Listhesis

Anatomy -

In our spine there are total 33 vertebrae ... those are arranged one over the other like a building ... those are divided into four anatomical segments ,

1.     Cervical

2.     Thoracic

3.     Lumbar

4.     Sacral

Functional unit of spine -

Movements in spine occurs at functional unit of spine . These are comprised of

-    Vertebra above ( Bone )

-    Intervertebral Disc

-    Vertebra below ( Bone or vertebral body )

-    Facet joints

-    Adjoining ligaments

Our spine is always under load and stress . When we sit, stand and walk movements occurs at this functional unit . So this unit is always under stress ...

Pars Interarticularis -  as the name, its inter-articularis….. means it joins the facet joints in spine. It is located between superior and inferior articular process of facet joint.

What is a Listhesis ?

Listhesis means slipping of one vertebra over other .... the above or upper vertebra slips over lower vertebra .

Classification for Listhesis

Spondylolisthesis has several main causes. There is a classification system to help talk about the different causes of spondylolisthesis

Type I: This is also called dysplastic or congenital spondylolisthesis. Congenital means that you're born with it. Type I spondylolisthesis, then, is a defect in the articular processes of the vertebra (the part that's supposed to control the movement of the vertebra; your facet joints are made of the articular processes). It usually happens in the area where the lumbar spine and the sacrum come together: the L5-S1 area. The defect allows the L5 vertebra (your last vertebra in your lumbar spine) to slip forward over the sacrum.

Type II: Also called isthmic, this is the most common kind of spondylolisthesis. With type II spondylolisthesis, there's a problem with the pars interarticularis, a particular region of your vertebra. Isthmic spondylolisthesis is divided further:

Type II A: Gymnasts, weight lifters, and football linemen are especially prone to this kind of spondylolisthesis. It's caused by multiple micro-fractures on the pars interarticularis—micro-fractures that occur because of hyperextension (overarching) and overuse. The pars fractures completely in type II A.

Type II B: This type is also caused by micro-fractures. The difference, though, is that the pars don't fracture completely. Instead, new bones grow as the pars heals, causing it to stretch. A longer pars can then cause the vertebra to slide forward.

Type II C: Like type II A, this type has a complete fracture. However, it's caused by trauma, injury The impact in a car accident could fracture your pars, for example.

A pars fracture can lead to a mobile piece of bone; the detached inferior articular process can actually move around. This bone fragment, also called a Gill fragment, can pinch the exiting nerve root, so the bone may need to be removed.

Problems with the pars interarticularis can also be called spondylolysis. The word looks like spondylolisthesis, and they are somewhat related. Micro-fractures in the pars interarticularis—the kind that gymnasts, football linemen, and weightlifters are prone to—are a form of spondylolysis. The fractures are called spondylolysis; if the vertebra slips forward because it's not being held in place properly, it's called spondylolisthesis.

Type III: Aging can also cause spondylolisthesis. As you grow older, the parts of your spine can degenerate; they can wear out. Usually your intervertebral discs change first. The older you get, the less water and proteoglycan content the discs have—and less fluid makes them less able to handle movement and shock. Less fluid can also cause the disc to thin, and a thinner disc brings the facet joints closer together. Without the disc acting as the cushion, the facets can't control the spine's movement as well, and they become hypermobile. Eventually, a vertebra can slip forward because the facets aren't holding it in place effectively as the spine moves. Type III spondylolisthesis usually happens at the L4-L5 region (the fourth and fifth vertebrae in your low back), and it's more common in women older than 50 years old.

Type IV: Similar to type II C, type IV involves a fracture. However, it's a fracture of any other part of the vertebra other than the pars interarticularis. Your facet joints, for example, can fracture, separating the front part of your vertebra from the back part.

Type V: Tumors on the vertebra can also cause spondylolisthesis because they weaken the bones and can cause fractures that split your vertebra, leading to instability and a potential slip.

