Spondylitis/ Spondylosis

Lumbar / cervical spine - neck spondylosis/spondylitis, as shown in the image below, describes bony

overgrowths (osteophytes), at margins of vertebral centra (bodies). This dynamic process increases with

aging of human body and not a disease process. If it causes discomfort and affects daily living, then only

treatment is needed.

Anteroposterior view of lumbar spine. Vertical overgrowths from margins of vertebral bodies represent osteophytes.

Lumbar spondylosis usually produces no symptoms. When back or sciatic pains are symptoms, lumbar

spondylosis is usually an unrelated finding.

For further reading, please see the eMedicine article Lumbar Spondylosis and Spondylolysis.

History of the Procedure

Lumbar osteophytes, shown below, have long been thought to cause back pain because of their frequency

and size, as depicted in the image below. This has led to many studies of the distribution of vertebral

osteophytes, not all of which are pertinent. The frequency of signs or symptoms among individuals with

osteophytes is no greater than among those individuals without osteophytes.²

Problem

Lumbar spondylosis is usually asymptomatic, with no diagnostic or prognostic significance.

Frequency

Lumbar spondylosis is present in 27-37% of the asymptomatic population.

In the United States, more than 80% of individuals older than 40 years have lumbar spondylosis, increasing from 3% of individuals aged 20-29 years.

Internationally, lumbar spondylosis can begin in persons as young as 20 years. It increases with, and perhaps is an inevitable concomitant of, age.

Approximately 84% of men and 74% of women have vertebral osteophytes, most frequently at T9-10 and L3 levels. Approximately 30% of men and 28% of women aged 55-64 years have lumbar osteophytes. Approximately 20% of men and 22% of women aged 45-64 years have lumbar osteophytes.

Sex ratio reports have been variable but are essentially equal. Spinal osteophytosis in postmenopausal Japanese women correlated with the CC genotype of the transforming growth factor β ₁ gene.³

Lumbar spondylosis occurs in animals with upright posture (eg, chimpanzees) and, possibly, in some domestic animals.⁴

Etiology

Lumbar spondylosis appears to be a nonspecific aging phenomenon. Most studies suggest no relationship to lifestyle, height, weight, body mass, physical activity, cigarette and alcohol consumption, or reproductive history. Adiposity is seen as a risk factor in British populations, but not Japanese populations. The effects of heavy physical activity are controversial, as is a purported relationship to disk degeneration.⁵

Spondylosis often affects the following spinal elements:

Intervertebral Discs The structural alterations from degeneration may decrease disc height and increase the risk for disc herniation.

Facet Joints (or Zygapophyseal Joints) Facet joint degeneration causes loss of cartilage and formation of osteophytes (eg, bone spurs). These changes may cause hypertrophy or osteoarthritis, also known as degenerative joint disease.

Bones and Ligaments Osteophytes (eg, bone spurs) may form adjacent to the end plates, which may compromise blood supply to the vertebra. Further, the end plates may stiffen due to sclerosis; a thickening or hardening of the bone under the end plates. Ligaments are bands of fibrous tissue connecting spinal structures (eg, vertebrae) and protect against the extremes of motion (eg, hyperextension). However, degenerative changes may cause ligaments to lose some of their strength. The ligamentum flavum (a primary spinal ligament) may thicken and buckle posteriorly (behind) toward the dura mater (a spinal cord membrane).

Spondylosis Symptoms and Different Spinal Levels

Cervical (Neck) The complexity of the cervical (neck) anatomy and its wide range of motion make this spinal segment susceptible to disorders associated with degenerative change. Neck pain from spondylosis is common. The pain may spread into the shoulder or down the arm. When a bone spur (osteophyte) causes nerve root compression, extremity (eg, arm) weakness may result. In rare cases, bone spurs that form at the front of the cervical spine, may cause difficult swallowing (dysphagia).

Thoracic (Mid-Back) Pain associated with degenerative disease is often triggered by forward flexion and hyperextension. In the thoracic spine disc pain may be caused by flexion--facet pain by perextension.

Lumbar (Low Back) Spondylosis often affects the lumbar spine in people over the age of 40. Pain and morning stiffness are common complaints. Usually multiple levels are involved (eg, more than one vertebrae). The lumbar spine carries most of the body's weight. Therefore, when degenerative forces compromise its structural integrity, symptoms including pain may accompany activity. Movement stimulates pain fibers in the annulus fibrosus and facet joints. Sitting for prolonged periods of time may cause pain and other symptoms due to pressure on the lumbar vertebrae. Repetitive movements such as lifting and bending (eg, manual labor) may increase pain.

