The main diseases of the lumbar spine are: degeneration, disc herniation, discopathy, spondylolisthesis, neuritis, osteophytes, inflammation, radiculitis, lumbago.
Regarding degeneration one should emphasize that it is due to the deterioration of anatomical characteristics over time. This includes both the spinal joints as well as the ligaments and muscles, tendons and surrounding tissues.
The term hernia on the other hand means a bulge which is present on the surface of the intervertebral disc. When this condition occurs the patient complains of severe pain in the lumbar spine. The condition is usually as a result of sudden movement and weight lifting.
Another condition of the lumbar spine is spondylolisthesis. This is the slipping or displacement of the upper vertebra on the lower. Spondylolisthesis is usually the result of a chronic degenerative condition of the lumbar spine.
Osteophytes are bony projections formed as a result of micro lesions of the vertebra caused by degenerative processes.
Another condition is neuritis caused by local inflammation due to irritation of the nerve root. In this case as well the neuritis is usually the result of a chronic degenerative condition of the lumbar spine.
Back pain, sciatica, lumbar disc herniation
The main cause of sciatica is pressure on the nerve root of lumbar spine. However for displacement of disc substance into the spinal canal or intervertebral foramen to occur there must be certain preconditions such as partial or total rupture of the fibrous ring in the posterior part of the disc.
Pressure of the nucleus pulposus on the fibrous ring causes the weaker section of the fibrous ring succumbs to the pressures of nucleus pulposus, it gradually expands and eventually the disc tissue is projected into the spinal canal or inner foramen. When the rupture is only in the inner layers of the fibrous ring up to the posterior longitudinal ligament, then the lesion is characterized as a protrusion of the disc. However a total rupture of the fibrous ring creates a passage for the nucleus pulposus. This is then a genuine prolapse of the intervertebral disc. If the hernia which has extruded is still connected to the interior of the disc it is possible under certain conditions for it to return to its original position. His condition is described as a retrograde hernia. Central hernias are the exception, because the posterior longitudinal ligament in the middle of the fibrous ring protects the disc and thus prevents its exit. Most commonly the disc L5/S1 is affected followed by L4/L5 and L3/L4.
Clinical Picture
The clinical picture is characterized by : severe pain, reduced mobility to a large degree with deformation of the spine (antalgic scoliosis), pain in the lumbar-sacral region when coughing and sneezing, pain when tapping and putting pressure at the position of the lesion and radicular leg pain. Deviations of reflexes, motor and sensory disorders of the lower limbs legs make it possible to locate the position of the lesion.
Conservative treatment advised is bedrest in a raised position(hips and knees at a 90° angle by placing more pillows under the knees.)This position neutralizes the patient’s lumbar lordosis and relieves the rear of the intervertebral disc. Furthermore, analgesics, anti-inflammatory and muscle relaxant medication are prescribed. Also, blocking the nerve root with a suitable local anesthetic can have good results. After the acute pain has subsided treatment is continued with physiotherapy (electrical stimulation, massage, spas, chiropractic techniques).
When conservative treatment fails to bring results and the neurological lesions increase, then surgical removal of the protruding disc tissue is indicated(discectomy). After the surgery the patient is immediately relieved of the symptoms. Physiotherapy is needed however to restore mobility and muscular strength. Cauda equina syndrome is a definite indication for surgery. This is a special type of lumbar disc herniation, mostly a mass central disc prolapse. The presence of loss of bladder/bowel control and bilateral perineal anesthesia help to make a quick diagnosis.
Diagnosis:
Initial diagnosis of lumbar disease is primarily obtained with simple x-ray and dynamic tests in extreme positions. With the x-rays we check the bony lesions, the intervertebral spaces, foramina, the alignment of the vertebrae.
We gain more information after a CT of the lumbar spine is performed. The bony lesions and soft tissues are imaged with greater clarity.
MRI is considered test of choice due its excellent enhancement of lumbar spine disorders. It highlights lesions of the discs, ligaments, muscles, joints, bones and the subcutaneous tissue and skin.
