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Spine

Description

Low back pain is one of the most common afflictions in our society. Almost every person will have at least one episode of low back pain at some time in his or her life. The pain can vary from severe and long term to mild and short lived. It will resolve within a few weeks for most people.

The low back (lumbar spine) is made up of five bones (vertebrae). The lumbar discs are between these bones in the front of the spine. They function as shock absorbers and allow for motion of the lumbar spine. Behind the discs is the spinal canal (see Figures 1 and 2).

The spinal nerves run through this area and exit at each level of the spine. They are enclosed within the meninges, often referred to as the dural sac. The dural sac allows for the spinal nerves to travel through this area and stay within the spinal fluid. The lamina and the facet joints make up the back of the spinal canal. The lamina is a relatively flat area of bone that covers most of the back of the spinal canal. The facet (also called zygoapophyseal or Z) joints are more to the side in back, and also allow for motion of the lumbar spine. They connect each vertebra to the one above and below it. Sticking backward from the lamina at each level of the spine is the spinous process. These are the bones that can be felt when you touch your back. The discs and nerves are too deep to be felt. The spinous processes function as an attachment point for a number of muscles. Many muscle groups surround the spine. They function to move and support the spine.

Cause

Doctors have many ideas about what causes low back pain, but no explanation applies to everyone. It may be related to damage to or aging of the disc, muscular problems, arthritis of the spine, problems with tendons or ligaments in and around the spine or malpositioning of vertebrae. Low back pain is sometimes caused by:

Occasionally, it happens with no cause.

Diagnosis

See your doctor to diagnose low back pain. Tell him or her your complete medical history. The doctor will examine you physically. Often the physical exam is completely normal except for pain with motion. The doctor checks for:

If you have short-term (acute) back pain, the doctor may not order X-rays or other imaging studies; these are not likely to help in diagnosis or treatment. When X-rays are used, they are often normal or they show an abnormality that may or may not be related the pain. (For instance, it is very common to see some disc degeneration in X-rays of people with back pain. But it is also very common to see it in people who do not have back pain. It is difficult to tell whether the degeneration is actually the cause of the pain.) The same is true for magnetic resonance imaging (MRI) and computed tomography (CT) scans.

X-rays and other studies are more likely to be helpful when low back pain does not get better on its own after a few weeks or a person has evidence of more severe problems. Tell the doctor if you have a history of a previous cancer, fevers or chills that might be caused by an infection or a significant trauma like a fall or car accident that might have caused a fracture. Significant weakness on physical examination could also indicate problems. If a person is having trouble controlling their urine or bowels, the doctor will usually order X-rays and other studies more quickly.

The main purpose of X-rays is to look for an explanation for the pain. There are many findings that are considered to be nonspecific (they may or may not be related to the pain). Some of these non specific findings are disc space narrowing, spurring, spina bifida oculta (incomplete formation of the lamina and spinous process), mild scoliosis and a decrease in lumbar lordosis. Lumbar lordosis is the normal curvature of the spine when viewed from the side. When viewed from the front, the spine is normally straight. Discs are not visible on x ray, only the disc spaces.

MRI (magnetic resonance imaging) is often the next imaging test ordered if the physician feels it is indicated. With MRI the doctor can see the discs and the nerves. He or she can see the level of degeneration of the discs and whether there is any material that has gone outside of the normal confines of the disc (herniation). MRI is also very good at showing infections, tumors and fractures. Although an MRI can sometimes help the doctor determine the source of a back problem, it also often shows nonspecific findings.

The doctor may also order CT scans which are similar to three dimensional X-rays, bone scans to look for areas of possible infection, tumor or fracture and tests to see how well nerves in the arms and legs conduct electrical signals (EMG/NCV tests). If osteoporosis is a concern, bone density studies may be ordered as well. Osteoporosis by itself should not cause back pain, but fractures due to osteoporosis can.