Type VI: You have this type of spondylolisthesis if surgery caused your vertebra to slip forward. It's also known as iatrogenic spondylolisthesis, and it's caused by a weakening of the pars, often as a result of a laminectomy (a typical back surgery, but type VI spondylolisthesis isn't a typical result of the surgery).

Slip Grades

Using the lateral (side) x-ray, your doctor will grade your spondylolisthesis. He or she will use a grade I through grade V scale that describes how far forward your vertebra has slipped.

Grade I is a less than 25% slip.

Grade II is a 25% to 49% slip.

Grade III is a 50% to 74% slip.

Grade IV is a 75% to 99% slip.

Grade V is for a vertebra that has fallen off the vertebra below it. (That's an extreme case of spondylolisthesis that has its own name: spondyloptosis.)

Symptoms of Spondylolisthesis

1.     Back pain

2.     Lower limb pain / Leg pain

3.     Thigh pain

4.     Calf pain

5.     Tingling and Numbness

6.     Leg pain and numbness after standing for long time

7.     Back pain after sitting for long time

8.     Made to sit after standing for long time

9.     Pain and Numbness in legs after walking for some distance, made to sir in between due to pain and Numbness

10.  Neurological claudication and decreasing distance day by day

11.  Weakness in legs , either one or two

12.  Heaviness in legs , either one or two

13.  Difficulty in urine , frequent passing of urine , difficult to control urine

14.  Difficult to control motion

15.  Numbness in private parts

16.  Disturbed sleep due to pain

Signs -

1.     Tenderness in spine

2.     Facetal tenderness

3.     Slip palpable in high grade Listhesis

4.     SLR may be free for lower limbs

5.     Hamstring tightness

6.     Neurodeficit

Treatment options

1.     Conservative – Medications like Pain killers, anti inflammatory , Pregabalin medicaitons

2.     Pain Block

Indications for surgery –

1.     Failed conservative treatment for longer time

2.     Worsening of symptoms

3.     Decreasing claudication distance

4.     Persistent back pain

5.     Back pain disturbing in sleep

6.     Weakness in one or two legs

7.     Difficulty in holding chappals in legs or history of sleeping of chappals from legs

8.     Difficulty in passing urine or motion

Surgery in the form of Lumbar Decompression with or without stabilisation

Mechanical Low back ache

This is the most common type of back pain. The majority of cases of sudden-onset (acute) low back pain are classed under this name. This is the type of back pain that most people will have at some point in their lives. It is called mechanical because it is usually not clear what is actually causing the pain. In other words, there is no specific problem or disease that can be identified as the cause of the pain. The severity of the pain can vary from mild to severe.

What is the cause of mechanical low back pain?

Mechanical low back pain means that the pain is not due to any specific or underlying disease that can be found. It is thought that in some cases the cause may be an over-stretch (sprain) of a ligament or muscle. In other cases the cause may be a minor problem with a disc between two spinal bones (vertebrae), or a minor problem with a small facet joint between two vertebrae. There may be other minor problems in the structures and tissues of the lower back that result in pain. However, these causes of the pain are impossible to prove by tests. Majority of pain is there in patients who are having sitting job, lack of exercises and improper diet.

To some people, not knowing the exact cause of the pain is unsettling. However, looked at another way, many people find it reassuring to know that the diagnosis is mechanical back pain which means there is no serious problem or disease of the back or spine.

Disc degeneration due to vitamin deficiency ( Vit B12, Vit D3 ) is also one of the cause for mechanical low back ache .

What are the symptoms of Mechanical low back pain?

Sometimes a pain may develop immediately after you lift something heavy, or after an awkward twisting movement. Sometimes it can develop for no apparent reason. Some people just wake up one day with low back pain.

Although mechanical back pain is sometimes called simple back pain, simple does not mean that the pain is mild. The severity of the pain can range from mild to severe. Typically, the pain is in one area of the lower back but sometimes it spreads to one or both buttocks or thighs. The pain is usually eased by lying down flat. It is often made worse if you move your back, cough, or sneeze. So, nonspecific low back pain is mechanical in the sense that it varies with posture or activity.

