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Lumbar Spine Conditions and Treatments

Posted by Midwest Orthopaedic Consultants on December 12, 2017

lumbar-spine-conditions-and-treatments.pngIf you have low back pain, you may be concerned that surgery is the only option. Many times, problems with the low back — or lumbar spine — can be treated using nonsurgical options. This blog describes common problems of the lower back and typical courses of care. If you have any questions about what you are experiencing and how it can best be treated, talk to an orthopedic specialist as soon as possible.

Herniated Nucleus Pulposus

A herniated nucleus pulposus (HNP) — commonly called a herniated disc — is caused by the progressive degeneration of a disc (part of the lumbar spine anatomy) or traumatic event, which can lead to a failure of the annulus to adequately contain the nucleus pulposus.

Symptoms of HNP in the lumbar spine include:

  • Back pain
  • Leg pain
  • Dysthesias (abnormal sensations)
  • Anesthesias (Loss of sensation or numbness)

Discs can herniate to varying degrees. In a case in which a disc is bulging and symptoms are mild, the patient can usually opt for nonoperative treatment and the problem will subside. These cases are rarely an indication for spine surgery.

In cases in which there is an extrusion — or herniation — and symptoms range from moderate to severe, nonoperative treatment may still be an option. An orthopedic specialist will likely make a diagnosis using magnetic resonance imaging (MRI) and a patient exam.

Nonoperative care could include:

  • Initial bed rest
  • Nonsteroidal anti-inflammatory (NSAID) medication
  • Physical therapy and exercise, such as walking
  • Steroid injections

Nonoperative care would likely be tried for a period of at least six weeks, but could be tried for a period of months. If nonoperative treatment fails, lumbar spine surgery may be needed.

A discectomy for treatment of HNP would involve the removal of the herniated portion of the disc, usually through a small incision. This type of procedure has a high rate of success.

In cases of cauda equina syndrome, which is caused by a central disc herniation, the need for surgical intervention is typically urgent.

Symptoms of cauda equina syndrome include:

  • Bilateral leg pain
  • Loss of perianal sensation
  • Paralysis of the bladder
  • Weakness of the anal sphincter

Seek treatment as soon as possible if you believe you may have this condition.

Spinal Stenosis

Several conditions are grouped together under the term “spinal stenosis.” They are:

Central stenosis: Narrowing of the central part of the spinal canal

Foraminal stenosis: Narrowing of the foramen, resulting in pressure on the exiting nerve root

Far lateral recess stenosis: Narrowing of the lateral part of the spinal canal

The symptoms of spinal stenosis include back pain or pain, abnormal sensations or numbness in the buttocks, thighs and legs. Symptoms can be unilateral or bilateral, which means they can affect one or both sides of the body.

Symptoms can occur while walking or standing, and then subside when sitting. They may also start in the buttocks and traverse to the legs or vice versa.

A diagnosis for spinal stenosis is usually made via a patient exam and MRI or acomputerized tomography (CT) scan. Nonoperative care may be appropriate for spinal stenosis. Similar to HPN, non-surgical treatment could include:

  • Rest
  • NSAID medication
  • Physical therapy
  • Exercise/walking
  • Steroid injections

If symptoms persist after three to six months, spine surgery may be required. Decompression involves removing bone to widen the area in the form of a laminectomy or foraminotomy. Adjunct fusion may be required to address instability. These procedures have a high rate of success.

Segmental Instability

Segmental instability of the lumbar spine could be several conditions. These include:

Spondylolisthesis: This is a forward translation of one vertebral body over the adjacent vertebra. It could be degenerative or "adult onset"and involve the progressive slip of the vertebral body. Lytic spondylolisthesis, on the other hand, develops in children or adolescents, but only 25 percent of them experience symptoms.

Spondylolysis: A fracture or defect in the vertebra, usually in the posterior elements— most frequently in the pars interarticularis, which is a small portion of bone that connects the facet joints.

Spondyloloptosis: This is a complete dislocation of a segment.

