Of the many causes for low back pain, one of the most common is a "slipped vertebra", or spondylolisthesis. Spondylolisthesis refers to the inability of the spine to maintain normal vertebra alignment, and a shifting forward of one vertebra on the vertebra below is the net result. Women have this condition more often than men. The most common symptoms from spondylolisthesis include low backache, aching which is worse with activity, posterior thigh pain, and occasionally radiating leg pain.

One of the most common causes of spondylolisthesis or slipped vertebra is severe arthritis in the small joints behind the vertebral body (facet joints) which allows the vertebra to shift forward in an uncontrolled fashion. This type (degenerative spondylolisthesis) of slipped vertebra is usually accompanied by nerve root compression and the clinical symptoms of back pain, buttock pain and radiating leg pain. It is usually better with sitting or lying down, and worse with standing and walking.

A second type of spondylolisthesis is present in up to 5% of the American population, and results from an old stress fracture from childhood. This type of spondylolisthesis often causes episodic low backache which is self limited and usually goes away. In some cases, hamstring spasms, radiating leg pain, and constant back pain can result. For patients with isthmic spondylolisthesis, or a slipped vertebra from a stress fracture, as the spine ages and develops arthritis, a previously asymptomatic situation can begin to hurt.

Low back pain needs to be investigated and a clear diagnosis should be made so that appropriate treatment can be started. In almost all cases, conservative care, daily exercise program, and general trunk strengthening exercises are all that is.

What's the Difference?

One of the biggest problems with osteoporosis (soft bones) is the development of bone fractures of the spine, hip, and wrist. Of these, spinal compression fractures are the most common, affecting 700,000 Americans each year. These fractures occur when the bone strength is diminished to the point that even minor trauma causes the vertebra to crush. Compression fractures can cause spinal deformity, severe back pain and loss of height. Traditional treatment of compression fractures has included bedrest, pain medications, bracing, and in rare cases surgery. Surgical treatment has been an option of last resort because of the long recovery, poor outcome, and risks. It was only considered in cases of spinal cord compression and for the most significant deformity. Patients with compression fractures secondary to osteoporosis or cancer usually have other medical illnesses. They require a treatment that would allow immediate pain relief, minimal stress on their health, and allow them to return to a full level of activity. Recently two minimally invasive surgical techniques have emerged, Kyphoplasty and Vertebroplasty, as potential answers to the problems posed by osteoporotic compression fractures of the spine.

Vertebroplasty was developed in the mid 1980's by a radiologist in France. It was embraced for use in the USA in the mid 1990's. Kyphoplasty was first described in 1998 by a Berkley California orthopedic surgeon. Let's compare the two procedures, their similarities and differences, and their respective risks and long term prospects for benefit in patients with osteoporosis related compression fractures. 

Vertebroplasty

Vertebroplasty begins with the introduction of a needle into the collapsed vertebra under xray guidance. The vertebral body, or front portion of the spine bone, is then injected with bone cement. In order for the cement to be able to enter into the bone, the cement must be in a liquid state and high pressure must be used to push it through the needle. The liquid state cement hardens over a period of 12-15 minutes secondary to a chemical reaction. Once the cement is hard, the bone is stable and immediate weight bearing can be resumed. The French and some American studies found 70 – 90% of patients experienced pain relief.

The problems with Vertebroplasty are two fold. The first is the liquid cement will follow the path of least resistance. Best case scenario is that the collapsed vertebra has a hard outer surface (cortex) of the bone being intact to contain the cement as it is being injected. If there is any defect in the vertebra wall, there is a risk of cement leaking into the spinal canal or into the abdomen or chest. Cement entering into areas that were unintended in an uncontrolled fashion has led to problems in some of these patients, including liquid cement migrating to the lungs or into the spinal canal to compress the spinal cord. The second problem with Vertebroplasty is both a short and long term one. The cement fills the broken vertebra, freezing the spine in its collapsed position. We are all familiar with people who have progressively become “hunched over” with time, often secondary to multiple compression fractures. Vertebroplasty does not address the deformity issue nor prevent patients from becoming hunched over. 