Risk Factors/Prevention

Low back pain can happen after an injury, especially if there is a fracture of the spine. Some other factors associated with low back pain are smoking and long term exposure to vibration. Obesity may also be related. Factors such as posture, the type of work one does, diet and amount of exercise are not closely related to low back pain.

Doctors do not know why some people with acute back pain go on to suffer from long term (chronic) low back pain. They also don't know why some people go on to feel quite well between episodes of severe pain.

Symptoms

The symptoms of low back pain vary in some ways and are similar in others. Most people find that reclining or lying down will improve their pain and after their initial severe episode, many will be able to rest at night without severe pain. Most people are worse when they bend over to pick something up. Some get relief from arching backward (extending the back). Leg pain also can be part of the problem. The pain is most common in the back or outer side of the thigh, and can go all the way to the foot. Pain that goes to the foot is called sciatica because it is pain that follows the course of the sciatic nerve. Sciatica is often made worse by coughing or sneezing.

With an acute episode, back pain can be very severe for a few days or a week, and then will often improve. By 2 weeks to 4 weeks, the large majority of people are much better. Individuals vary greatly in length of time between episodes, length of each episode and intensity of each episode, and how they cope with the pain.

Treatment Options

Treatments for back pain are multiple and varied. At times counseling and education about the problem to ease a person's anxiety is enough to make it tolerable until the episode resolves. A few days of rest can often calm the pain down as well. Prolonged bed rest (more than 2 days to 3 days) is no longer generally recommended. Medications such as non steroidal anti inflammatory drugs (NSAIDS) or acetaminophen (Tylenol) can be helpful. Occasionally stronger medications such as muscle relaxants and narcotics are used for a short period.

Although there is minimal scientific evidence of their effectiveness in treating low back pain, back braces are commonly used. Most common is a corset type brace that can be wrapped around the back and abdomen. People who use them sometimes report feeling better supported and more comfortable. Although there is little definite proof that they help, there is also little risk to using them.

A number of treatments called passive modalities are also used frequently. These are treatments in which the patient isn't required to actively do anything. Passive modalities include heat, cold, massage, ultrasound, electrical stimulation, traction and acupuncture. All of these measures can help some people with back pain. How long the benefit will be or what the chances are of receiving benefit from any of these treatments isn't completely known.

Another form of passive treatment is spinal manipulation. There are many different practitioners of spinal manipulation, each with their own style of manipulation. This has also at times improved symptoms of back pain.

Injections are sometimes used as well. The most commonly used medications are local anesthetic and/or steroids. They are usually given either in the area that is felt to possibly be the source of the pain, such as in to a muscle or facet joint, or around the nerves of the spine (an epidural or nerve root injection). Injections are occasionally placed into the disc, but this is done far less frequently.

The next more invasive type of procedure that is done for low back pain is the procedure aimed at removing or destroying the area that is felt to be causing the pain. Some examples of this are intra discal electrothermy (IDET) in which a coiled wire is placed in to the disc and then heated, and radiofrequency ablation (RFA). These are more invasive and because they do damage tissue, have higher risk and potential for longer-term side effects than the other treatments. If successful, they can help a person avoid a larger surgery, but there is still controversy over exactly when and to whom these procedures should be offered.

What is generally felt to be most appropriate and effective for most people with back pain is a good course of exercise and stretching. Restoring motion and strength to a painful lumbar spine can be very helpful at improving pain. Although there is controversy as to what are the best spine exercises, it is generally agreed that exercise should be both aerobic (aimed at improving heart and lung function) as well as specific to the spine. Aerobic exercises include walking, jogging, swimming, bicycling etc.

Instruction in lifting techniques can be helpful as well. Improperly bending over to lift can cause a large increase in strain on the low back. Proper lifting keeps the back straight while you bend with the knees.

