends to L2. Below this level, the spinal canal encloses a bundle of nerves that goes to the lower limbs and pelvic organs. The Latin term for this bundle of nerves is cauda equina, meaning horse’s tail.

Cauda Equina

Two sets of bones form the spinal canal’s bony ring. Two pedicle bones attach to the back of each vertebral body. Two lamina bones complete the ring. The place where the lamina and pedicle bones meet is called the pars interarticularis, or pars for short. There are two such meeting points on the back of each vertebra, one on the left and one on the right. The pars is thought to be the weakest part of the bony ring.

Bony Ring

Intervertebral discs separate the vertebral bodies. The discs normally work like shock absorbers. They protect the spine against the daily pull of gravity. They also protect the spine during strenuous activities that put strong force on the spine, such as jumping, running, and lifting.

The lumbar spine is supported by ligaments and muscles. The ligaments, which connect bones together, are arranged in layers and run in multiple directions. Thick ligaments connect the bones of the lumbar spine to the sacrum (the bone below L5) and pelvis.

Thick Ligaments

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

Facet Joints

The anatomy of the lumbar spine is often discussed in terms of spinal segments. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the facet joints that link each level of the spinal column.

Spinal Segments

Lumbar Spine Anatomy

Causes

Why do I have this problem?

Spondylolisthesis may very rarely be congenital, which means it is present at birth. It can also occur in childhood as a result of injury. In older adults, degeneration of the disc and facet (spinal) joints can lead to spondylolisthesis.

Spondylolisthesis from degeneration usually affects people over 50 years old. This condition occurs in African Americans more often than in whites. Women are affected more often than men. The effect of the female hormone estrogen on ligaments and joints is to cause laxity or looseness. The higher levels of estrogen in women may account for the greater incidence of spondylolisthesis. Degenerative spondylolisthesis mainly involves slippage of L4 over L5.

In younger patients (under 20 years old), spondylolisthesis usually involves slippage of the fifth lumbar vertebra over the top of the sacrum. There are several reasons for this. First, the connection of L5 and the sacrum forms an angle that is tilted slightly forward, mainly because the top of the sacrum slopes forward. Second, the slight inward curve of the lumbar spine creates an additional forward tilt where L5 meets the sacrum. Finally, gravity attempts to pull L5 in a forward direction.

Facet joints are small joints that connect the back of the spine together. Normally, the facet joints connecting L5 to the sacrum create a solid buttress to prevent L5 from slipping over the top of the sacrum. However, when problems exist in the disc, facet joints, or bony ring of L5, the buttress becomes ineffective. As a result, the L5 vertebra can slip forward over the top of the sacrum.

A condition called spondylolysis can lead to the slippage that happens with spondylolisthesis. Spondylolysis is a defect in the bony ring of the spinal column. It affects the pars interarticularis, mentioned earlier. This defect is most commonly thought to be a stress fracture that happens from repeated strains on the bony ring. Participants in gymnastics and football commonly suffer these strains. Spondylolysis can lead to the spine slippage when a fracture occurs on both sides of the bony ring. This slippage is called spondylolisthesis. The slippage is graded from I through IV, one being mild, IV often causing neurological symptoms. The back section of the bony ring separates from the main vertebral body, so the injured vertebra is no longer connected by bone to the one below it. In this situation, the facet joints can’t provide their normal support. The vertebra on top is then free to slip forward over the one below.

A traumatic fracture in the bony ring can lead to slippage when the fracture goes completely through both sides of the bony ring. The facet joints are no longer able to provide a buttress, allowing the vertebra with the crack in it to slip forward. This is similar to what happens when spondylolysis (mentioned earlier) occurs on both sides of the bony ring, but in this case it happens all at once.

Degenerative changes in the spine (those from wear and tear) can also lead to spondylolisthesis. The spine ages and wears over time, much like hair turns gray. These changes affect the structures that normally support healthy spine alignment. Degeneration in the disc and facet joints of a spinal segment causes the vertebrae to move more than they should. The segment becomes loose, and the added movement takes an additional toll on the structures of the spine. The disc weakens, pressing the facet joints together. Eventually, the support from the facet joints becomes ineffective, and the top vertebra slides forward.

Symptoms

What does the condition feel like?

An ache in the low back and buttock areas is the most common complaint in patients with spondylolisthesis. Pain is usually worse when standing, walking, or bending backward and may be eased by resting or bending the spine forward. Leaning on a counter top, piece of furniture, or shopping cart are common ways to alleviate (reduce) the symptoms.

Spasm is also common in the low back muscles. The hamstring muscles on the back of the thighs may become tight.

The pain can be from mechanical causes. Mechanical pain is caused by wear and tear on the parts of the spine. When the vertebra slips forward, it puts a painful strain on the disc and facet joints.