Most people with mechanical low back pain improve quickly, usually within a week or so, sometimes a bit longer. However, once the pain has eased or gone it is common to have further bouts (recurrences) of pain from time to time in the future. Also, it is common to have minor pains on and off for quite some time after an initial bad bout of pain. In a small number of cases the pain persists for several months or longer.

1.       Constant dull aching low back ache

2.       Usually not having radiation of pain in lower limbs

3.       Usually not associated with tingling and numbness

4.       Experience pain on sitting rather on standing and walking’

5.       Usually no pain on standing and walking

6.       Sometimes severity of pain increases

What is the treatment for mechanical low back pain?

Keeping active

Continue with normal activities as much as possible. This may not be possible at first if the pain is very bad. However, move around as soon as you are able, and get back into normal activities as soon as you can. As a rule, don't do anything that causes a lot of pain. However, you will have to accept some discomfort when you are trying to keep active. Setting a new goal each day may be a good idea. For example, walking around the house on one day, a walk to the shops the next, etc.

Also, sleep in the most naturally comfortable position on whatever is the most comfortable surface. Advice given in the past used to be to sleep on a firm mattress. However, there is no evidence to say that a firm mattress is better than any other type of mattress for people with low back pain. Some people find that a small firm pillow between the knees when sleeping on the side helps to ease symptoms at night.

If you have a job, aim to get back to work as soon as possible. There is no need to wait for complete freedom from pain before returning to work. Returning to work often helps to relieve pain by getting back to a normal pattern of activity and providing a distraction from the pain.

Medication

If you need painkillers, it is best to take them regularly for short time… This is better than taking them now and again just when the pain is very bad. If you take them regularly the pain is more likely to be eased for much of the time, enabling you to exercise and keep active.

Anti-inflammatory medicines

Muscle relaxant medicines

Physiotherapy

1.     Modalities

2.     Most important is exercises , one should do exercises as advised by physiotherapist , at least twice a day for 20 mins each.

Pain Block – Facet Blocks..

Cervical Spondylosis

Basic Anatomy

The back of the neck includes the cervical spine and the muscles and ligaments that surround and support it. The cervical spine is made up of seven bones called vertebrae. The first two are slightly different to the rest, as they attach the spine to the skull and allow the head to turn from side to side. The lower five cervical vertebrae are roughly cylindrical in shape - a bit like small tin cans - with bony projections.

The sides of the vertebrae are linked by small facet joints. Between each of the vertebrae is a 'disc'. The discs are made of a tough fibrous outer layer and a softer gel-like inner part. The discs act like 'shock absorbers' and allow the spine to be flexible.

Strong ligaments attach to adjacent vertebrae to give extra support and strength. Various muscles attached to the spine enable the spine to bend and move in various ways.

The spinal cord, which contains nervous tissue carrying messages to and from the brain, is protected by the spine. Nerves from the spinal cord come out from between the vertebrae in the neck to take and receive messages to the neck and arms. A major blood vessel called the vertebral artery also runs alongside the vertebrae to carry blood to the rear (posterior) part of the brain.

What is cervical spondylosis?

Cervical spondylosis is an age-related degeneration ('wear and tear') of the bones (vertebrae) and discs in the neck. To an extent, we all develop some degeneration in the vertebrae and discs as we become older. It tends to start sometime after the age of about 30.

One feature of the degeneration is that the edges of the vertebrae often develop small, rough areas of bone called osteophytes. Also, over many years, the discs become thinner. This degeneration is a normal ageing process which can be likened to having 'wrinkles in the spine'. In many people, the degeneration does not cause any symptoms. For example, routine X-rays of the neck will show these features (osteophytes and disc thinning) in many people who do not have any symptoms.