Treatment Options: Surgical

Indications for surgery: Surgery for low back pain should only be performed when a number of conditions have been met. The first is that nonsurgical treatment options have been tried and have failed. Surgery should not be done if an exercise program is effective but the person does not want to do it. The second condition is that the surgeon feels there is enough possibility that the individual patient will have a good chance of having a successful result with surgery. An example of this would be a person with severe degeneration at one level of their spine and normal findings at the other levels. Another factor that goes along with this is that low back pain, like many other pain problems, can be worse during times of stress. It may not be a good idea to commit to an operation like this when there are other major stressful events going on in one's life. Occasionally, the back problem can become more tolerable once the stress is reduced. The final factor is that the patient must decide if they are having enough of a problem to undergo an invasive procedure that is not guaranteed to work.

Surgical options: Historically, the most commonly performed operation for back pain has been spinal fusion. There are a variety of ways this is done but the basic idea is to take the painful segment of the spine and get it to become a solid piece of bone. This will eliminate motion and, in theory at least, if it doesn't move, it shouldn't hurt. This can be done through the back (posterior) or through the front (anterior), or sometimes both ways. Spinal fixation of some sort is often combined with some form of bone graft or bone substitute. Bone graft can either be obtained from another part of the skeleton such as the pelvis (autograft) or be donated bone that is processed and used in a spine fusion (allograft). The results of spine fusion for low back pain vary. A good result is a decrease in pain. It is very rare for someone to be completely out of pain after a spine fusion. Full recovery can take more than a year.

A newer technique that has recently been introduced in to the United States is disc replacement. The procedure involves removing the disc and replacing it with artificial components, similar to what is done in the hip or the knee. Doing this lets the segment of the spine keep some flexibility and hopefully maintain more normal motion. The recovery time may be shorter than with spine fusion because the bone does not have to solidify. Although it has been used in Europe for a number of years, it has only recently been used in the United States. Early results are promising.

Currently disc replacements are done through an anterior approach and are primarily done on the lower two discs of the lumbar spine.

Research on the Horizon/What's New?

A great deal of research is being performed to help doctors understand and treat low back pain. Some of the more exciting research includes new forms of disc replacement that someday may be injectable, and research into gene therapy that may someday allow doctors to alter the aging process of the spine.

Scoliosis

What is scoliosis?

Everyone's spine has natural curves. These curves round our shoulders and make our lower back curve slightly inward. But some people have spines that also curve from side to side. Unlike poor posture, these curves can't be corrected simply by learning to stand up straight.

This condition of side-to-side spinal curves is called scoliosis. On an X-ray, the spine of an individual with scoliosis looks more like an "S" or a "C" than a straight line. Some of the bones in a scoliotic spine also may have rotated slightly, making the person's waist or shoulders appear uneven.

Who gets scoliosis?

Scoliosis affects a small percentage of the population, approximately 2 percent. However, scoliosis runs in families. If someone in a family has scoliosis, the likelihood of an incidence is much higher - approximately 20 percent. If anyone in your family has curvature of the spine, you should be examined for scoliosis.

Children - The vast majority of scoliosis is "idiopathic," meaning its cause is unknown. It usually develops in middle or late childhood, before puberty, and is seen more often in girls than boys. Though scoliosis can occur in children with cerebral palsy, muscular dystrophy, spinal bifida and other miscellaneous conditions, most scoliosis is found in otherwise healthy youngsters.

Adults - Scoliosis usually develops during childhood, but it also can occur in adults. Adult scoliosis may represent the progression of a condition that actually began in childhood, and was not diagnosed or treated while the person was still growing. What might have started out as a slight or moderate curve has progressed in the absence of treatment.

In other instances, adult scoliosis can be caused by the degenerative changes of the spine. Other spinal deformities such as kyphosis or round back are associated with the common problem of osteoporosis (bone softening) involving the elderly. As more and more people reach old age in the U.S., the incidence of scoliosis and kyphosis is expected to increase.

If allowed to progress, in severe cases adult scoliosis can lead to chronic severe back pain, deformity, and difficulty in breathing.

The importance of early detection - tips for parents

Idiopathic scoliosis can go unnoticed in a child because it is rarely painful in the formative years. Therefore, parents should watch for the following "tip-offs" to scoliosis beginning when their child is about 8 years of age:

Any one of these signs warrants an examination by the family physician, pediatrician or orthopaedist.

