Spine Services

Spondylolysis refers to a defect in one of the vertebrae in the lower back, usually the last vertebra of the lumbar spine. The area of the vertebra that is affected is called the pedicle. The pedicle is part of the bony ring that protects the spinal nerves, and is the portion that connects the vertebral body to the facet joints. When a spondylolysis is present, the back part of the vertebra (and the facet joints) are separated from the rest of the bone. It is almost as if the back portion had been broken off and tried to heal back - but never did. Actually, there is good evidence to suspect that this is exactly what has occurred. Spondylolysis is not something people are born with, but it appears that it first shows up sometime in childhood. Interestingly, boys who are football linemen and girls who are gymnasts seem to be affected the most. The current thought is that the spondylolysis is probably a stress fracture that never completely healed.

Spondylolisthesis is the term used to describe when one vertebra slips forward on the one below it. This usually occurs because there is a spondylolysis in the vertebra on top. There are two main parts of the spine that keep the the vertebrae aligned: the disk and the facet joints. When a spondylolysis occurs, the facet joint can no longer hold the vertebra back. The intervertebral disk may slowly stretch under the increased stress and allow the upper vertebra to slide forward. In the vast majority of cases, the stretching only allows a small amount of forward slip. In some cases, however, the slip may progress to the extent that pain and even nerve compression results. There is a particular type of spondylolisthesis that occurs in teenagers in which the forward slipping is severe and can allow the upper vertebra to slip completely off the lower vertebra. This often results in nerve injury.

Just because you have one of these conditions does not mean that you will necessarily ever have problems with your back, but you are at a higher risk of developing chronic low back pain than the normal population. Symptoms may be in the form of mechanical pain (caused by irritated bones in the spine), or compressive pain (caused by a compressed nerve). There is usually pain across the small of the back and into the buttocks. If there is nerve compression, there may be pain down the leg to the foot, numbness in the foot and possibly weakness in trying to raise the foot. Such symptoms demand immediate medical attention.

Treatment for spondylolysis and spondylolisthesis is not really much different than for other causes of mechanical and/or compressive back pain. In most cases, surgery will not be necessary. The mechanical symptoms that are a result of the segmental instability can be reduced by strengthening the back muscles. A physical therapist will probably be recommended to help you with a series of exercises designed to help stabilize the spine by strengthening the back and abdominal muscles.

Medications may be used for short periods of time to control pain, ease muscle spasm, and help regain a normal sleep pattern if you are having trouble sleeping. Short periods of bed rest may help with acute painful episodes. A back brace, or corset, may reduce pain. Surgery is necessary only if all of the above treatments fail to keep your pain at a tolerable level.

The back is held upright by muscles attached to the backbone. Doctors often refer to the backbone as the spine, spinal column, or vertebral column. The backbone isn't one long bone, but actually 24 separate bones called vertebrae. These 24 vertebrae are stacked one on top of another to form the backbone.

The points where two vertebrae or bones fit together are called joints. They make it possible for the spine to move and turn in many different directions. There are discs located between each vertebra. These discs are made of cartilage, which is a soft, elastic material. Discs act as cushions, or shock absorbers, much like the shock absorbers in your car. Their main job is to protect the joints from wearing out. Most joints contain a slippery substance called synovial fluid that keeps them moving smoothly.

Occasionally, these discs between the vertebra protrude out (or herniate) and consequently compress adjacent nerves leaving the spinal cord. The compression cause pain in the back and often down the respective extremities. If the herniated disc occurs in the neck, the pain often travels down the arms. If the herniated disc occurs in the low back, the pain often travels down the legs.

Discs that are herniated may spontaneously heal with proper medical management and physical therapy. Discs that have ruptured may not heal. When non-surgical management fails or if nerve compression is so severe that weakness develops, then surgery is indicated. Surgery involves removing the discs, or other materials, and alleviating the compression on the nerves. In some cases, fusing the two adjacent vertebrae are necessary.

Scoliosis is a curvature of the spine. This occurs in three dimensions. The spine appears curved when an affected child is viewed from the back, from the side and from the top (because the spine twists as it curves sideways).

Some children are born with scoliosis. This type is referred to as congenital. It is caused by an abnormal formation of one or more vertebrae, which are the building blocks of the spine. Some children develop scoliosis as they get older. This type is referred to as idiopathic, because it does not have a known cause. Idiopathic scoliosis is the most common form. It tends to run in families, but no gene or other specific risk factor has been identified. Some children develop scoliosis as a result of nerve disease or injury, such as paralysis.

There are several common misconceptions about scoliosis. Below are some true statements regarding scoliosis:

• Backpacks and other heavy objects will not produce scoliosis.
• Scoliosis is not an occupational hazard.
• Exercises, stretching and other physical activities are good for general health, but have never been shown to affect magnitude or progression of scoliosis.
• Similarly, while good diet is essential to good living, there is no evidence that diet can cause or cure or in any other way significantly influence scoliosis.