However, in some people, the nearby muscles, ligaments, or nerves may become irritated or 'pressed on' by the degenerative changes. So, cervical spondylosis often causes no problems but can be a cause of neck pain, particularly in older people

What are the symptoms of cervical spondylosis?

If symptoms develop, they can range from mild to severe. Symptoms may include:

·       Pain in the neck:

·       This may spread to the shoulders and base of the skull. Movement of the neck may make the pain worse.

·       The pain sometimes spreads down an arm to a hand or fingers. This is caused by irritation of a nerve which goes to the arm from the spinal cord in the neck.

·       The pain tends to come and go with flare-ups from time to time. You may have a flare-up of pain after unaccustomed use of your neck, or if you sprain a neck muscle or ligament.

·       However, a flare-up often develops for no apparent reason. Some people develop chronic (persistent) pain.

·       Some neck stiffness, particularly after a night's rest.

·       Headaches may occur. The headaches often start at the back of the head just above the neck and travel over the top to the forehead.

·       You may develop 'pins and needles' in part of an arm or hand. This symptom is caused by irritation of a spinal nerve as it leaves the bony (vertebral) area. However, do tell a doctor if loss of feeling (numbness) or weakness develops in a part of a hand or arm. These symptoms suggest more pressure on a nerve. This is called a 'cervical radiculopathy'.

·       sometimes, clumsiness of a hand, problems with walking, or problems with bladder function occur when pressure from a worn bone (vertebra) or disc damages the spinal cord. This is called 'cervical myelopathy'. Again, it is important to report these symptoms to a doctor.

What are the treatments for cervical spondylosis ????

Medicines

Painkillers are often helpful. Should not be used for long time…..

Physiotherapy

1.     Cervical Traction

2.     IFT to neck

3.     Hot packs

4.     TENS to upper limb

5.     Manual therapy

Other treatments

Some other treatments which may be advised include:

·       A good posture may help. Check that your sitting position at work or at the computer is not poor (that is, not with your head flexed forward with a stooped back). Sit upright. Yoga, Pilates and the Alexander Technique all improve neck posture; however, their value in treating neck pain is uncertain.

·       A firm supporting pillow seems to help some people when sleeping. Try not to use more than one pillow.

Pain Block – can be used intermediate pathway for pain relief before surgery if pain doesn’t relives with the help of medicines…

Indications for surgery-  ( Red Flags )

1.       Rarely required

2.       Failed conservative trial for longer duration

3.       Was better for some time after pain block and symptoms again recurred

4.       Weakness in upper limbs

5.       Sever tingling and numbness upper limbs with large disc prolapse in MRI

6.       Difficulty in walking , loss of balance while walking

7.       Difficulty in passing urine and motion

Surgical Options available….

Cervical Fusion Surgery

Cervical Disc replacement surgery

             

Disc replacement surgery

Cervical myelopathy

This occurs when there is pressure on or damage to the spinal cord itself. Again, cervical spondylosis is a common cause of this condition, as the degenerative changes to the vertebra can narrow the canal through which the spinal cord passes. A prolapse of a cervical disc can also cause myelopathy if the prolapse is into the central canal of the vertebra. This may happen suddenly or develop over a period of time. There are various other rare causes of cervical myelopathy. For example, a tumour or infection that affects this part of the spinal cord.

As the spinal cord is made up of groups of nerve fibres carrying messages to the brain from the rest of the body, pressure on these nerves in the neck region can produce symptoms from several parts of the body.

The symptoms of a cervical myelopathy may include:

·       Difficulties with walking. For example, the legs may feel stiff and clumsy.

·       Changes to the sensation of the hands. For example, it may be difficult to feel and recognise objects in the usual way and you may have a tendency to drop things.

·       Problems with your bladder. For example, you may experience problems with emptying your bladder, or incontinence.

·       Needs support while walking like a stick or walker

·       Eventually not able to walk and patient requires either wheelchair or stature..