Kyphoplasty

Kyphoplasty was developed by an orthopedic surgeon to straighten the broken or collapsed vertebra and address the issue of becoming hunched over. One of the basic principles of orthopedics is to straighten or correct broken bones. In other words, "If it''s bent, straighten it ou". Kyphoplasty begins similar to Vertebroplasty, with a needle introduced into the fractured vertebral body. However, that is where any similarity ends. Kyphoplasty calls for insertion of a small tube over the needle. Through this tube, a balloon tipped catheter is inserted into the broken vertebra. The balloon is slowly inflated. With new fractures, inflation of the balloon raises up the collapsed vertebrae to its normal height. More importantly, the balloon creates a space in the bone as it inflates. This space allows for cement to be placed at low pressure and thicker, putty like consistency. This substantially reduces the risk of cement leaking out of the bone. Kyphoplasty patients also describe immediate relief from fracture pain. In our series at the Sonoran Spine published in The Spine Journal last year, we saw pain improvement in 90% of our patients.

Both Vertebroplasty and Kyphoplasty allow surgeons to treat compression fractures through a minimally invasive procedure. Both relieve the pain caused by the vertebral fracture. Only Kyphoplasty allows for correction of the collapsed vertebra and decreases the risk of the patient becoming hunched over. Adding a safer placement of the cement into the fractured vertebra makes Kyphoplasty our clear and safer choice for patients who are suffering from osteoporotic compression fractures.

By Bert Bednar, DPT

Remember when your mom would tell you to sit up straight or walk with your head up and shoulders back? Once again, your mother was right. Posture does matter. In fact, we all know it's better to use good posture. So why do we still slouch? Research has proven that poor posture contributes to back and neck pain. Sitting in a poor posture can contribute to other aspects of your health including eye strain, headaches, shoulder pain, and carpal tunnel syndrome.

Posture Affects Pain

Painful, and potentially disabling, conditions can insidiously develop as a direct result of poor sitting or standing posture, improper lifting mechanics and working habits, or begin with unrelated injuries that are then made worse by poor ergonomics.

When you deviate from normal anatomic posture, unnecessary stress and strain are placed on the normal curves of your spine causing these curves to slowly change. Over time these minor alternations make your spine more vulnerable to injury. For this reason, utilizing the principles of your best posture is critical to keeping stress and strain as low as possible. This will decrease injury to your spinal discs, decrease unnecessary muscle strain, prevent muscular imbalances, as well as protect small joints within your spine (facets) and supporting structures. Common outcomes of poor posture results in rounded shoulders, flat back, forward head positioning, improper muscular tension, and upper and lower back pain.

Proper posture is achieved by understanding the principles of appropriate seated and standing positioning along with proper flexibility, muscle strength and self-discipline. Let's discuss the best posture for standing, sitting, lying down and the importance of positional changes.

Standing Posture

Did you know that a bending forward posture can contribute to increased degenerative disc wear? To protect from disc wear and tear, it's best to utilize proper standing posture as much as your own body stance will allow. Although pathology can prevent you from achieving ideal alignment, adhering to the principles of proper posture can still help you attain your best and prevent the worsening of many conditions.

Picture an imaginary line from your ear to your shoulder to your hip to your ankle. With perfect posture, this imaginary line would align perfectly with these joints. Proper standing posture also includes holding your head up, looking forward with your shoulders held back and your chest out. Maintaining this posture provides for equal and well-distributed weight-bearing on the spinal discs, which allows the back muscles to be in a balanced position and decrease undue stress on the small facet joints and ligaments of the spine. Reducing these stresses will decrease pain and help to prevent injury.

To maintain your best posture, it's important to check yourself periodically as to how you are standing. Initially it will seem awkward; however, it becomes easier as your muscles get used to your new posture.

Sitting Posture

Slumping in a chair will overstretch and fatigue muscles. This posture can lead to injury resulting in severe neck and back pain.

When seated, sit back in your chair as far as possible. Your buttocks should be at the end of the chair to maintain a straight back with a normal low back (lumbar) curve. While seated, good posture is achieved by looking forward, keeping your shoulders pulled back and your spine up against the back of your chair. Select your chair height so your feet can be placed flat on the floor. If your chair is too high for your feet to reach the ground, use a small foot stool.

Keep your work close to you. Whenever possible, position your work so your arms do not extend past your chest. Adjust your chair's arm rests so that your elbows can be supported. Get in the habit of working while your elbows are on your arm rests. If you are able to implement these principles correctly your body position should promote a right angle at your elbows, hips, and knees.