Pathophysiology

Lumbar spondylosis occurs as a result of new bone formation in areas where the anular ligament is stressed.

Presentation

Lumbar spondylosis usually produces no symptoms. When back or sciatic pains are symptoms, lumbar spondylosis is usually an unrelated finding. Lumbar spondylosis is usually not found unless a complication ensues.

Other problems to consider include the following:

• • Spondyloarthropathy

• Spinal stenosis

  • Diffuse idiopathic skeletal hyperostosis

• Fibromyalgia

  • Postural disturbance

  • Aortic aneurysm

  • Psychogenic rheumatism

  • Ischial bursitis

  • Trochanteric bursitis

  • Hip arthritis

  • Spondylolisthesis

• Osteoporosis⁶

  • Compression fracture

  • Neoplasia

• Hemangioma

  • Infectious spondylitis

  • Endocarditis

  • Disc disease

Surgery is indicated only for complications (eg, for impingement-documented sciatica that is unresponsive to conservative/medical management and rest) of lumbar spondylosis.

Relevant Anatomy

The margins of vertebral bodies are normally smooth. Growth of new bone projecting horizontally at these margins identifies osteophytes. Most osteophytes are anterior or lateral in projection. Posterior vertebral osteophytes are less common and only rarely impinge upon the spinal cord or nerve roots.

Physical and Neurological Examination

A thorough physical examination reveals much about the patient's health and general fitness. The physical part of the exam includes a review of the patient's medical and family history. Often laboratory tests such as complete blood count and urinalysis are ordered. The physical exam may include:

• • Palpation (exam by touch) determines spinal abnormalities, areas of tenderness, and muscle spasm.

  • Range of Motion measures the degree to which a patient can perform movement of flexion, extension, lateral bending, and spinal rotation.

  • A neurologic evaluation assesses the patient's symptoms including pain, numbness, paresthesias (e.g. tingling), extremity sensation and motor function, muscle spasm, weakness, and bowel/bladder changes. Particular attention may be given to the extremities. Either a CT Scan or MRI study may be required if there is evidence of neurologic dysfunction.

X-rays and Other Tests

Radiographs (X-rays) may indicate loss of vertebral disc height and the presence of osteophytes, but is not as useful as a CT Scan or MRI. A CT Scan may help reveal bony changes sometimes associated with spondylosis. An MRI is a sensitive imaging tool capable of revealing disc, ligament, and nerve abnormalities. Discography seeks to reproduce the patient's symptoms to identify the anatomical source of pain. Facet blocks work in a similar manner. Both are considered controversial.

The physician compares the patient's symptoms to the findings to formulate a diagnosis and treatment plan. The results from the examination provide a baseline from which the physician can monitor and measure the patient's progress.

Non-Surgical Treatment

Non-surgical treatment is successful 90% of the time.

Some patients may think because their condition is labeled 'degenerative' they will not be able to be productive and active. This is seldom the case.

Many patients find their pain and other symptoms can be effectively treated without surgery.

Pain relief Medicines, Oil Massage, Ice / Hot therapy, Belts

Pain-relieving gels like Brugel, Voveron etc

Exercises

Healthy eating & Lifestyle

HAPPY and positive attitude

Weight reduction - BMI 20 - 24

Usually no surgery.

Sometimes Target Joint / Bone / Fascial injections

During the acute phase, anti-inflammatory agents, analgesics, and muscle relaxants are prescribed for a short period of time.

The affected area may be immobilized and/or braced.

A soft cervical collar may be used to limit movement and alleviate pain. Lumbosacral (low back, sacrum) orthotics may decrease the low back load by stabilizing the lumbar spine.

A course of physical therapy may include heat, electrical stimulation, and other modalities to help ease muscle spasm and pain. During physical therapy, the patient learns how to strengthen their paravertebral (back) and abdominal (stomach) muscles to lend support to the spine. Isometric exercises can be helpful when movement is painful or difficult.

Exercise in general helps to build strength, flexibility, and increase range of motion.

Lifestyle modification may be necessary. This may include an occupational change (e.g. from manual labor), losing weight, and quitting smoking.

