Osteoarthritis of the spine is one of the most common causes of back and lumbar pain in particular. It is a degenerative condition that results in the destruction (degeneration) of the cartilage between the facet joints, part of the posterior elements of the spine that causes a mechanically induced pain.
Facet joints are inflamed and progressive degeneration in the articular surfaces causes increasing pain due to mechanical friction and inflammatory reaction products. At the same time, varying degrees of stiffness are observed, initially at the extreme flexion and extension positions and later on even at simple daily stances.
At the same time, the characteristic bone protrusions, called osteophytes, appear around the vertebral bodies and facets and represent the hopeless effort of the body to respond to the instability created over time. Osteophytes are part of normal aging and do not cause pain to the patient, but can grow to such a degree that they can cause compressive effects and irritation to the spinal nerves and spinal cord (spinal stenosis).
Osteoarthritis (degenerative spine) of the spine is anatomically divided into two categories:
- Lumbar Osteoarthritis which causes pain in the lumbar region
- Cervical Osteoarthritis which causes pain and stiffness with reflection to the shoulders and hands
There are a number of causes that can be associated with the development of osteoarthritis. However, as with all pathological conditions, a combination of risk factors is needed to develop osteoarthritis.
Repeated minor injuries (sports injuries, traffic accidents), poor posture and heavy weight lifting are common causes of degenerative osteoarthritis.
As mentioned above, athletes and people performing heavy manual labor are at greater risk of developing early degenerative lesions. In addition, a number of risk factors affect the development and course of the disease:
- Age – Aging: The constant and progressive degeneration of spine structures associated with the patient’s working habits.
- Gender: Osteoarthritis of the spine is more common in women during the postmenopausal period (at ages below 45 years it is more common in men).
- Obesity: results in greater mechanical loads on the spine joints.
- Genetic factors: Family history plays a key role in the development of osteoarthritic lesions.
- Comorbidities: The presence of conditions such as diabetes mellitus, cardiovascular disease, rheumatoid arthritis and gout contribute to degenerative spinal osteoarthritis.
When the development of osteoarthritis is not directly related to any particular cause, it is characterized as primary osteoarthritis and is attributed mainly to normal aging lesions. Long and repeated load charging of the joints leads to inflammation, causing pain and edema and ultimately damage of cartilage.
When the cause of osteoarthritis is specific, it is classified as secondary and may be due to traumatic causes or congenital abnormalities.
Osteoarthritis is mainly characterized by stiffness and joint pain, although many times the patient does not actually experience severe disability. Feeling pain and stiffness is worse in the morning (mainly during the first 30 minutes) and deteriorates again in the evening due to fatigue. It is usually less intense during daytime as the patient performs daily activities. Pain that disturbs sleep is often an indicator to seek for treatment options.
Other symptoms may include:
- Swelling and tenderness at one or more spinal levels, often during weather alterations.
- Sensitivity detected under pressure applied by the examiner
- Constant or intermittent joint pain that worsens with movement.
- Loss of movement and stiffness, e.g. inability of the patient to bend and collect an object from the ground.
- Characteristic sounds or a feeling of friction during movement (especially in the cervical spine).
- Deformity of the normal spine curvatures, which is mainly due to the muscular spasm of the spine.
- Neurological symptoms, such as numbing and burning sensation when the presence of osteophytes irritates the roots of the spinal nerves that exit the spinal cord.
Osteoarthritic lesions develop progressively. At first, the patient feels pain only after physical work or exercise. As the articular cartilage of the facet joints weakens and degenerates, the pain becoming constant, making it difficult to walk or use a ladder. Later, the pain and stiffness is also observed after periods of rest; e.g. after several hours at the same body posture on trips/cinema/theater.
Typically, the orthopedist will evaluate a combination of findings from family history, clinical examination and other laboratory and imaging tests. Proper diagnosis is very important for the proper treatment choice.
Family and Individual Medical History:
The patient answers questions about their symptoms (the intensity and duration of pain). In addition, it is requested to describe the patient’s activities to determine the level of mobility and pain.
The examination assesses the lumbar region and the overall state of the patient’s health. In particular, muscular strength, range of motion and pain location will be assessed.
Radiographs will assess degenerative lesions. In particular, cartilage damage as well as osteophytes will be depicted. In addition, X-rays can help in the differential diagnosis e.g. fractures. However, it should be noted that the radiological images do not always correspond to reality.
For example, the majority of people over 60 years old are presented with pathological findings in X-ray imaging, but 85% of them are asymptomatic. On the contrary, radiography performed in the early stages of osteoarthritis does not reveal the above-mentioned lesions. For all these reasons, clinical examination and detailed medical history are necessary for accurate diagnosis.