Two principal mechanisms underlie scoliosis. First, if there is abnormal development of the vertebrae (for example, one may be wedge-shaped instead of rectangular), then the spine will grow crooked because the bones which make it up grow crooked. Second, if there is an imbalance of the nerve signals to the muscles which support and move the spine, then they will pull against the spine in an asymmetric manner and make it grow crooked.

As spinal curvature increases, posture worsens, and this can result in significant social disability. In addition, abnormal posture may interfere with activities of daily living and with work. In theory, once spinal curvature exceeds 90 degrees, lung and heart function can become compromised as the chest cavity becomes distorted and there is less room for the internal organs.

The principal non-surgical option is bracing. The most widely used brace for scoliosis is known as a thoracolumbosacral orthosis, or TLSO, of the Boston type, after the location where it was designed. This is made of rigid plastic. It has a front half and a back half, which are tightened together by straps. On the inside, there are several foam pads which push against the ribs and flanks to hold the spine in areas determined by the type of curvature and the x-ray image. The brace is worn full-time, which is defined as more than 20 hours every day. This includes sleeping, eating and going to school. The decision to brace needs to be well thought out and carefully discussed by the child, the family and the orthopaedic surgeon.

Once curvature of the spine exceeds 50 degrees, surgery is recommended. The primary purpose of surgery is spinal fusion, which makes the vertebrae stick together so that they no longer can curve. The vertebrae may be likened to beads on a string: if they are transformed into a single, long bead (or bone mass), the spine can not curve. Despite these considerations, children with scoliosis are able to enjoy a normal life and to participate fully in all activities, including sports.

Twenty-five million Americans have osteoporosis. Fifty thousand people die each year because of complications related to osteoporosis. Yet, most of us know little about protecting ourselves from this disease.

Osteoporosis is a disorder of the bones characterized by decreased bone mass (generalized thinning of the bones), which also decreases bone strength. Because weakened bones are more fragile and more likely to break, people with osteoporosis are at increased risk of fractures, especially fragility fractures (broken bones that happen with little or no trauma). It is not a form of arthritis, although it may cause fractures that, in turn, lead to arthritis.

In the United States, osteoporosis causes more than 1.3 million fractures annually and is much more common in women than in men. The most common first fracture is a wrist fracture, which typically occurs at age 50 to 70 in women. Hip fractures and fractures of the spine (compression fractures) may also occur and are most common in patients who are in their 70s. Particularly when it leads to hip fracture, osteoporosis can cause a great deal of suffering, including an increased risk of institutionalization or death.

Most people with osteoporosis have no symptoms and are totally unaware that they have the problem. One early sign can be a loss of height caused by curvature of the spine (Dowager's hump), which is caused by weakened vertebrae (spine bones). The weakened vertebrae undergo compression fractures — tiny breaks that cause the spine bones to collapse vertically. When this happens, the height of the vertebrae is decreased, and the shape of each single vertebra goes from a normal rectangle to a more triangular form. Although the loss of height caused by compression fractures can sometimes be associated with back pain or aching, more typically it is asymptomatic (causes no symptoms).

When taking your history, your doctor will look for factors that increase your risk of osteoporosis. These risk factors include:

• Being female
• Being age 40 or older
• Being a postmenopausal woman who does not take estrogen replacement medication
• Having a diet low in calcium or an intestinal problem that impairs absorption
• Having an overactive thyroid
• Leading a sedentary lifestyle, with little or no routine exercise
• Being thin
• Taking certain medications, such as prednisone
• Having a certain ethnic background (white people and those of Asian descent are more at risk of osteoporosis than are African-Americans)
• Smoking
• Using alcohol to excess
• Having a family history of osteoporosis
• Having a history of at least one fragility fracture

The diagnosis of osteoporosis should be strongly suspected in any person who has a fragility fracture. It can also be established by a bone density test, or bone densitometry. There are several techniques available to measure bone density. The most complete and accurate method is DEXA (dual- energy X-ray absorptiometry), which is the best for both diagnosing osteoporosis and assessing response to treatment. DEXA is a quick (10 to 15 minutes) and painless test that uses minute amounts of radiation (less than dental X-rays) and is generally done on the spine and hip. DEXA is available at Greater Metropolitan Orthopaedics.

Bone densitometry can diagnose osteoporosis when the condition is asymptomatic and mild and can help lead to treatment that will prevent the condition from getting worse. In people with loss of height or suspicious fractures, bone density tests not only confirm the diagnosis of osteoporosis, they also serve as a baseline for treatment and can be used to follow the response to therapy.

Ask your physician or therapist at Greater Metropolitan Orthopaedics if you are at risk for osteoporosis and if bone densitometry may be indicated.