Slippage can also cause nerve compression. Nerve compression is a result of pressure on a nerve. As the spine slips forward, the nerves may be squeezed where they exit the spine. This condition also reduces space in the spinal canal where the vertebra has slipped. This can put extra pressure on the nerve tissues inside the canal. Nerve compression can cause symptoms where the nerve travels and may include numbness, tingling, slowed reflexes, and muscle weakness in the legs.

Nerve pressure on the cauda equina (mentioned earlier), the bundle of nerve roots within the lumbar spinal canal, can affect the nerves that go to the bladder and rectum. When this happens, bowel and/or bladder function can be affected. The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle.

Diagnosis

How do health care providers diagnose the problem?

Diagnosis begins with a complete history and physical exam. When you first visit First Choice Physical Therapy, we will ask questions about your symptoms and how your problem is affecting your daily activities. Our Physical Therapist will also want to know what positions or activities make your symptoms worse or better.

Next, our Physical Therapist will examine you by checking your posture and the amount of movement in your low back. We check to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Our Treatment

Non-surgical Rehabilitation

Back pain associated with spondylolisthesis will gradually improve in up to one-third of all patients. Slippage of one vertebra over the other does not increase in this group, and worsening of symptoms is not expected in patients who don’t have neurologic symptoms at the time of diagnosis.

Nonsurgical treatment for spondylolisthesis commonly involves Physical Therapy, such as that offered at First Choice Physical Therapy. Although the time required for recovery is different for each patient, our Physical Therapist may recommend that you attend Physical Therapy session a few times each week for four to six weeks. In some cases, patients may need a few additional weeks of care.

Our Physical Therapist may ask that you rest your back by limiting your activities. This is to help decrease inflammation and calm muscle spasm. You may need to take time away from sports or other strenuous activities to give your back a chance to heal.

The first goal of treatment is to control symptoms. Our Physical Therapist works with you to find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulation may be used to calm pain and muscle spasm. We will show you how to stretch tight muscles, especially the hamstring muscles on the back of the thigh.

Your Physical Therapist can assign positions and exercises to ease your symptoms. We can design a personalized exercise program to improve flexibility in your low back and hamstrings and to strengthen your back and abdominal muscles.

The use of a stationary bike can promote aerobic conditioning and puts you in the optimal position to open the spaces where the nerve roots exit. This type if exercise program can aid in reducing the painful symptoms.

If your doctor diagnoses an acute pars fracture that has the potential to heal, it may be recommended that you wear a rigid back brace for a few months. This usually occurs in children and teenagers who begin having back pain and see their doctor early on.

As you recover, our Physical Therapist will gradually advance you in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps patients move easier and lessens the chances of future pain and problems.

A primary purpose of your Physical Therapy is to help you learn how to take care of your symptoms and prevent future problems. You’ll be given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. Our Physical Therapist will also describe strategies you can use if your symptoms flare up.

Post-surgical Rehabilitation

Rehabilitation after surgery is more complex. Patients who have surgery for spondylolisthesis usually stay in the hospital for a few days afterward.

Some surgeons require patients to wear a rigid brace or cast for up to four months after fusion surgery for spondylolisthesis. Patients who’ve had fusion surgery for a severe slip may also be required to stay off their feet for a period of time.

After lumbar fusion surgery for spondylolisthesis, patients must normally wait four months before beginning our rehabilitation program. This delay is needed to give the fusion a chance to start healing. Although time required for recovery is different for each patient, First Choice Physical Therapy patients typically need to attend Physical Therapy sessions for six to eight weeks and should expect full recovery to take at least 12 months.

Ideally, our patients are eventually able to return to their previous activities. However, some patients may need to modify or discontinue certain activities to avoid future problems.

When your recovery is well under way, your regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

With cases of lumbar spondylolisthesis, doctors will usually order X-rays of the low back. The X-rays are taken with your spine in various positions. They can be used to see which vertebra is slipping and how far it has slipped.

X-rays

If more information is needed, your doctor may order computed tomography (a CT scan). This is a detailed X-ray that lets the doctor see slices of the body’s tissue. If you have nerve problems, the doctor may combine the CT scan with myelography. To do this, a special dye is injected into the space around the spinal canal, the subarachnoid space. During the CT scan, the dye highlights the spinal nerves. The dye can improve the accuracy of a standard CT scan for diagnosing the health of the nerves.

Your doctor may also order a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It can help in the diagnosis of spondylolisthesis. It can also provide information about the health of nerves and other soft tissues.

Studies have not been done yet to determine the best treatment for this condition. Conservative care is preferred, especially when the vertebra hasn’t slipped very far. Most patients with symptoms from degenerative spondylolisthesis do not need surgery and respond well to nonoperative care, such as Physical Therapy. Medications may be prescribed by your doctor to help ease pain and muscle spasm. In some cases, the patient’s condition is simply monitored to see if symptoms improve.