Some schools sponsor scoliosis screenings. Although only a physician can accurately diagnose scoliosis, school screenings can help alert parents to the presence of its warning signs in their child.

Treatment

In planning treatment for each child, an orthopaedist will carefully consider a variety of factors, including the history of scoliosis in the family, the age at which the curve began, the curve's location and severity of the curve.

Most spine curves in children with scoliosis will remain small and need only to be watched by an orthopaedist for any sign of progression. If a curve does progress, an orthopaedic brace can be used to prevent it from getting worse. Children undergoing treatment with orthopaedic braces can continue to participate in the full range of physical and social activities.

Electrical muscle stimulation, exercise programs, and manipulation have not been found to be effective treatments for scoliosis.

If a scoliotic curve is severe when it is first seen, or if treatment with a brace does not control the curve, surgery may be necessary. In these cases, surgery has been found to be a highly effective and safe treatment.

Summary

Scoliosis is a common problem that usually requires only observation with repeated examination in the growing years. Early detection is important to make sure the curve does not progress. In the relatively small number of cases that need medical intervention, advances in modern orthopaedic techniques have made scoliosis a highly manageable condition. Orthopaedists, specialists in diseases of the muscles and skeleton, are the most knowledgeable and qualified group of physicians to diagnose, monitor and treat this condition.

Your orthopaedist is a medical doctor with extensive training in the diagnosis, and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.

This brochure has been prepared by the American Academy of Orthopaedic Surgeons, in cooperation with the Scoliosis Research Society (SRS), and is intended to contain current information on the subject from recognized authorities. However, it does not represent official policy of the Academy and SRS and its text should not be construed as excluding other acceptable viewpoints.

Herniated Disk / Slipped Disc

Description

You've probably heard people say they have a "slipped" or "ruptured" disk in their neck or lower back. What they're actually describing is a herniated disk, a common source of neck, or lower back and arm or leg pain.

Disks are soft, rubbery pads found between the hard bones (vertebrae) that make up the spinal column. In the middle of the spinal column is the spinal canal-a hollow space that contains the spinal cord and other nerve roots. The disks between the vertebrae allow the back to flex or bend. Disks also act as shock absorbers.

Disks in the lumbar spine (low back) are composed of a thick outer ring of cartilage (annulus) and an inner gel-like substance (nucleus). In the cervical spine (neck), the disks are similar but smaller in size. A helpful comparison is a jelly donut: its thick outer portion represents the annulus, while the jelly is similar to the nucleus.

A disk herniates or ruptures when part of the center nucleus pushes through the outer edge of the disk. To continue with the donut analogy, the jelly pushes backwards toward the spinal canal. This puts pressure on the nerves. Spinal nerves are very sensitive to even slight amounts of pressure. Pain, numbness or weakness may occur in one or both legs.

Risk Factors/Prevention

In children and young adults, disks have high water content. As people age, the water content in the disks decreases. They become less flexible. The disks begin to shrink. The spaces between the vertebrae get narrower. The disk itself becomes less flexible. Conditions that can weaken the disk include:

Lower Back: Low back pain affects four out of five people. Pain alone isn't enough to recognize a herniated disk. See your doctor if back pain results from a fall or a blow to your back. The most common symptom of a herniated disk is sciatica-a sharp, often shooting pain that extends from the buttocks down the back of one leg. It is caused by pressure on the spinal nerve. Other symptoms include:

 

Neck: Like pain in the lower back, neck pain is also common. When pressure is placed on a nerve in the neck, it causes pain in the muscles between your neck and shoulder (trapezial muscles). The pain may shoot down the arm. Sometimes the pain causes headaches in the back of the head. Other symptoms include:

Diagnosis

To diagnose a herniated disk, give the doctor your complete medical history. Tell him or her if you have neck/back pain with gradually increasing arm/leg pain. Tell the doctor if you were injured. The doctor will physically examine you. This can determine which nerve roots are affected (and how seriously). A simple X-ray may show evidence of disk or degenerative spine changes.