General measures to help treat osteoarthritis/spondylitis/spondylosis

Exercise

If possible, exercise regularly. This helps to strengthen the muscles around affected joints, to keep you fit, and to maintain a good range joint movement. Swimming is ideal for most joints, but any exercise is better than none. Many people can manage a regular walk.

Weight control

If you are overweight, try to lose some weight as the extra burden placed on back, hips, and knees can make symptoms worse. Even a modest weight loss can make quite a difference.

• • Wearing a Lubar belt or knee brace.

These measures slightly alter the distribution of weight and pressure on the knee joint, which is why they are thought to ease symptoms in some cases. A podiatrist or physiotherapist can advise exactly how to use them.

Braces or supports may also be helpful for other joints affected by OA. For example, a support around the thumb for painful thumb OA.

Daily walking for 30 to 45 minutes with or without Walking aids

If you have OA of your hip or knee, when walking try using a cane (walking stick). Hold it in the hand on the opposite side of the body to the affected joint. This takes some pressure off the affected joint and helps to ease symptoms in some cases.

Diet - Vitamins, minerals, calcium should be obtained from natural dietary resources and

not by 'vitamin tablets/capsules' which can increase your risk of 'medicinal side-effects'.

Fruits, Salads, green vegetables/leaves, Sprouts -250 grammes

Curd/Yoghurt -250 grammes,

Lemon juice with little salt/sugar.

Water -5-6 lit per day or more, daily slow sustained yoga type physiotherapy exercises as given in website is essential for good health of bones and body.

Daily brisk/speed walking for 1 hour, getting enough vitamin D from your diet, sunlight will decrease your risk.

Cycling outdoors and non-gym outdoor exercises such as brisk walking, using stairs at home and office, walk at work bring overall improvement in health, well being besides controlling and curing many diseases such as Hypertension, diabetes, depression, cancer, osteoporosis, arthritis, muscular pains and joint pains.

Physical activity. Not exercising and being inactive or staying in bed for long periods can increase your risk.

Smoking. Smokers harm their blood circulation, damage all tissues in body by free radicals of smoke and absorb less calcium from their diets.

Medications. Some commonly used medicines can cause loss of bone mass. These include steroids used to control arthritis and asthma; some drugs used to treat seizures; some cancer drugs; and, too much thyroid hormone.

Low body weight. Women who are very thin – and small-boned – are at greater risk for osteoporosis.

Physiotherapy help if unable to follow correct exercises

Sometimes advice or treatment from a physiotherapist is helpful. For example:

• • For advice on which exercises to do to strengthen the muscles above the knee (quadriceps) if you have OA of the knee. Strengthening the 'quads' has been shown to improve symptoms caused by OA of the knee.

  • For advice on how to keep active and fit.

  • For advice on shoes insoles, knee braces, taping to the knee, and how to use walking aids properly (to make sure you have one of the correct height).

Manipulation and stretching around affected joints may be helpful. This is something that physiotherapists may also be able to help with.

Occupational therapy

An occupational therapist may be able to help if you need aids or modifications to your home to cope with any disability caused by OA. Special devices, such as tap turners to help with turning on a tap, may mean that you can carry out tasks around the house more easily.

Other therapies

• • Some people have found that TENS (Transcutaneous Electrical Nerve Stimulator) machines help to ease pain from OA. A TENS machine delivers small electrical pulses to the body via electrodes placed on the skin.

  • Acupuncture may also help to ease symptoms in some cases.

  • Some people find that they can also get some pain relief from using hot or cold packs on the affected joint(s). This is also called thermotherapy. You can use a hot water bottle filled with either hot or cold water and apply it to the affected area. Or, special hot and cold packs that can either be cooled in the freezer, or heated in a microwave, are also available.

Medicines used to treat osteoarthritis

Paracetamol

Paracetamol is the common medicine used to treat OA. It often works well to ease pain. It is best to take it regularly to keep pain away, rather than 'now and again' when pain flares up. A normal adult dose is two 500 mg tablets, four times a day. It usually has little in the way of side-effects, and you can take paracetamol long-term without it losing its effect.

Anti-inflammatory painkillers

You may find that a topical preparation of an anti-inflammatory painkiller that you rub onto the skin over affected joints is helpful instead of, or in addition to, paracetamol tablets. This may be particularly helpful if you have knee or hand OA. Compared to anti-inflammatory tablets, the amount of the drug that gets into the bloodstream is much less with topical preparations, and there is less risk of side-effects (see below).