CT- myelography is used in cases where magnetic resonance (MRI) cannot be performed provided that it can be carried out safely and with minimal complications.
It often seems useful to evaluate an electromyography (EMG) of the lower limbs especially when lesions are multilevel and difficult to examine clinically, so that the evaluation of electromyography can assist in the final preparation in the planning of the surgery and surgical decision.
Lesions of the intervertebral disc
Chondrosis, Osteochondrosis, spondylosis
The process of degeneration of the intervertebral disc begins with the loss of water from the nucleus pulposis. This is followed by loss of elasticity and tissue damage to the disc with early stenosis of the intervertebral space. This lesion is described as intervertebral chondrosis (chondrosis intervertebralis).
The degeneration of the quality of the intervertebral disc, which is included in the general concept of "lesions of the intervertebral disc" is closely linked to posture problems of humans. In an effort to maintain posture, the discs contribute as a means to help absorb load forces, flexion and rotation and the uniform transfer of powerful loads. Besides stabilizing the vertebrae, they provide the necessary mobility of the spine. Premature, lengthy and excessive mechanical stress are causes of disc degeneration.
For the assessment of degenerative changes of the intervertebral disc, which can generally be checked radiographically, it is important for us to know if the body has been able to stabilize the affected mobile disc. If the intervertebral space is surrounded by a strong ring of osteophytes, then this development of osteophytes can be defined as a type of healing, which although it removes the mobility of the affected disc, it relieves the patient from pain and makes it possible for it to accept loads.
Treatment
The treatment chosen depends on the cause.
Conservative treatment is consists of:
Bedrest:
Although the majority of patients with lumbar sciatica do not require bedrest, some patients with intense lumbar sciatica(radicular symptoms ie. pain travelling down the limb is sciatica with or without tingling -numbness, pins & needles and / or dysesthesias –burning sensations- electric shock like sensation) can benefit from 5-7 days of bedrest. The benefit is that in a supine position the following are excluded: a) the factor of gravity which as a result reduces the compression of the affected anatomical structures of the spine and B) painful movements which the patient is experiencing are restricted. It is now commonly accepted that the bedrest should not exceed 7 days, after which a gradual return to normal physical activity should begin. In a randomized clinical trial, bedrest for more than four days was accompanied by a longer period of recovery, increased muscle weakness and increased incidence of complications, mostly in the form of deep venous thrombosis.
Restriction of Normal Activities
The objective here is to maintain the everyday activities of the patient, with minimal discomfort from their condition. Limiting weight lifting, prolonged sitting or standing is recommended, and recommendations are given for correct posture in daily activities as well as sleeping. The majority of patients with lumbar sciatica regardless of the cause, will improve to some extent by adhering to a daily schedule of spine care.
Exercise:
Exercise, possibly as part of an integrated program of physiotherapy, may help not only the remission of symptoms but also prevent the recurrence of pain. Moderate aerobic exercise which places no strain on the spine (eg swimming) is recommended. After 2 weeks, the patient may begin strengthening exercises for back and abdominal muscle groups, with gradually increasing intensity. International studies recommend controlled exercise with gradually increasing intensity - from the early days of a lumbar sciatica crisis- allows the patient to resume to normal activity sooner than the traditional limitation of any physical activity.
Analgesics :
The use of analgesics (paracetamol or NSAIDS) can help control the pain the first few days. In some cases of intense radiculopathy however the use of opioids are required. In both cases, the use of analgesics is not accompanied by a reduction in the total recovery time of patients with non-specific lumbar sciatica.
Muscle relaxants:
Despite popular belief, muscle spasms play a very small part in lumbar sciatica. However, it seems that the administration of muscle relaxants relieve pain more than placebo preparations. They should not be administered for longer than 3 weeks.