More About Spondylolisthesis

The gradation of spondylolisthesis is measured by the Meyerding’s Scale:

  • Grade 1 = up to 25%
  • Grade 2 = up to 50%
  • Grade 3 = up to 75%
  • Grade 4 = up to 100%
  • Grade 5 >100% (complete dislocation, spondyloloptosis)

Symptoms of spondylolisthesis include:

  • Low back pain, with or without buttock or thigh pain
  • Pain aggravated by standing or walking
  • Pain relieved by lying down
  • Associated spinal stenosis — or a condition in which the spaces between the spine narrow — with or without leg pain, may be present
  • Tired legs, numbness or abnormal sensations
  • Partial pain relief by leaning forward or sitting

A diagnosis of spondylolisthesis is usually made with plain radiographs or a CT scan, in some cases involving leg symptoms.

For cases in which nonoperative care is appropriate, an orthopedist may recommend:

  • Rest
  • NSAID medication
  • Physical therapy
  • Steroid injections

In cases where nonoperative treatment fails, surgical care in the form of decompression and fusion could be needed.

More About Spondylolysis

Spondylolysis — also known as pars defect or pars fracture — is a fracture or defect in the vertebra. It is usually found in the posterior elements of the vertebra — most frequently in the pars interarticularis. It can come with or without a diagnosis of spondylolisthesis.

Symptoms include:

  • Low back pain or stiffness
  • An increase in pain with forward bending
  • A worsening of symptoms with activity
  • Occasionally, leg symptoms caused a stenotic component

Spondylolysis is caused by repeated strain. This condition is seen most often in athletes, and gymnasts are at particular risk.

A diagnosis is often made with plain oblique radiographs and in some cases a CT scan. Nonoperative care includes limiting of athletic activities and physical therapy. Most fractures heal without other medical intervention.

If nonoperative treatment fails, orthopedic surgery options include a posterior fusion procedure that may require decompression as well.

Degenerative Disease

Degenerative disease can occurs at all levels of the spine. The spinal structures most affected by degenerative disease are invertebral discs and articular facet joints.

These conditions are similar to osteoarthritis and degenerative disease of the spine, which is often referred to as “osteoarthritis of the spine,” or spondylosis. A diagnosis of spondylosis usually requires confirmation by radiologic examination, though changes in the body generally occur long before symptoms are present. Based on radiologic findings, degenerative disc disease (DDD) may be classified into stages of progression

Degenerative disc disease is thought to begin in the annulus fibrosis — or the tough outer portion of the intervertebral disc — with changes to the structure and chemistry of the concentric layers. Over time, these layers suffer a loss of water content and proteoglycan, which changes the disc’s mechanical properties, making it less resilient to stress and strain.

Symptoms of DDD include pain in the low back or buttocks, or both. In cases that include leg pain, there is likely an additional cause, such as HNP, stenosis or the like — DDD is not usually the sole diagnosis.

Diagnosis typically involves a patient exam and an MRI. In some cases, a CT scan is needed to rule out other diagnoses. Discography is also used.

Nonoperative care for DDD includes:

  • Rest for acute, low back pain
  • NSAID medication
  • Physical therapy
  • Exercise and walking
  • Low-impact aerobics
  • Trunk strengthening

Surgical care for DDD will likely only be considered after a minimum of six weeks of nonoperative treatment has been followed.

Surgical treatment may include lumbar fusion surgery or arthroplasty. Fusion involves the removal of the disc and replacement with a bone graft, a cage-filled bone graft, or a bone graft substitute. Arthroplasty involves replacing or reconstructing a joint.

If you are experiencing pain of the lumbar spine, talk to an orthopedic expert. A doctor who specializes in treating the spine can help determine whether nonoperative treatment or spine surgery is needed for your condition. If you need surgical treatment, read our posts about how to prepare for spinal surgery and the most frequently asked questions about spine surgery.

If you're going to have spinal surgery, there are steps you can take to be prepared for a successful procedure and recovery.

 spine surgery tips for successful preparation and recovery ebook

Topics: Spine