Interviews

Dr. Amitabha Chanda, Senior Consultant and Coordinator, Department of Neurosurgery, Apollo Hospitals Dhaka.

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Cervical and Lumbar Spondylosis – A MENACE

Understanding Spondylosis
Spondylosis is an aging phenomenon. With age, the bones and ligaments in the spine wear, leading to bone spurs (osteoarthritis). Also, the intervertebral discs degenerate and weaken, which can lead to disc herniation and bulging discs. Symptoms are often first reported between the ages of 20 and 50. Over 80% of people over the age of 40 have evidence of spondylosis on X-ray studies. The rate at which spondylosis occurs is partly related to genetic predisposition, injury history, bad postures, overweight, lack of exercise and muscular strength. This is similar to degenerative changes (osteoarthritis) in other joints. Spondylosis can occur in the cervical spine (neck), thoracic spine (upper and mid-back), or lumbar spine (low back). Lumbar spondylosis and cervical spondylosis are the most common, as they are the most mobile segments of the spine.
There are several medical terms that sound similar and are often confused with spondylosis including the following:
Spondylitis is inflammation of one or more vertebrae, such as in ankylosing spondylitis. This is an inflammatory rather than degenerative process.
Spondylolisthesis is forward or backward displacement of the body of one vertebra in relation to an adjacent vertebra. For example, anterior spondylolisthesis of L4 on L5 means that the fourth lumbar vertebra has slipped forward on the fifth lumbar vertebra.
Spinal Stenosis is narrowing of the spinal canal. This narrowing of the spinal canal limits the amount of space for the spinal cord and nerves resulting in pressure on the spinal cord and nerves causing pain, numbness, and tingling.
Sciatica is pain shooting down the sciatic nerve as it runs from the low back down the buttocks and the leg, either on one side or both sides. This occurs when a herniated disc or thick ligament puts pressure on the nerve root(s), forming the sciatic nerve as it exits the spinal canal in the lower back.
SPOTTING SPONDYLOSIS
The symptoms and signs of spondylosis are of three types. The commonest presentation is neck pain or low back pain. This is directly due to local arthritic changes. This is similar to the knee pain we have in arthritis of the knee. The second type of presentation is due to compression of nerve roots by a herniated disc, thickened ligaments, or bony spurs. This results in shooting pain in the upper limb or lower limb with associated tingling, numbness or focal weakness, for example in foot, or grip, or elevation of the shoulder, etc. In long-standing cases, the patient might not have problems while in rest. The pain in leg appears while standing or walking. The third kind of presentation is due to compression of the spinal cord or cauda equina. This can result in weakness of both lower limbs or all four limbs or urinary bladder symptoms, like loss of control of micturition and defecation.
Immediate medical attention is needed when pain becomes unmanageable, appearance of weakness in any limb, loss of bladder or bowel control in the setting of acute back or neck pain, such as inability to start or stop urinating. “Saddle anesthesia,” meaning numbness in the distribution where the bottom would contact a saddle: This indicates a serious nerve dysfunction and should be evaluated at the emergency department immediately.

TREATING SPONDYLOSIS
There is no treatment to reverse the process of spondylosis because it is a degenerative process. The initial treatments for spondylosis target the back pain and neck pain that spondylosis can cause. Available treatments fall into several categories: medications, self-care, exercise, and physical therapy, some pain management procedures, and surgery. Doctors will use X-ray, MRI, and a CT scan to diagnose the onset of spondylosis.
The line of treatment can be stratified according to clinical presentations. In the case of local pain, the patient should stay away from operative treatment as much as possible. The patient should be managed with medications, physiotherapy, pain management. The operation should be kept away as much as possible. When the patient has features of root compression – this happens when spondylosis or spinal stenosis causes root compression resulting in difficulty in walking, intractable shooting pain, numbness or weakness of a part of the limb, a conservative trial may be tried first in some cases. If non-operative treatment fails, operative treatment should be considered strongly. Patients with spinal cord or cauda equina compression will exhibit clinical features like weakness of all four limbs, saddle anesthesia, difficulty in voiding urine and stool. These patients need operative treatment without delay. Delay would result in irreversible damage of neural tissue
No medication has been proven to reverse the degenerative process of spondylosis. Treatment of pain from spondylosis is entirely symptomatic. Then why do we give medications? Most of the initial presentations are self-limiting. Hoping that there will be a spontaneous resolution of pain, symptomatic medications are given to give interim relief to the patient.

TACKLING SPONDYLOSIS AT HOME
Home treatment is important in pain caused by spondylosis. Pain may frequently improve or resolve after several days. Long bed rest prolongs the time to recovery. Therefore, it is recommended to continue normal or near normal activities. However, one should avoid doing anything that could exacerbate the problem, such as heavy lifting. Home remedies, including warm compresses and/or ice, may be helpful for back and neck pain caused by spondylosis.
Physical therapy may be needed for back or neck pain that does not resolve on its own after a few weeks. Physical therapy is often prescribed for chronic back or neck pain for muscle strengthening and stretching. Traction or use of belt and collar has very limited role.
Chiropractic spinal manipulation may be helpful to some people, especially within the first month of pain. However, certain patients, like those with inflammatory arthritis, stenosed spine, should not undergo spinal manipulation for safety reasons. Studies of acupuncture for back and neck pain have had mixed results. Other alternative therapies such as homeopathic treatments have not been shown in studies to improve the symptoms of spondylosis.

SURGICAL OPTIONS FOR SPONDYLOSIS
The principle of operative treatment is the decompression of the spinal cord and/or nerve root. This involves various surgical procedures that can relieve pressure on the nerves due to spinal stenosis, herniated intervertebral discs, or spondylolisthesis. During operation, the normal structures are preserved as much as possible. However, in some cases, the normal structures need to be sacrificed to achieve adequate decompression so much so that it can jeopardize the spinal stability. In those cases, a fixation and fusion surgery with titanium screws, rods or cages are needed. Common techniques for decompression include the following: 1) Laminectomy: a procedure to remove the bony arches of the spinal canal (lamina) subsequently increasing the size of the spinal canal and decreasing pressure on the spinal cord. This procedure alone is hardly done these days. 2) Discectomy is a procedure to remove a portion of an intervertebral disc that is putting pressure on a nerve root or the spinal canal. 3) Foraminotomy is a procedure to expand the openings for the nerve roots to exit the spinal canal. 4) Corpectomy is a procedure to remove a vertebral body and discs. 5) Fusion of the vertebrae is sometimes combined with one or more of these procedures in order to stabilize the spine.
Spondylosis is a degenerative process, and there is no known method to prevent the degenerative pathologic process. However, some measures may be helpful to delay the onset and progress, like weight reduction, strengthening core spinal muscles.

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