Arthritis of the spine
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
Click here: Second Opinion Arthritis Treatment Kit
Arthritis of the spine most presents with pain- either in the neck or the low back.
Neck or low back pain (LBP) is most common in the 40 to 70 year old age group. Up to 90 per cent of people will have an episode of neck or low back pain at some point in their lives.
While most patients will recover from their incident, but approximately ten per cent will go on to develop chronic neck or low back problems.
The amount of money spent on arthritis of the spine, including the cost of treatment, legal, and economic (days lost from work, etc.) is enormous and estimates run to as high as 40 billion dollars annually.
While the cause of neck or low back pain is usually arthritis, it is important to eliminate the more serious causes of back and neck pain such as tumor, infection, aortic aneurysm, or fracture.
The spine is comprised of a stack of vertebrae, each separated from the other in front by a disc containing a sack of gel that acts as a cushion and in back by a pair of cartilage-lined facet joints. The vertebrae and discs are supported by a complex series of muscles, ligaments, and tendons. The spinal cord runs down through a central canal in the vertebral column. At each disc level, the spinal cord sends out a pair of nerve roots- one to each side. These nerve roots provide the innervation for the structures in the chest, upper back and arms (for the neck) or hips and legs (for the low back).
Spine pain is caused by a number of different problems including trauma, inflammation, degenerative and mechanical processes, infection, and malignancies.
The history is important because it can point out symptoms that might suggest causes of spine pain that are not degenerative. In most cases, though, a history of trauma, repetitive motion, or other activity is elicited. Sometimes the inciting episode is relatively trivial. A patient may state they were “just brushing my teeth”, or “just bending over to pick up the newspaper, or turning their head to look for oncoming traffic.”
It is this type of history that will point towards strain being the cause of the pain. Strain refers to pain due to stretching of muscles or nerves. There are many causes of strain including repetitive motion, unexpected movements, lifting, rotating/twisting of the neck or trunk, or even emotional stress. Physical examination will reveal limited range of motion, muscle spasm, and tenderness of the muscles that run along the spine.
Factors predisposing to strain include occupations or hobbies that are characterized by repetitive motion in the neck or low back, obesity, deconditioning, poor posture, and extended exposure to vibration (heavy equipment operators).
Another key point is that the spine shares an interdependence with the hips, knees, ankles and feet. So... any problem occurring lower down will eventually lead to spine problems. An example would be a patient with a significant leg length discrepancy.
Structures in the spine that are often responsible for pain syndromes are the discs and the facet joints. The discs can herniate – i.e., the gel inside the disc explodes out and causes pressure on the nerve root. The discs can also degenerate and expand causing nerve root pressure. The facet joints in the back part of the spine can develop arthritis and cause nerve root irritation as well.
Arthritis progression in the spine either in the facet joints or in the disc can lead to narrowing of the spinal canal – a condition called spinal stenosis. Spinal stenosis pain in the low back is aggravated by standing, walking, or extension of the spine. In the neck, stenosis commonly causes pain or difficulty walking.
Sciatica is pain that radiates into the buttock and down the outside of the leg. This is due to pressure on a nerve root from either disc disease or arthritis in the fact joint... or both. Sciatica due to disc herniation is aggravated by sitting or bending forward.
The equivalent to this in the neck is cervical radiculopathy where the pain radiates down the arm or down between the shoulder blades.
Sometimes low back pain will radiate down the front of the thigh. It is important to rule out hip disease, inguinal hernia, pressure on the femoral nerve, aneurysm of the aorta, and kidney disease.
Some other unusual symptoms that are a tip off to more serious problems include pain at night that interferes with sleep (malignancy), pain and stiffness in the morning (ankylosing spondylitis), pain accompanied by fever or weight loss (infection or tumor), back pain accompanied by numbness in a “saddle distribution” and loss of bladder/bowel control (cauda equina syndrome – pressure on all the nerve roots in the lower part of the spine- this is a surgical emergency!) Patients who have arthritis in the spine that causes pressure on the spinal cord in the neck will develop a condition called cervical myelopathy. This causes weakness in the legs and loss of bladder and bowel function. This condition is also a surgical emergency.
Physical examination should evaluate range of motion, the presence or absence of muscle spasm, the presence or absence of nerve root compression signs, deep tendon reflexes, and muscle strength.
A careful examination of organ systems is mandatory to exclude the less common causes of back pain in patients where the history is suspicious.
The laboratory is not particularly useful other than to help exclude systemic causes of spine pain.
Electrical testing can determine the presence of radiculopathy (pinched nerve).
X-rays are not that helpful. Most spine pain syndromes don’t have readily apparent x-ray findings, and the majority of older patients will have x-ray abnormalities that are not symptomatic.
CAT scanning and magnetic resonance imaging are more sensitive and specific for diagnosis.
Spine pain treatment is highly dependent on diagnosis. For the 90 per cent of patients who have mechanical low back pain, a number of modalities have merit. For acute low back syndromes, bed rest for 24 to 48 hours may be helpful but no longer than that since prolonged bed rest is actually detrimental.
Aggressive physical therapy is often helpful. Spinal manipulation (chiropractic) may be beneficial as well.
Specific stretching and strengthening exercises accompanied by non impact aerobic exercise is one of the most helpful modalities. Traction can help in some instances.
Anti inflammatory drugs and muscle relaxants are helpful in alleviating symptoms.
For patients with more chronic problems, a number of modalities have been used with varying degrees of success. Soft tissue, facet, and epidural injections are often helpful. Transcutaneous electrical nerve stimulation (TENS) has also found advocates.
Recent studies have also shown botulinum toxin injections may be helpful for patients with mechanical spine problems associated with muscle spasm. Platelet-rich plasma (PRP) injections may be helpful for ligament injuries that are responsible for muscle spasm.
Surgery is indicated for patients who have intractable pain with a well-defined anatomic reason for the pain and who have a progressive neurological deficit.
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