Anti-inflammatory painkillers that are taken by mouth are not used as often as paracetamol. This is because there is a risk of serious side-effects, particularly in older people who take them regularly. However, one of these medicines is an option if paracetamol or topical anti-inflammatories do not help. Some people take an anti-inflammatory painkiller for short spells, perhaps for a week or two when symptoms flare up. They then return to paracetamol or topical anti-inflammatories when symptoms are not too bad. There are many different brands of anti-inflammatory painkillers. If one does not suit, another may be fine.

Side-effects may occur in some people who take anti-inflammatory painkillers:

• • Bleeding from the stomach is the most serious possible side-effect. This is more of a risk if you are over 65, or have had a duodenal or stomach ulcer, or if you are also taking low-dose aspirin. Stop the medicine and see a doctor urgently if you develop indigestion, upper abdominal pain, or if you vomit or pass blood. Read the leaflet that comes with the medicine for a list of other possible side-effects. You doctor can prescribe another medicine that can help to protect your stomach if you are taking anti-inflammatory painkillers in the long-term. You should discuss this with them.

  • Some people with asthma, high blood pressure, kidney failure, and heart failure may not be able to take anti-inflammatory painkillers.

Codeine

Codeine is sometimes combined with paracetamol for added pain relief. Constipation is a common side-effect from codeine. To help prevent constipation, have lots to drink and eat a high fibre diet.

Capsaicin cream

This cream is made from chilli peppers and it works by blocking the nerve signals that send pain messages to the brain. It may be helpful if you have knee or hand OA. It takes a while for the effects of this cream to build up and may take around one month to get the maximum benefit. You should rub in a pea-sized amount of cream around the affected joint four times a day, and not more often than every four hours.

Don't use this cream on broken or inflamed skin. You may notice some burning after you apply the cream but this tends to improve the longer you have used it. Avoid having a hot bath or shower, before, or after, applying the cream because it may make the burning sensation worse. Also, be careful to wash your hands after applying the cream. Because it is made from chilli peppers, it can cause burning if it gets into your eyes, mouth or around your genital area.

An injection of antiinflammatory medicine

An injection directly into a joint is useful if a joint becomes badly painful / inflamed.

Treatments that are not normally recommended

Glucosamine, cartilage regenerative drugs are Usually not helpful in long term as no reliable studies on them. besides they may affect liver function and kidneys.

Hyaluronic acid

The use of regular injections of hyaluronic acid directly into a joint is a relatively new treatment that has been tried for OA. The theory is that it may help with 'lubrication' and 'shock absorption' in a damaged joint. It may produce a small beneficial effect in some people. However, the National Institute for Health and Clinical Excellence (NICE) has looked at the use of hyaluronic acid as a possible treatment for OA and does not recommend its use. This is because there is little evidence that it is effective.

Chondroitin

This is another food supplement that has become popular as a potential treatment for OA. It is a chemical that is part of the make-up of normal cartilage. A recent big study showed that chondroitin has little, or minimal, effect on reducing symptoms in people with OA. Also, NICE does not recommend the use of chondroitin for the treatment of OA. This is because they could find no clear evidence from studies to show that it is an effective treatment.

Surgery for osteoarthritis/spondylitis

Most people with OA/spondylitis do not have it badly enough to need surgery. However, OA of a joint may become severe in some cases. Some joints can be replaced with artificial joints. Hip and knee replacement surgery has become a standard treatment for severe OA of these joints. Some other joints can also be replaced.

Surgery

Seldom is surgery used to treat spondylosis. Most patients respond well to non-surgical treatment for spinal osteoarthritis.

If the patient experiences a neurologic deficit (such as bowel or bladder problems), surgery may be considered. The doctor considers many factors about the patient's health before surgery is recommended. Some of these factors include the patients age, lifestyle and severity of the patient's spinal disorder. A spinal specialist can determine if surgery is the best treatment for the patient.

Recovery

Always follow the instructions provided by the doctor or physical therapist. This includes:

• • Take medication as directed. Report side effects immediately to your doctor.

  • Follow the home exercise program provided by the physical therapist.

  • Avoid heavy lifting and activities that aggravate pain and symptoms.

  • Try to keep your weight close to ideal.

  • Stop smoking.

  • If symptoms persist or change. contact your doctor.

Discuss questions or doubts about activity modification or restriction with the doctor or physical therapist. They will be happy to provide information to help speed recovery.

Contraindications

Surgery is not indicated if no complications (eg, impingement) of lumbar spondylosis are present