MRI (magnetic resonance imaging) or CT (computed tomography) scans (imaging tests to confirm which disk is injured) or an EMG (a test that measures nerve impulses to the muscles) may be recommended if pain continues.

Treatment Options

Conservative treatment is effective in treating symptoms of herniated disks in more than 90 percent of patients. Most neck or back pain will resolve gradually with simple measures.

Any physical activity should be slow and controlled, especially bending forward and lifting. This can help ensure that symptoms do not return. Take short walks and avoid sitting for long periods. For the lower back, exercises may also be helpful in strengthening back and abdominal muscles. For the neck, exercises or traction may also be helpful. It's essential that you learn how to properly stand, sit and lift. This can help you avoid future episodes of pain.

Treatment Options: Surgical

If conservative treatment fails, epidural injections of a cortisone-like drug may lessen nerve irritation and allow better participation in physical therapy. These shots are given on an outpatient basis over a period of weeks.

Surgery may be required if a disk fragment lodges in the spinal canal and presses on a nerve, causing significant loss of function. Surgical options in the lower back include microdiskectomy or laminectomy depending on the size and position of the disk herniation. In the neck, an anterior cervical discectomy and fusion is usually recommended. This involves removing the entire disk to take the pressure off the spinal cord and nerve roots. Bone is placed in the disc space and a metal plate may be used to stabilize the spine. On occasion, a smaller surgery may be performed on the back of the neck that does not require fusing the bones together. Each of these surgeries is performed under general anesthesia. It may be performed as an outpatient or require an overnight hospital stay. You should be able to return to work in two to six weeks.

Kyphosis (Curvature of the Spine)

Description

Few things bother parents more than their child's posture. This is particularly true for an exaggerated rounding to the back. Some degree of curvature to the spine is normal. The term "kyphosis" (kI-fO-sis) is usually applied to the curve that results in an exaggerated "round-back." A variety of disorders may be responsible for this condition. Several are listed below.

Usually, a visit to the doctor is brought on by a scoliosis screening at school, concern about the cosmetic deformity of a rounded back or pain combined with poor posture. The doctor may ask the child to bend forward so that he or she can see the slope of the spine. X-rays of the spine will show if there are any bony abnormalities. X-rays will also let the doctor measure the degree of the kyphotic curve. Any kyphotic curve that is more than 50 degrees is considered abnormal.

Types of kyphosis

Postural kyphosis. Postural kyphosis is the most common type. It is often attributed to "slouching." It represents an exaggerated, but flexible, increase of the natural curve of the spine. This usually becomes noticeable during adolescence. It is more common among girls than boys. It rarely causes pain. Exercises to strengthen the abdomen and stretch the hamstrings may help take away associated discomfort. But exercises probably won't result in significant correction of the postural kyphosis. This condition does not lead to problems in adult life.

Scheuermann's kyphosis. Scheuermann's (shoe-er-mans) kyphosis is named after the Danish radiologist who first described the condition. Like postural kyphosis, it often becomes apparent during the teen years. However, Scheuermann's kyphosis will present with a significantly worse cosmetic deformity. This is particularly the case in thin individuals. Scheuermann's kyphosis usually affects the upper (thoracic) spine. It can also occur in the lower (lumbar) back area. If pain is present, it is usually felt at the apex of the curve. Activity can aggravate the pain. So can long periods of standing or sitting. Exercises and anti-inflammatory medication help ease the discomfort. When X-rays are examined, the vertebrae and disks will appear normal in postural kyphosis. But they are irregular and wedge-shaped in Scheuermann's kyphosis.

Congenital kyphosis. In some infants, the spinal column does not develop properly while the fetus is still in the womb. The bones may not form as they should. Several vertebrae may be fused together. Either of these abnormal situations may cause progressive kyphosis as the child grows. Surgical treatment may be needed at a very young age. This can maintain a more normal spinal curve. Consistent follow-up is required to monitor any changes.

