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Lumbar arthritis


 Low back pain is extremely common affecting 60-90% of the population.  The vast majority suffer from lumbar arthritis as a primary or contributing factor to their pain.  Lumbar arthritis is a degenerative condition that develops over time in response to the normal demands that are placed on the five lumbar vertebrae.  It is symptomatic to varying degrees in different individuals and is a significant cause of disability.

The spine is composed of seven cervical, twelve thoracic, and five lumbar

vertebrae.   The lumbar vertebrae are separated by intervertebral disks.  The disk is composed of an outer fibrotic annulus fibrosis and a central nucleus pulposis.  The collagen fibers of the annulus fibrosis anchor the disk to vertebral endplates.  This structure allows for movement between vertebral bodies and dispersion of weight bearing from one vertebra to the many that lay below it in the spine. 

            With age, the intervertebral disks begin to lose their elasticity and hydration.  This loss of elasticity decreases the ability of a disk to handle the weight it must bear. The disks become shorter which changes the position of the vertebrae and their associated connecting fibers in relation to the rest of the spine. Over time, a situation develops whereby bone lays directly on bone, causing pain and decreasing range of motion. 

Ultimately, this pattern of degeneration results in microfractures and additional cartilage destruction. Although the body attempts to replace that which is lost, it is often insufficient to overcome the degenerative process. As bone surface erodes, mechanical stress on the joints increase.  The bodyís response to this stress is the formation of new bony outgrowths called osteophytes. This process is seen often in the facet joints and end plates of the lumbar spine. If combined with compression and bulging of intervertebral disks and hypertrophy of spinal ligaments the size of the spinal canal might decrease creating a condition known as spinal stenosis.  With the development of spinal stenosis, comes the risk that the spinal cord and its exiting nerves will be compressed.

 

What are the symptoms of Lumbar arthritis?

 Classic symptoms of any form of arthritis include joint pain, swelling, and stiffness.  Patients with lumbar arthritis often have low back or pelvic pain. They tend to have difficulty with mobility secondary to postural changes and decreased flexibility.  As with most forms of osteoarthritis, pain and stiffness is most pronounced in the morning. As movement increases over the course of the day, symptoms tend to subside. In general, if there is no evidence of nerve root compromise, pain from an arthritic spine is localized to the low back with possible dull aching referred pain in the buttocks. Patients with degenerative changes resulting in spinal stenosis may experience numbness, tingling, or weakness in the legs due to irritation of the lumbar nerve roots.

 

How is Lumbar arthritis diagnosed?

 

A physician is able to make the diagnosis of lumbar arthritis when the constellation of symptoms and physical exam are consistent with degenerative changes in the spine.  A description of back pain for a long period of time that increases with mechanical stress may alert your doctor to the presence of lumbar arthritis. Therefore, it is important to provide your physician with detailed information about your back pain including timing, severity, and exacerbating or alleviating factors.  The physical exam will focus on the range of motion within your spine, muscle strength, and reflexes within your legs. Patients with lumbar arthritis will notice pain when bending backwards because this places maximal pressure on the osteoarthritic facet joints. Likewise, patients may find that the pain decreases when bending forward because this relieves joint pressure.

An X-ray will likely be ordered to look at the bones that make up the lumbar spine. Specifically, your physician will look for new bone growth (osteophyte formation) and narrowing of the intervertebral disk space. A CT (computed topography) scan, a study more detailed than an X-ray, may be ordered to visualize more specific areas of your spine.  MRI (magnetic resonance imaging) scans utilize magnetic rays to visualize soft tissue. An MRI may be helpful because it allows your physician to better visualize the facet joints and surrounding soft tissues. Also, MRI scans do not have the risk of radiation exposure, whereas X-rays use radiation, and CT scans use even more radiation.  Ultimately injections to anesthetize the nerves that supply the arthritic joints, also known as medial branch blocks, may be needed to confirm the diagnosis.

 

What are the treatment options for Lumbar arthritis?

Lumbar arthritis is usually responsive to conservative management.  During an acute attack of low back pain, relative rest that avoids activities that aggravates the symptoms may reduce inflammation. For long term relief, lifestyle modification must be undertaken.  Weight loss when appropriate will have a tremendous impact on back pain because it is the lumbar spine that bears the weight of the body. Exercise is also critical and can help reduce weight and increase muscle strength to support the lower back. You should consult your doctor before beginning any exercise or diet program.  Your doctor may prescribe physical therapy.  Working with a physical therapist to design a proper exercise regimen may be useful for strengthening core muscles and minimizing back pain. Therapists may utilize modalities such as ultrasound, heat, ice, and manipulation to reduce pain. While, a back brace or corset helps to limit the motion of your lumbar spine and correct posture it should not be used unless discussed with your doctor.

Your physician may prescribe a variety of medications to help control the symptoms of lumbar arthritis. Nonsteroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen (Advil), Naproxen, or Meloxicam (Mobic) are helpful in controlling back pain and inflammation. Cox-2 inhibitors (i.e., Celebrex) are also quite effective. A non-narcotic pain reliever called Tramadol (Ultram) may be indicated in resistant cases. Since muscle spasms sometimes accompany lumbar arthritis, your physician may prescribe a muscle relaxant such as Flexeril.  All medication have the potential for side effects, and that includes medications such as Advil and Tylenol that are sold over the counter.  Before taking any medication, you should have a full discussion about the relative risks and benefits of each medication for your body.

If medication and physical therapy are not effective interventional procedures may be necessary.   Fluoroscopiclly guided interventional procedures such as facet joint injections and radiofrequency neurotomy are two treatment options.  Facet joint injections use x-ray guidance for accurate needle placement in order to inject the diseased joints with medication such as cortisone.  Radiofrequency neurotomy uses heat to ablate nerve fibers around the joint that are responsible for pain. This also uses x-ray guidance for precise electrode placement.

Unfortunately, most patients with osteoarthritis have repeated episodes of back pain.  Patients who respond to conservative treatment and physical therapy do not require surgical intervention.  In the rare cases that do not respond to conservative management, surgery may be considered.  Generally, a laminectomy is reserved for those with spinal stenosis or nerve compression.  A laminectomy removes a small portion of bone in your vertebra.  This allows for an increase in the size of the spinal canal and relief of nerve pressure.  Other surgical procedures include removal of bone spurs and fusion of the spine. Lumbar disk replacement (disk arthroscopy) is another option.  Studies of this technique are emerging but are still incomplete.  An orthopedic surgeon or neurosurgeon can assess if surgery is indicated in your particular case. .

Finally, in patients with back and/or leg pain and any of the following symptoms, immediate medical attention should be sought.  These symptoms include: fever, chills, pain that wakes you from sleep, unintended weight loss, history of cancer, and bowel or bladder changes such as incontinence.  Any of these symptoms may be signs of a more serious underlying process and should merit emergent medical attention.

 

Authors: Jennifer Avallone, B.S., New York College of Osteopathic Medicine, Old  Westbury, NY

Elise Weiss, M.D., New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell, New York, NY

               Joseph E. Herrera, DO, Mount Sinai Hospital, New York City, NY

 

 

 

 

 Arthritis MD. © 2005