It is used to rule out inflammation, tumor and fractures. In case of suspicious findings, a CT or MRI scan should follow.
It accurately depicts the spine and the surrounding structures.
Magnetic Resonance Imaging:
This is a specialized examination that accurately describes soft tissues. Upon adjustment, it can depict different tissues, including the percentage of water available, determining and describing disk degeneration, infections, or potential tumors.
Conservative treatment of spinal osteoarthritis is the first line of treatment and usually relieves pain and stiffness. Most treatment protocols include a combination of medicinal options and take into account several factors, such as the severity of the arthritic lesions and the patient’s comorbidities.
In cases where osteoarthritis causes severe lesions and pain, the physician must alleviate and manage the severe pain experienced by the patient. Resting, applying hot or cold pads and NSAIDs can greatly alleviate pain for a period of time.
Pain control of osteoarthritic lesions in the spine involves a number of medicinal products with different properties. The two most important factors to consider are the level of the patient’s pain and the potential side effects of the drug.
For mild pain acetaminophen may be an adequate treatment. It does not reduce the level of inflammation but acts as a mild painkiller, causing less stomach problems than anti-inflammatory drugs (ibuprofen, aspirin etc.).
NON STEROIDAL ANTI-INFLAMMATORY DRUGS
Non-steroidal anti-inflammatory drugs (NSAIDs) modulate the body’s inflammatory response while acting as painkillers. Examples of NSAIDs include ibuprofen, naproxen, diclofenac, etc. They should be used only for a few days to avoid the risk of side-effects.
The most common side-effects of NSAIDs include gastrointestinal disorders, diarrhea, stomach or duodenal ulcer and gastric bleeding. It is also believed that they increase the risk of serious cardiovascular disease in patients with relevant medical history. All of these side-effects are associated with large doses and long-term administration of such drugs.
COX-2 inhibitors, another type of NSAIDs, have been on the market for a few years upon prescription and seem to cause less gastrointestinal side-effects. However, studies on their safety as regards cardiovascular disease are still pending.
Oral cortisone is not used for osteoarthritis, but when injected directly into the spine joints it can reduce pain and partially restore function for a reasonable amount of time. The glucocorticoids (also called corticosteroids) are potent anti-inflammatory drugs for patients who do not respond to NSAIDs. These injections of steroids in combination with topical anesthetics relieve the patient. Since repeated injections of cortisone can be harmful to the body, no more than three treatments per year are recommended.
EXERCISES AND PHYSIOTHERAPY
Many patients suffering from arthritis report significant relief through physical activity and physiotherapy. In general, certain exercises can be used.
Cervical and lumbar spine strengthening exercises.
Increased muscle strength better supports the joints by reducing the pressure applied to them.
Low intensity aerobic exercise.
Aerobic exercise maintains the cardiovascular system and helps control weight. Walking, stationary cycling and water exercises are some alternative options.
Although degenerative spinal osteoarthritis is a progressive and chronic condition, the patient’s symptoms rarely justify a surgery. Some patients with severe osteoarthritis leading to instability (degenerative spondylolisthesis) or stenosis (spinal stenosis) may need to undergo surgery. Often the aforementioned conditions coexist.
The only effective surgical treatment for severe spinal arthritic lesions is the spinal fusion that stops any painful movement between the articular surfaces. Currently, total intervertebral disc replacement surgery is contraindicated in patients with osteoarthritis of the facet joints, since pain during movements is not totally eradicated.
Based on the fact that intra-articular movements trigger pain, the purpose of a spinal fusion surgery is to stop any movement and thereby relieve pain. However, spinal fusion is not always the best solution for spinal osteoarthritis as spinal lesions are multiple and multiple spinal fusion surgeries should be avoided. When movement is interrupted at multiple levels of the spine, corresponding symptoms may occur in the adjacent vertebrae.
In cases where osteoarthritic lesions in the facet joints lead to instability (degenerative spondylolisthesis), the spinal fusion is required to stabilize the particular vertebrae. This occurs most often at the level of L4-L5 and sometimes at the level of L3-L4 (lumbar spine).
In cases where osteoarthritis begins to affect the nerves exiting the spine, then surgical decompression of the nerve roots is a good option. In addition, the formation of osteophytes can also lead to compression phenomena on the spinal cord or nerves upon exiting the spine (vertebral stenosis). Osteophytes are usually removed with laminectomy. The purpose of laminectomy is to relieve pain and neurological symptoms by removing part of the osteophytes and thickened ligaments that cause compressive effects.
However, laminectomy alone is not indicated for patients with compressive effects due to osteoarthritis because decompression (laminectomy) will improve neurological symptoms, but will not assist in pain relief.