What is meant by spondylosis, spondylolysis and spondylolisthesis?
Any problem affecting the spine, to emphasize, “any problem” of the spine is referred to as spondylosis. The spinal column is made up of a number of bones stacked on each other. Each bone “catches” onto the lower bone by means of a hook.
As a developmental problem, this hook may sometimes develop a break or deficiency that is referred to as spondylolysis. As a result of this weakness, the bone on top may sometimes slip forwards over the lower one. This results in spondylolisthesis.
What are the causes of spondylolysis and spondylolisthesis?
As mentioned above spondylolysis is due to a weakness or deficiency in the “hook”. This weakness is present since birth in some individuals. At about the age of 5-6 years, this weakness gives way into a full-fledged fracture due to some kind of injury sustained while playing or doing some kinds of exercises that involve excessive backward bending of the spine. Many a times, this fracture goes unnoticed. During the adolescent growth spurt, this fracture can lead to a slip of the vertebra above over the lower one. In addition to this, sometimes this kind of slip can occur due to age-related degenerative changes in the joints of the spine. This second kind of presentation is commonly seen in ladies above the age of 40-50 years.
How do spondylolysis and spondylolisthesis manifest?
In the younger age group, these problems may lead to predominant low back pain. This low back pain is often most pronounced during activities that involve backward bending of the spine. Additionally, in severe cases of spondylolisthesis, there may be a foreshortening of the trunk with the development of a deep transverse crease over the lower abdomen along with an abnormal walking pattern. Sometimes, because of this slip, the spinal nerves may be affected leading to some tingling numbness or weakness in the lower limbs or sometimes, even disturbance in urination. In pregnant females, it can lead to obstruction of child delivery. In the older age group, though there may be some back pain, the predominant complaint often relates to pain in the lower limbs particularly on standing or walking for some distance.
How does the doctor diagnose spondylolysis and spondylolisthesis?
An accurate history is the most important diagnostic tool. The way the pain started and progressed; specific aggravating and relieving factors of pain; distribution of pain over your body, associated complaints such as weakness or numbness over the lower limbs will be a guide to short listing the possible causes of your low back pain.
A detailed clinical examination involving assessment of spinal motion, assessment of your neurology and certain special tests will allow to further narrow down the causes to 2-3 most probable ones.
Though this process of history-taking and clinical examination may appear boring and long-drawn, it is the most crucial part towards prescribing the correct treatment to you. So, it is essential to cooperate with your doctor throughout this entire procedure, which gives more information to the doctor regarding your ailment than any other investigation on earth.
How does the doctor investigate for spondylolysis and spondylolisthesis?
Commonly, plain x-rays of the spine may be ordered with or without some basic blood investigations such as hemoglobin, erythrocyte sedimentation rate [ESR], CRP, RA test, serum calcium, phosphorus and alkaline phosphatase. Additionally, dynamic views may be asked for to document the presence of any abnormal mobility of the spine at the level of the spondylolysis or spondylolisthesis. These are views taken when you would be asked to bend forwards as much as possible and then, to bend backwards as much as possible. In cases of spondylolysis, oblique views may be asked for so as to better delineate the bony deficiencies.
Based on these tests, or sometimes, in the presence of some very significant signs or symptoms, you may be asked to undergo MRI scanning. Plain x-rays demonstrate bony features; while MRI demonstrates the spinal cord, its nerve roots, the intervertebral disc between the two bones of the spine. Both these tests are complimentary in nature; doing one does not necessarily mean that the other one is not needed.
Occasionally, in cases of spondylolysis, a CT scan may be ordered to better delineate the bony defect.
In some cases such as peripheral neuropathy, additional investigation in the form of EMG-NCV test, to assess the function of each of the various nerves in your limbs may be required.
Rarely, a bone scan or a SPECT scan may be asked for.
Is there any nonsurgical treatment for spondylolysis and spondylolisthesis?
The treatment would depend on the duration of your problem, whether your pain is purely localized to the lower back or whether it radiates down to the lower limbs, neurological function, response to previous nonoperative treatment and lastly, the subjective severity of your pain. Various nonoperative means of treatment include bed rest, painkillers, muscle relaxants, various modalities such as heat and electrical stimulation, activity restrictions, etc.
For cases of spondylolysis, complete bed rest is helpful. For spondylolisthesis however, complete bed rest may not really be effective. How should you sleep? You should sleep on your side, either right or left, whichever is comfortable, with a pillow in between your legs. What kind of bed should you sleep on? A cotton mattress is ideal! No need to sleep on hard beds, nor do you need to fall for any kind of so-called “spine-friendly” expensive mattresses sold out in the market! This bed rest should be for a period of 2-3 days. During this period, you should eat, drink and sleep in the bed. Only sponge bath is allowed. Ideally, you should not get up even to visit the washroom; you should use a bedpan or urine-pot. However, if this is too much of an inconvenience, you may be allowed to get up to use the washroom alone. How long should you take bed rest? If the pain has to respond to bed rest, it will do so within 2-3 days; continuing beyond this much time only further weakens your spinal muscles without really decreasing your pain; in other words, beyond 2-3 days, complete bed rest will do more harm than good to your back.