Patient Education
The briefing – training may be part of more comprehensive rehabilitation program and informing the patient on issues related to their condition, treatment and prognosis is recommended. The patient should be trained in the correct posture during physical activity and sleep, proper weight lifting techniques, other daily activities etc.
Local injection Therapy:
Epidural glucocorticoid injections - local anesthetic are not recommended for the relief of lumbar sciatica, either in the acute or chronic phase. The epidural injections can be of benefit in the relief of acute sciatica (radicular pain) in cases where conservative treatments have failed or are unsuitable for surgery. For back pain without sciatica there are no indications that epidural glucocorticoid injections - local anesthetic and/or opioids are effective.
Alternative Therapies:
Other types of physical therapies are included in the treatment of sciatica such as Transcutaneous electrical nerve stimulation- TENS, ultrasound therapy, diathermy, LASER, acupuncture and hypnotherapy, but their use is experimental and their effectiveness limited.
Not recommended:
Steroids have no benefit in the treatment of acute non-specific sciatica. An international study showed that oral administration of dexamethasone had no benefit in relieving pain. The same was shown in a corresponding study for anti-depression treatment.
Surgical treatment is indicated for cases which do not improve with conservative therapy as well as for the following:
Surgical Treatment:
From the above it is clear that acute non-specific sciatica is a benign disease, which has a good chance of cure even with minimal medical intervention.
The surgical indication arises only in cases where there is persistent lumbar sciatica with or without neurologic deficit when there is imaging correlation-confirmation (MRI) of underlying structural damage, eg disc herniation, Synovial cyst, facet syndrome, tumor, hematoma, infection, osteoporotic fracture.
Intervertebral disc herniation(IDH):
- 75% of patients with acute lumbar sciatica due to IDH will improve with conservative methods. Nonetheless, the presence of sciatica (radiculopathy) with radiographically confirmed IDH may indicate surgery when it extremely persistent (it does not subside after 4-8 weeks of analgesic treatment) and the patient wants immediate relief.
- The presence of progressive neurological disorder (mainly motion eg, foot drop) indicates surgery. The presence of paresis for more than 5-8 weeks is a relevant indication that the benefit of the surgery with respect to motor restoration is doubtful.
- The presence of cauda equina syndrome(bowel and bladder disturbances, muscle weakness in both extremities, multiradicular distributed numbness) is an indication for emergency surgical treatment (within 24 hours).
Synovial cyst
Synovial cysts are a rare benign entity that can cause intense lumbar sciatica. Although conservative measures (facet injected corticosteroids) can bring temporary relief, surgical has very good results in more than 80% of cases.
Facet syndrome
Facet syndrome is the irritation or degeneration in one or more joints between the vertebrae. The pain remains constant in a specific area of the waist and may radiate to the buttocks and back of the thigh, and rarely radiates beyond the knee. The pain worsens when stretching and walking. In the cases where there is radiographic confirmation of compression of the roots by elements of the ipsilateral joint and the pain is persistent – prolonged, percutaneous treatment (injection of corticosteroids or electrocoagulation) or surgical treatment is recommended.
Other Causes
Rare cases of lumbar sciatica which require further investigation and possible surgical treatment are:
- Tumors of the spine or spinal cord (metastatic tumors or hematopoietic tumors, meningiomas, neurofibromas)
- Epidural hematoma (traumatic or automatic in patients with clotting disorders)
- Infection of bone and nerve tissue (tuberculosis, osteomyelitis, etc.)
- Implicit- minor trauma
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CONCLUSIONS
The decision for conservative or surgical treatment must include the following parameters:
- Duration of lumbar sciatica
- Underlying nature of the anatomical lesion causing the lumbar sciatica
- Age, general health and psychological state, personality
- Lack of response to conservative treatment
- Selection of appropriate surgical treatment - experience of the surgeon
Surgical treatment is indicated only with a confirmed disc herniation, where the symptoms remain unaffected by conservative treatment and coexisting instability. Surgical treatment is recommended firstly to remove the hernia and secondly by the fusion of adjacent vertebrae.
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