If your doctor diagnoses an acute pars fracture that has the potential to heal, it may be recommended that you wear a rigid back brace  for two to three months. This usually occurs in children and teenagers who begin having back pain and see their doctor early on. X-rays may show a fresh fracture of the pars area of the vertebra on one, or both, sides. A CT scan or bone scan may be recommended to determine if the fracture is likely to heal. If so, a brace is recommended. X-rays or a CT scan may be ordered in six to eight weeks to see if the fracture is healing. IF not, the brace will be discontinued.

Some patients who continue to have symptoms are given an epidural steriod injection (ESI). Steroids are powerful anti-inflammatories, meaning they reduce pain and swelling. In an ESI, medication is injected into the space around the lumbar nerve roots. This area is called the epidural space. Some doctors inject only a steroid. Most doctors, however, combine a steroid with a long-lasting numbing medication. Generally, an ESI is given only when other treatments aren’t working. But ESIs are not always successful in relieving pain. If they do work, they may only provide temporary relief.

Epidural Steriod Injection

Surgery

Surgery is used when the slip is severe and when symptoms are not relieved with nonsurgical treatments. Symptoms that cause an abnormal walking pattern, changes in bowel or bladder function, or steady worsening in nerve function require surgery. Deterioration of symptoms is common in patients with a history of significant neurologic symptoms who don’t have surgery to correct the problem.

If a reasonable trial of conservative care (three months or more) does not improve things and/or your quality of life is significantly reduced, then surgery may be the next best solution. The main types of surgery for spondylolisthesis include:

• laminectomy (decompression)
• posterior fusion with or without instrumentation
• posterior lumbar interbody fusion

Laminectomy

When the vertebra slips forward, the nearby nerves that exit the spine can become pinched or irritated. In addition, the size of the spinal canal in the problem area shrinks, placing pressure on the nerves inside the canal. To fix this, the lamina of the bony ring is removed to ease pressure on the nerves. The procedure to remove the lamina and release pressure on the nerves is called laminectomy. Decompression alone is usually not advised. Studies show much better results when the operation is combined with a fusion of the involved vertebrae (see below).

Posterior Fusion with Instrumentation

A spinal fusion is normally done immediately after laminectomy for spondylolisthesis. The fusion procedure is designed to fuse the two vertebrae into one bone and stop the slippage from worsening. The fusion is used to lock the vertebrae in place and stop movement between the vertebrae, easing mechanical pain. When combined with laminectomy surgery (mentioned earlier), fusion helps relieve nerve compression.

In this procedure, the surgeon lays small grafts of bone over the back of the problem vertebrae. Sometimes fusion is done just with bone graft material. This is a fusion without fixation (non-instrumentation). Instrumentation is the use of metal plates or screws to stabilize the segment during healing. Most surgeons combine fusion with instrumentation to prevent the two vertebrae from moving. This protects the graft so it can heal better and faster.

Outcomes are improved when decompression is combined with fusion (compared with decompression alone). Fusion and functional improvement are even better when spinal instrumentation is used. There are fewer long-term problems with pain and pseudoarthrosis (formation of movement or false joints within the fusion).

Posterior Lumbar Interbody Fusion

When fusion surgery is needed for mild spondylolisthesis (up to 50 percent slippage), posterior lumbar interbody fusion may be considered. In this procedure, the problem vertebrae are fused from the anterior (front) and posterior (back). Combining fusion of both portions of the spine increases the fusion surface area and improves the fusion rate. The surgeon works from the back of the spine and removes the disc between the problem vertebrae. Bone graft material is inserted from the back of the spine into the space between the two vertebrae where the disc was removed (the interbody space). The graft may be held in place with a special fusion cage that spreads and holds the vertebrae apart. Surgeons usually apply some form of instrumentation (described above) on the back of the vertebrae. In some cases, additional strips of bone graft are placed along the back surfaces of the vertebrae to be fused. This increases the mechanical strength of the spine.

Fusion with Biologics

New materials for fusion are being developed and tested. For example, bone morphogenetic proteins (BMP) mixed with bone graft in a putty is under investigation. This substance may help reduce the need for instrumentation with fusion.

BMP helps promote faster and more bone growth in the unstable spinal segment. Studies of safety and effectiveness of this material have been very favorable so far. Without the need to harvest bone graft and place instrumentation, surgical time is much less with BMP putty. And the fusion rate is much higher with BMP alone compared with fusion alone or fusion with fixation.

Motion-Sparing Technologies

The Food and Drug Administration (FDA) is reviewing the use of devices inserted without invasive surgery to limit vertebral motion. For example, a special titanium implant has been designed to fit between the spinous processes of the vertebrae in your lower back.

These motion-sparing devices are currently used with patients who have spinal stenosis (narrowing of the spinal canal or foramen). With spondylolisthesis, the goal is to reduce the load on the disc and facets while increasing the space inside the spinal canal and foramen, thus relieving your symptoms. The vertebral segment is stabilized enough to prevent further progression of the spondylolisthesis.