Painkillers will be prescribed to allow a smoother and easier return to normal function. You would generally be prescribed these on a shorter term or on a longer-term tapering program so as to guard against possible over dependence on these agents, as these are associated with significant side effects if used excessively in the long term. These side effects may range from hyperacidity, gastric ulcer, kidney damage, bleeding disorders, constipation, addiction, etc. In addition, based on individual merit, you may also be prescribed muscle relaxants so as to relax and soothe your back muscles. This is so because whenever you have back pain, your muscles tend to go into spasm [sustained contraction] and hence, lead to pain. It is essential to break this spasm with a muscle relaxant so as to give effective pain relief.
Physiotherapy modalities may be used. This consists broadly of passive and active physiotherapy. During acute pain, generally, only passive physiotherapy would be used. This would be in the form of heat in various forms or electrical stimulation in various forms such as SWD [short-wave diathermy], TENS [transcutaneous electrical nerve stimulation] and IFT [interference therapy]. After pain relief, you would be prescribed active physiotherapy i.e., spinal flexion exercises. This exercise protocol is the most effective tool in the nonoperative treatment of this problem.
Though complete bed rest would be prescribed only for 2-3 days, you would need to have some activity restrictions to help your spine get back into shape and stay that way!! You would not be allowed to bend your spine backwards or get involved in sports that lead to such a kind of movement such as gymnastics, fast bowling in cricket, soccer, golf, etc. These restrictions would be generally enforced for a minimum period of about one month. Smoking would be forbidden lifelong! You may be prescribed a brace for a short period of time. This brace would generally need to be worn at all times other than while lying down.
When is surgery essential for spondylolysis and spondylolisthesis?
Surgery would be necessary if the pain keeps recurring despite all the above-mentioned treatment. Additionally, if there is significant neurological deficit, significant slippage of >50% of one vertebra over the other one, significant cosmetic deformity, gait disturbances or pain in the leg, surgery would be essential. In all these situations, surgery would become a “no-choice” situation, i.e. the last and final resort. If there were a weed growing on the wall, repeated attempts to remove the top portion would only lead to recurrence of the growth of the weed unless the roots themselves are removed! Surgery is the only mode of tackling this problem of spondylolysis and spondylolisthesis at its roots!
What is the nature of surgery?
Surgery in spondylolysis may involve repair of the bony hook by putting a screw across the defect. For spondylolisthesis, surgery would involve fusing the involved area by inserting screws and rods so as to block the abnormal movement occurring there. In cases of leg pain, decompression of the nerves that supply the leg would also be carried out.
Is it a safe surgery?
The option for surgery would be offered only if the benefits of surgery significantly outweigh the risks. Rather than asking as to what are the risks of going in for surgery, it would be more prudent to ask as to what are the risks and benefits of getting the surgery done as compared to not getting the surgery done? Spine surgery has had a lot of advances in the past decade or two; there are better imaging facilities like MRI, better surgical instruments, surgical microscope to aid vision in the surgery, computer navigation system to further increase the safety level of surgery, better training and information in an overall sense making spine surgery no longer the taboo that it once was! So, if you have a problem that genuinely requires surgery, there is no point in tying yourself down to the bed for days or months on end; because ultimately life is mobility and mobility is life! Discuss the details of your surgery and its attendant risks with your doctor to quell any fears and to clear any and every doubt of yours! If you so desire, your doctor can even arrange to give you references of patients who have undergone similar surgeries.
How is the postoperative recovery and rehabilitation?
Generally, you would be admitted one day prior to the day of surgery. You would be advised to stay starving after dinner the previous night. Surgery would generally be carried out the next day morning. After surgery, on the 2nd-3rd day, you would be made to walk with a lumbosacral belt. You may be discharged after 4-5 days. Sutures [stitches] would be removed generally on the 10th-14th day following the surgery. By this time, you would be walking around and essentially be independent in doing activities of daily life. You would be allowed to take bath 48 hours after the suture removal. For 3-4 weeks, you would be allowed restricted mobilization within the house. During this period, you would be encouraged to increase all your activities in gradual weekly increments. 3 months later, you would be started on spinal strengthening exercises. 6 months later, you would be started on spinal stretching exercises. For 6 months at least, you would not be allowed to bend forwards, lift up weights, travel on 2-wheelers/ auto rickshaws/ jeeps, sit on the floor, or use Indian type of toilet commode. You would have to use the lumbosacral belt for 3-6 months at all times other than lying down and while taking bath. Thereafter, the belt would gradually need to be weaned off. Towards this end, you would have to take off the belt for 2 hours in the day time in the first week, for 4 hours in the day time in the second week, for 6 hours in the third week and so on. You would not be allowed to smoke for lifelong!
Will I be able to return back to work after the surgery?
Though you would be up and about, walking about within the first ten days following the surgery, you would be allowed only limited mobilization within the house in the first one month following surgery. Thereafter, if you are having a sedentary light job, then you may be allowed to resume work, provided you do not have to travel for a prolonged time on some bumpy road(s). If you were having some job that required some moderate labor, you would be allowed to resume work about three months after surgery. If you were involved in heavy manual labor, it would be wiser to seek some permanent job modification in these situations. Staying off work for more than three months post-surgery is not recommended at all.