Degenerative disease of the spine (also known as spondylosis, arthritis or simply wear and tear) is part of the normal ageing process. All age groups can be affected. Whilst the process cannot be reversed, it can be slowed down by taking care of the spine, specifically paying attention to posture, avoidance of unnecessary lifting (and doing so in a sensible way). For the lumbar spine weight control and strengthening of core and back muscles also help: muscles can be developed and can share the load with the spine, reducing wear on the discs and facet joints.
The most frequent symptom is pain. For the majority of patients, pain is self-limiting, and generally respond to simple measures such as rest, pain-killers and anti-inflammatories, and physiotherapy / manipulation / massage. In a tiny proportion of cases, symptoms may be due to more serious problems (eg trauma, infection, tumour), and an assessment by a doctor is important if symptoms persist. If serious problems are ruled out, most patients will require pain relief in order to embark upon an appropriate exercise program to restore posture and develop muscle strength.
Degenerative disease of the spine usually starts in the intervertebral discs (the cartilaginous shock absorbers between the individual vertebrae in the spine). Degenerate changes result in abnormal motion in the segment and secondary degenerative changes in the ligaments and the facet joints. These changes may cause localised pain or compression of nerve roots that travel through the spine or the spinal cord itself. When these structures are compressed there are often symptoms of pain / tingling/ numbness or cramps in the limbs, weakness and clumsiness may develop as well.
Younger patients (under 50 years old) often develop disc prolapse - i.e. a fragment of degenerate disc material that bulges or ruptures into the spinal canal to compress the nerves or spinal cord. In association with the mechanical pressure on the nerve there will be some associated inflammation. Both processes combine to provoke symptoms. Local pain results in localised muscle spasm that contributes to the back or neck pain, and the spine can become quite twisted or contorted. The muscle spasm can result in severe pain. In the lumbar spine, the symptoms tend to be worse in the sitting position due to increased pressure through the disc, with lying best.
In older patients, thickening of the ligaments and arthritic changes in the facet joints can result in nerve root or spinal cord compression. In the lumbar spine, the symptoms are worst when standing fora duration or when walking, patients often bend forwards or lean on a stick or trolley to improve symptoms.
Disc prolapses generally tend to shrivel up. Inflammation also usually settles. Over 98% of patients with symptoms from disc prolapses get better over a few weeks. Pain relief may be needed whilst waiting for disc prolapses to shrivel up and inflammation to settle. Anti-inflammatories (eg ibuprofen, diclofenac, naproxen) are best taken regularly over 2-6 weeks. Pain killers e.g. cocodamol, tramadol and morphine (tablets or patches) can be taken as required. Special tablets can reduce or control pain from the nerves themselves e.g. amitriptyline, gabapentin or pregabalin. These tablets can have side effects, including causing drowsiness.
Injection therapy is best delivered by pain specialists. A steroid injection can target local inflammation without having widespread side-effects like tablets can cause. Targeted injections may be required if tablets fail and there is no surgical option e.g. when pain persists but disc prolapses have settled, when patients have excessive risks from surgery or anaesthetic, when patients wish to avoid surgery, to temporise if tablets are ineffective.
Surgery has an important role in degenerative disease of the spine. Surgeons can cut away lumps of worn disc material to relieve the pressure on the nerves or spinal cord. Generally surgery in the lumbar spine is performed from behind, and in the neck from in front, but there are some excellent options from behind. Decompressive surgery is associated with excellent results in appropriately selected patients. Sometimes decompression is not associated with relief of symptoms - and this may be because time is required for the nerves to heal. In my experience 85-90% of patients have an excellent result, with complications in less than 5%, and the remaining having uncomplicated outcomes, but without relief of symptoms. In this group, prolonged medications may be required, and pain specialists may have an important role to play. In my experience, nerve injury from surgery is very rare. Rates reported in the literature can be around 2% of cases. This could result in pain, weakness, numbness in limbs, and possibly incontinence and loss of sexual function.
Implants in the lumbar spine are very rarely needed. Their use increases the complexity of surgery, leading to increased risks. Implants are important in stabilising the spine in trauma (fractures), some tumour work, and in deformity correction. Occasionally some patients could develop instability after decompression, and stabilisation (fixation) at the time of decompression may be important. Lumbar instrumented fixation and fusion or disc replacement for back pain has a 50% chance of benefit, with 15% complication rate, and is proven to be worse than an intensive physiotherapy programme.
By contrast, disc replacement or fusion in the neck are a standard part of the surgical procedure of decompression of the spinal cord or nerve roots, and are associated with excellent short and long term results. Again, results are very poor if offered to treat neck pain alone, and there can be long term implications.
In my own experience I expect patients to be walking on the day of surgery, and home on the day after surgery. I quote 85-90% chance of success, with less than 5% risk, with nerve injury being exceptionally rare. Sometimes, the chance of success may be lower, but the risk remains the same, for patients with atypical (unusual) symptoms, who have failed all alternatives, and have significant compression of nerves. For all patients undergoing surgery, the aim is to return to normal activities. It is vitally important that healing occurs first, and then appropriate exercises are performed to strengthen the muscles to support the spine. In a proportion of patients, physiotherapists have an important role in guiding the exercise programme. The programme should be lifelong. Currently I am undertaking approximately 200 spinal decompressions each year (30% neck, 70% lumbar), with no lumbar devices (rods or screws). In the neck I am increasing the proportion of disc replacements, but still undertake more fusions.
General tips:
- Always give medications and physiotherapy a chance, especially after assessment by a specialist.
- Have realistic expectations about the aims and results of surgery.• Avoid speculative surgery.
- Choose injection therapy from a pain specialist rather than an orthopaedic surgeon (very few neurosurgeons undertake injections), pain specialists have a greater range of options. (Exception, in rare cases, the response to an injection can guide the orthopaedic surgeon when planning surgery).
- Ask the surgeon for their expectations, and experience in your situation.
- Avoid lumbar spine implants unless offered by surgeons specialising in high volume lumbar instrumentation - and ask specifically for their rates of success and complications.
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About Mr Raghu Vindlacheruvu:
Mr Raghu Vindlacheruvu is a neuro-surgeon in Springfield Hospital in Chelmsford.
Raghu Vindlacheruvu qualified as a doctor from Cambridge University in 1993. He is a key member of a team of seven consultant neurosurgeons, who are developing a first-class service for the adult population of Essex and North-East London affected by disorders of the brain or spine.
Mr Vindlacheruvu is a member of the British Medical Association, Royal College of Surgeons of England and British Neurovascular Group.
Raghu Vindlacheruvu has expertise in a range of back and neck operations, including cervical disc replacement and minimally invasive techniques (keyhole surgery) for the decompression of spinal cord and nerve roots in degenerative disease of the spine (spondylosis) and treatment of benign and malignant tumours. He always takes an evidence-based approach.
Read more about Mr Vindlacheruvu qualifications, background and clinical interests.
About Ramsay Health Care UK
Ramsay Health Care UK is a leading provider of spinal surgery and non-surgical back pain treatments in the UK.