Outweigh Benefits of Surgery for Spondylolisthesis Mediated Low Back Pain
You may have SPONDYLOLISTHESIS, when one vertebra in the spine slips over another, or SPONDYLOSIS, a type of arthritis.Direct injury to the spine may cause a bone fracture anywhere along your vertebral column. Osteoporosis — loss of bone density — can weaken vertebrae, causing them to fracture or collapse.The following conditions may require surgery if they're progressive, painful or causing nerve compression:
- Scoliosis, a curvature of the spine
- Kyphosis, a humpback deformity
- Spondylolisthesis, the forward slippage of a segment of the spine
Your lower back is called your lumbar spine. It is made up of five bones called lumbar vertebrae. The vertebrae have two major parts, a solid part called the body and a bony ring through which the lower part of the spinal cord and nerves travel. Between the bodies of the vertebrae is shock absorbing material called disks. Part of the ring of each vertebra, called the pars, touches the vertebra above it and the vertebra below it.
Spondylolysis and spondylolisthesis are not your everyday terms thrown around by people who suffer from back pain. However, for some people, these words do have meaning. These two conditions affect about five to six percent of the population, and can lead to chronic back pain.The compressive forces that aggravate the condition are magnified if the individual has an exaggerated lumbar lordosis. When the lumbar lordosis is increased, the posterior vertebral arch bears a greater percentage of the upper body weight.
Spondylolysis refers to a defect in one of the vertebra in the lower back, usually the last vertebra of the lumbar spine.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.Spondylolisthesis is officially categorized into five different typed by the Wiltse classification system: Dysplastic, Isthmic, Degenerative, Traumatic, and Pathologic.
Approximately 5-6% of males, and 2-3% of females have a spondylolisthesis. It becomes apparent more often in people who are involved with very physical activities such as weightlifting, gymnastics, or football. Males are more likely than females to develop symptoms from the disorder, primarily due to their engaging in more physical activities.
Spondylolisthesis may be caused by any of a number of problems with the small joints in your back. You could have:
- A defective joint that you've had since birth (congenital).
- A joint damaged by an accident or other trauma.
- A vertebra with a stress fracture caused from overuse of the joint.
- A joint damaged by an infection or arthritis.
Although some children under the age of five may be pre-disposed towards having a spondylolisthesis, or may indeed already have an undetected spondylolisthesis, it is rare that such young children are diagnosed with spondylolisthesis. Spondylolisthesis becomes more common among 7-10 year olds. The increased physical activities of adolescence and adulthood, along with the wear- and-tear of daily life, result in spondylolisthesis being most common among adolescents and adults. Some health care providers feel that certain people are born with weak vertebral rings.
Athletes most commonly troubled by spondylolysis or spondylolisthesis are gymnasts, dancers, and football players. In cases of degenerative spondylolisthesis with spinal stenosis, a condition that affects six times as many women as men and is especially prevalent among African-American women, surgery was twice as effective as non-surgical approaches in reducing pain and restoring functionality for patients.
Unstable stenotic degenerative lumbar spondylolisthesis is a special clinical entity that merits special diagnostic efforts to identify pre-stenotic levels as well as the pathological changes responsible for stenotic symptoms. Although the majority of adult patients with low grade lytic spondylolisthesis can be satisfactory managed with conservative measures, active patients with severe symptoms are uncommonly become satisfied with non operative modalities.
If your doctor determines that a spondylolisthesis is causing your pain, he or she will usually try nonsurgical treatments at first. These treatments may include a short period of rest, anti-inflammatory medications (orally or by injection) to reduce the swelling, analgesic drugs to control the pain, bracing for stabilization, and physical therapy and exercise to improve your strength and flexibility so you can return to a more normal lifestyle.Stabilization exercises are the mainstay of treatment.
Surgery might be necessary if the vertebra continues to slip or if the pain is not relieved by conservative treatment and begins to interfere with daily activities. The main goals of surgery for spondylolisthesis are to relieve the pain associated with an irritated nerve, to stabilize the spine where the vertebra has slipped out of place, and to increase the person’s ability to function.
In the adult patient presenting with degenerative spondylolisthesis in which spinal stenosis is present, a decompression or laminectomy procedure is done, and this is combined with a fusion using implants and bone graft. In some cases, the disc is removed and an interbody fusion is performed as outlined in the section on degenerative spondylolisthesis.