Treatment Options

Treatment will depend on the reason for the deformity. Most teens with postural kyphosis will do well throughout life. In some, their posture may improve over time. An exercise program may help with back pain, if present.

An initial program of conservative treatment is also recommended for patients with Scheuermann's kyphosis. This includes exercises and anti-inflammatory medications. If the child is still growing, the doctor may prescribe a brace. The child wears the brace until skeletal maturity is reached.

Treatment Options: Surgical

Surgery may be recommended if the kyphotic curve exceeds 75 degrees. The goals of surgery are:

Sciatica / radiculopathy

If you suddenly start feeling pain in your lower back or hip that radiates down from your buttock to the back of one thigh and into your leg, your problem may be a protruding disk in your lower spinal column pressing on the roots to your sciatic nerve. Sciatica (lumbar radiculopathy) may feel like a bad leg cramp that lasts for weeks before it goes away. You may have pain, especially when you sit, sneeze or cough. You may also feel weakness, "pins and needles" numbness, or a burning or tingling sensation down your leg. See a doctor to have your condition diagnosed and start a course of treatment.

You're most likely to get sciatica when you're 30-50 years old. It may happen due to the effects of general wear and tear, plus any sudden pressure on the disks that cushion the vertebrae of your lower (lumbar) spine. The gel-like inside (nucleus) of a disk may protrude into or through the disk's outer lining (annulus). This herniated disk may press directly on nerve roots that become the sciatic nerve. The nerve may also get inflamed and irritated by chemicals from the disk's nucleus. About one in every 50 people experience a herniated disk. Of these, 10-25 percent have symptoms lasting more than six weeks. About 80-90 percent of people with sciatica get better, over time, without surgery.

Treatment

The condition usually heals itself if you give it enough time and rest. Tell your doctor how your pain started, where it travels and exactly what it feels like. A physical exam may help pinpoint the irritated nerve root. Your doctor may ask you to squat and rise, walk on your heels and toes or perform a straight leg raising test or other tests. Most cases of sciatica affect the L5 or S1 nerve roots. Later, X-rays and other specialized imaging tools such as MRI (magnetic resonance imaging) may confirm your doctor's diagnosis of which nerve roots are affected.

Treatment is aimed at helping you manage your pain without long-term use of medications. First, you'll probably need at least a few days of bed rest while the inflammation goes away. Nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen, aspirin or muscle relaxants may also help. You may find it soothing to put gentle heat or cold on your painful muscles. Find positions that are comfortable, but be as active as possible. Motion helps to reduce inflammation. Most of the time, your condition will get better within a few weeks. Sometimes, your doctor may inject your spine area with a cortisone-like drug. As soon as possible, start physical therapy with stretching exercises to help you resume your physical activities without sciatica pain. To start, your doctor may want you to take short walks.

You might need surgery only if after 3 months or more of treatment you still have disabling leg pain. A part of the herniated disk may be removed to stop it from pressing on your nerve. The surgery (laminotomy) may be done under local, spinal or general anesthesia. You have a 90 percent chance of successful surgery if most of your pain is in your leg. Avoid driving, excessive sitting, lifting or bending forward for at least a month after surgery. Your doctor may give you exercises to strengthen your back.

Following treatment for sciatica, you will probably be able to resume your normal lifestyle and keep your pain under control. However, it's always possible for your disk to rupture again. This happens to about 5 percent of people with sciatica.

Emergency situation

In rare cases, a herniated disk may press on nerves that cause you to lose control of your bladder or bowel. If this happens, you may also have numbness or tingling in your groin or genital area. This is an emergency situation that requires surgery. Phone your doctor immediately.

Spinal Stenosis

Back aches and pains are a health concern for millions of people. Nearly 29 million Americans saw their doctors because of back and low back pain in 2002. There may be many reasons for backaches and pains. One cause could be spinal stenosis.

Stenosis means narrowing. In spinal stenosis, the spinal canal, which contains and protects the spinal cord and nerve roots, narrows and pinches the spinal cord and nerves. The result is low back pain as well as pain in the legs. Stenosis may pinch the nerves that control muscle power and sensation in the legs.

