Back brace spondylolisthesis treatment
In spondylolysis, there is a defect in the pars interarticularis (which literally means the "piece between the articulations"). So spondylolysis means a defect in the thin isthmus of bone connecting the superior and inferior facets, and could be unilateral (involving one side) or bilateral (involving both sides). Although the defect can be found at any level, the commonest vertebra involved is the 5th Lumbar vertebra (or L5). In cases of bilateral spondylolysis, the posterior articulations can no longer provide the posterior stability, and anterior slipping of the L5 vertebra over the sacrum could result. Spondylolysis is the commonest cause of spondylolisthesis, and is sometimes referred to as isthmic spondylolisthesis, since the defect is in the isthmus. But there are other causes of spondylolisthesis. Any infection or tumor affecting the posterior bony ring including the facet joints, can also cause instability and spondylolisthesis. 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 vertebrae aligned - the disc and the facet joints. When a spondylolysis occurs, the facet joint can no longer hold the vertebra back. The intervertebral disc 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. There is a special type of spondylolisthesis in teenagers where the forward slipping is extremely severe. This can lead to the upper vertebra slipping completely off the lower vertebra. Spondylolisthesis is important because it can be a cause of low back pain. Just because you have it does not mean that you will necessarily ever have problems with your back. However, you are at a higher risk than the normal population of developing chronic low back pain. This condition can cause typical mechanical and/or compressive (or neurogenic) type back pain symptoms. The forward slip of the vertebra also makes the spinal canal smaller, leaving less room for the nerve roots. There is usually pain across the small of the back and into the buttocks. If there are compressive symptoms, there may be pain down the leg to the foot, numbness in the foot, and possibly weakness in trying to raise the foot. The diagnosis of spondylolisthesis is dependent on seeing the abnormality on either: X-rays, a CAT scan, or an MRI scan. In most cases, it is easily seen on regular X-rays of the low back. The symptoms are no different from other causes of low back pain. On the other hand, just because you have spondylolisthesis on your X-ray does not mean your symptoms are from the defect. You may still have a herniated disc or some other condition that is causing your pain. Your doctor will need to carefully look for any possible causes of pain. In order to make a proper diagnosis and rule out other possible conditions, the first step is to take a history. The provider may ask about the following: • Date of onset - When did you first notice the appearance of your spinal condition? • The presence or absence of pain - Not all cases of spondylolysis produce pain. However, if there is pain, the doctor will need to know where it is, what brings on or intensifies the pain, and if there is any radicular pain. Radicular refers to pain that radiates away from the spine to other parts of the body. This usually comes from irritation of the nerves as they leave the spine. • Bowel or Bladder Dysfunction - Are you having problems knowing when you have to urinate or have a bowel movement? This is extremely important because it could signal the presence of serious nerve damage. • Motor Function - Has there been a change in how your muscles work? This may be the result of pressure on the nerves or spinal cord itself. • Previous - If you have had any surgery on your spine, it may have caused some type of degenerative spondylolisthesis. In order to evaluate your condition properly, it is important that your physician knows about any spinal surgery you have had in the past. The physician will then perform a physical examination. During the exam, the doctor will try get an understanding of your back problem and how it is affecting you. Finally, your nerves will be tested by: checking your sensation, your reflexes, and the strength of your muscles. Usually, after the examination, X-rays will be ordered that allow the doctor to see the structure of the spine and measure the slippage from the spondylolisthesis. During the X-rays, you will be asked to hold certain positions while standing or lying on a table, and you will need to hold very still while pictures are taken of your spine. Depending on the outcome of your history, physical examination, and initial X-rays, other tests may be ordered to look at specific aspects of the spine. The most common tests that are ordered are: the MRI scan - to look at the nerves and spinal cord; the CAT scan - to get a better picture of the vertebral bones; and special nerve tests - to determine if any nerves are being irritated or pinched. Treatment for spondylolisthesis is not much different than for other causes of mechanical and/or compressive back pain. In most cases, surgery will not be necessary. Strengthening the back muscles can reduce the mechanical symptoms resulting from the segmental instability. Medications may be used for short periods to: control pain, ease muscle spasms, and help regain a normal sleep pattern (if you are having trouble sleeping). Short periods of bed rest may help with acute painful episodes. For Grades 1 and 2, conservative treatment is usually instituted. This will be similar to treatment for spondylolysis, except for use of a rigid Lumbosacral orthosis LSO or thermoplastic brace), and intensive physical therapy to strengthen the back and abdominal muscles, as well as stretching exercises for the tight hamstring muscles. X-rays (lateral views only) are done every 3 to 6 months to check on the severity of the slip. If the patient responds to conservative treatment, the pain resolves, the hamstring tightness improves, and the patient may return to limited sports. Gymnastics, weight-lifting and football should be avoided. If the pain does not improve, or if follow-up X-rays demonstrate further slip, surgery may be needed. Surgery consists of fusing the L5 to the S1 vertebrae to prevent further slipping. Depending on the degree of slip and other factors, your surgeon may fuse the vertebrae "as is", or fuse the vertebrae after attempting to reduce the slip. This latter technique entails significant risk to the spinal nerves, and will have to be taken into consideration in the pre-operative planning. 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. Surgical treatment for spondylolisthesis must address both the mechanical symptoms and the compressive symptoms if they are present. Usually this means that the nerves exiting the spine must be freed of all pressure and irritation. Performing a complete laminectomy (removing the lamina) usually does this. Removing the lamina allows more room for the nerves. The result is reduced irritation and inflammation on the nerves. Once the nerves are freed, a spinal fusion is usually performed to control the segmental instability.
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