Back surgery is not the final common pathway for everyone with persistent back pain. It offers specific therapy for specific anatomical derangements associated with specific complexes of symptomssurgery may preserve life or function. Absent major neurologic deficits, patients with herniated disks, degenerative spondylolisthesis, or spinal stenosis do not need surgery, but the appropriate surgical procedures may provide valuable pain relief. In such situations, decisions should be made jointly by well-informed patients and their physicians.
A study shown in nonrandomized as-treated comparisons with careful control for potentially confounding baseline factors, patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of 2 years than patients treated nonsurgically.
When it comes to low back pain, physicians generally advise exhausting nonsurgical options before resorting to surgery. But a new study shows that for degenerative spondylolisthesis with spinal stenosis, surgery provides significantly better results than nonsurgical alternatives. The study, published recently in the issue of the New England Journal of Medicine, is the second in a series reporting findings of the Spine Patients Outcomes Research Trial (SPORT), a five-year, multicenter study supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health.
Degenerative spondylolisthesis is a condition in which breakdown of the cartilage between the vertebrae of the spine causes one vertebra to slip over the one below. This can result in narrowing of the spinal column (spinal stenosis), which can put pressure on the nerves, resulting in pain in the buttocks or legs with walking or standing. The condition generally occurs after age 50 and it affects six times as many women as men.
The management of degenerative spondylolisthesis with spinal stenosis is controversial, says James N. Weinstein, D.O., M.Sc., lead author and chairman of the Departments of Orthopaedics at Dartmouth-Hitchcock Medical Center and Dartmouth Medical School. Surgery is widely used, but its effectiveness in comparison with nonsurgical treatment had not been demonstrated in controlled clinical trials. The purpose of this arm of the SPORT trial was to make that comparison.
SPORT followed 601 patients diagnosed with degenerative spondylolisthesis and symptomatic spinal stenosis. Of those, 372 received a surgery called decompressive laminectomy, which involved removing bone and soft tissue to relieve pressure on the nerves. The remaining 235 pursued nonoperative treatments such as physical therapy, steroid injections and analgesic medications. Two years after enrollment in the trial, patients in the nonoperative groups reported modest improvement in their condition; however, patients who had the surgery reported significantly reduced pain and improved function. Furthermore, for the surgery group, relief from symptoms came quickly; some reported significant improvement as early as six weeks after the procedure.
“The SPORT study was undertaken with one purpose in mind: to give physicians and patients solid information that would allow them to make informed choices when faced with a decision of how to treat their back condition,” says Dr. Weinstein. “As a surgeon, it’s very important to me that I have evidence that I can share with my patients as they are trying to decide how to proceed with treatment. Up until now, we suspected surgery produced better results, but we had little objective data to support that. With the results of this study, we can now discuss much more fully the surgical and nonsurgical options available to our patients so that they can make an informed choice.”
The study initially intended to randomize patients into either a surgical or nonsurgical group and then observe and compare the results of the two groups. Unfortunately, a comparison of the two groups wasn’t as easy as hoped. The researchers found that 40 percent of patients crossed over from the group into which they were randomized. That is, members of the nonoperative group chose to have surgery and members of the surgical group decided to forgo surgery for nonsurgical treatments.
For that reason, the researchers compared groups based on the treatment they actually received instead of the treatment group to which they were assigned. Because the scientists were also studying similar patients who wanted to select which treatment they would receive (instead of being randomly assigned to a surgical or nonsurgical option), they were able to pool results from both studies, essentially creating a more powerful osbservational study at the expense of information gained from the statistically rigorous study design originally planned.
Patient crossover was also an issue in the first arm of the SPORT trial, which showed that patients who underwent surgery for another common back problem — herniated discs — experienced slightly more improvement than those who opted for nonsurgical treatments. Results of that trial were published in the Journal of the American Medical Association last November.
Results from the third major SPORT study, on the effectiveness of surgery vs. nonsurgical options for spinal stenosis without spondylolisthesis, are expected to be released later this year.
NIAMS Director Stephen I. Katz, M.D., Ph.D., applauds the SPORT trial, saying its findings are beneficial for people with these common back problems. “While it is generally not a good idea to rush into back surgery, the SPORT trial shows there are conditions for which surgery clearly is the most effective treatment choice. These findings will help doctors better counsel their patients about treatment options.”
Additional support was provided for this research by the NIH Office of Research on Women’s Health and the National Institute of Occupational Safety and Health (NIOSH).