Causes of spinal stenosis

There are many potential causes for spinal stenosis, including:

Symptoms of spinal stenosis

Diagnosing spinal stenosis

These symptoms also can be caused by many other conditions, which makes spinal stenosis difficult to diagnose. There is usually no history of back problems or any recent injury. Often, unusual leg symptoms are a clue to the presence of spinal stenosis.

If simple treatments, such as postural changes or nonsteroidal anti-inflammatory drugs, do not relieve the problem, your orthopaedic surgeon may request special imaging studies to determine the cause of the problem. An MRI (magnetic resonance image) or CAT (computed tomography) scan may be requested. A myelogram (an X-ray taken after a special fluid is injected into the spine) may be arranged. These and other imaging studies provide details about the bones and tissues and assist the orthopaedic evaluation.

Treatment

Conservative treatment

When stenosis causes severe nerve root compression, these treatments may not be enough. Back and leg pain may return again and again. Because many stenosis sufferers are unable to walk even short distances, they often confine their activities to the home.

Surgical treatment

If conservative treatment does not relieve the pain, your orthopaedic surgeon may recommend surgery to relieve the pressure on affected nerves. In properly selected cases, the results are quite satisfactory, and patients are able to resume a normal lifestyle.

Spondylolysis and Spondylolisthesis

Description

The most common X-ray identified cause of low back pain in adolescent athletes is a stress fracture in one of the bones (vertebrae) that make up the spinal column. Technically, this condition is called spondylolysis (spon-dee-low-lye-sis). It usually affects the fifth lumbar vertebra in the lower back, and much less commonly, the fourth lumbar vertebra.

If the stress fracture weakens the bone so much that it is unable to maintain its proper position, the vertebra can start to shift out of place. This condition is called spondylolisthesis (spon-dee-low-lis-thee-sis). If too much slippage occurs, the bones may begin to press on nerves and surgery may be necessary to correct the condition.

Risk Factors/Prevention

Genetics: There may be a hereditary aspect to spondylolysis. An individual may be born with thin vertebral bone and therefore be vulnerable to this condition. Significant periods of rapid growth may encourage slippage.

Overuse: Some sports, such as gymnastics, weight lifting and football, put a great deal of stress on the bones in the lower back. They also require that the athlete constantly over-stretch (hyperextend) the spine. In either case, the result is a stress fracture on one or both sides of the vertebra.

Symptoms

Diagnostic tests

X-rays of the lower back (lumbar) spine will show the position of the vertebra.

The pars interarticularis is a portion of the lumbar spine. It joins together the upper and lower joints. The pars is normal in the vast majority of children.

If the pars "cracks" or fractures, the condition is called spondylolysis. The X-ray confirms the bony abnormality.

If the fracture gap at the pars widens, then the condition is called spondylolisthesis. Widening of the gap leads to the fifth lumbar vertebra shifting. It shifts forward on the part of the pelvic bone called the sacrum. The doctor measures standing lateral spine X-rays. This determines the amount of forward slippage.

If the vertebra is pressing on nerves, a CT scan or MRI may be needed before treatment begins to further assess the abnormality.

Treatment Options

Initial treatment for spondylolysis is always conservative. The individual should take a break from the activities until symptoms go away, as they often do. Anti-inflammatory medications such as ibuprofen may help reduce back pain. Occasionally, a back brace and physical therapy may be recommended. In most cases, activities can be resumed gradually and there will be few complications or recurrences. Stretching and strengthening exercises for the back and abnormal muscles can help prevent future recurrences of pain.

Periodic X-rays will show whether the vertebra is continuing to slip.

Treatment Options: Surgical

Surgery may be needed if slippage continues or if the back pain does not respond to conservative treatment and begins to interfere with activities of daily living. A spinal fusion is performed between the lumbar vertebra and the sacrum. Sometimes, an internal brace of screws and rods is used to hold together the vertebra as the fusion heals.

 

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