It is important to take frequent breaks from sitting. Even maintaining proper seated posture can eventually be hard on spinal structures. Getting up and stretching periodically will help to keep tension from mounting to an unsafe level in your spinal muscles. Proper upper back and core strength will make achieving proper posture feel more natural.

Lying Posture

Proper lying posture varies far more than seated and standing postures. Generally accepted guidelines include a mattress which supports bony prominences and keeps you in proper alignment whether you are lying on your back, side or abdomen. If you rest on your side, a pillow placed between your knees will decrease strain on your lower back. Supporting the natural spinal curve of your neck is also important. A good rule of thumb is to find a position that is comfortable. If you are lying in a position resulting in unnecessary strain on your muscles and joints you will have difficulty sleeping and typically awaken stiff or sore. Remember good alignment is hardly ever achieved when reading in bed. Comfort should be your guide when you select an appropriate mattress or pillow. Getting restful sleep can depend on using appropriate principles for lying on your back, side or abdomen.

Changing Positions

Change your position frequently during prolonged activities. If you have been sitting for awhile, stand and stretch your back into a straight or neutral position. If you are standing and working overhead, bend your back forward periodically to give your back a break.

Most of us can relate to having a work day that involves lifting, reaching, typing, or driving. Most of us maintain a forward rounded position while performing many of these tasks. After keeping this posture for hours per day, over the span of weeks, months and years, our body tends to adapt to this sustained position. This results in a flexed forward or rounded shoulder position. Incorporating proper postural and core strengthening as well as neck, trunk, arm and leg stretches into your daily schedule can help to prevent you from developing a rounded posture and resulting pain.

Posture is Only One Aspect of Maintaining Functionality as We Age

Everyone performs "work" or tasks daily and many believe the work or task is sufficient to sustain musculoskeletal health. Unfortunately as we grow older, this is less often the case. To insure continued strength, flexibility and endurance, it is best to incorporate activities that accomplish three important exercise types: 1) Stretch muscle groups to reduce risk of injury and maintain flexibility, 2) Perform strengthening exercises for shoulders, upper back, low back, abdomen and legs to help decrease stress and protect your joints 3) Engage in endurance activities to maintain a healthy heart muscle and pulmonary function. Regularly-scheduled exercises that address these important aspects of body maintenance become more critical as we age. Since our body eventually will break down when not supported and maintained properly, use exercise, posture and ergonomic principles to maintain and enjoy body health for life.

Back pain is as common as it is enigmatic. An estimated 90% of the population will experience at least one episode of back pain with the vast majority of symptoms resolving within one month. However, for certain people, back pain can become chronic and disabling.

There are multiple causes of back pain. These include the muscles of the back, ligaments, nerves and the bony architecture of the spine to name a few. Unfortunately, the normal process of aging is responsible for the majority of changes in our spinal anatomy, some of which can cause pain. However, degenerative change is commonplace. In fact, a study was done on asymptomatic patients in their twenties and 30% were found to have some changes found by MRI. By the time people are fifty approximately 97% of the population will have degenerative changes found on MRI. While the process of aging cannot be stopped, its effects can be minimized.

Symptoms from degeneration manifest themselves usually as back pain and/ or leg pain. These symptoms come from nerves that are being irritated as they exit the spine or spine anatomy that is wearing out and becomes painful when stressed.

The spine is very similar to a car. An automobile is a series of moving parts that allow the vehicle to move in space. The more miles you put on the car, the more likely the vehicle will have some component wear out (tires, shocks, etc.). Our spine is the same way. As we get older, the various moving parts of our anatomy degenerate (discs, facet joints). One of the first areas to begin to degenerate is the discs. The disc serves two functions: motion and shock absorption. As we get older, the disc will lose this ability and shrink in height and distribute more stress to other areas (bone and joints). This change in stress distribution will cause arthritic change to occur in our surrounding anatomy. This degenerative cascade will manifest itself as increased back pain and stiffness.

Nerve "pinching" or stenosis follows the same degenerative cascade. Nerves exit the central canal through holes in the spine called foramen. The foramen are bordered by disc, facet joints and ligaments. As the disc loses height and bulges, our facet joints are simultaneously becoming arthritic (enlarged from bone rubbing bone), the foramen becomes smaller and the exiting nerve becomes "pinched". We notice this as leg pain.

Another common manifestation of age is the fact our bones lose their mineral content over time (osteoporosis). This is more commonly seen in post menopausal women but occurs in men with increasing age. Our vertebra (spine bones) are unique in that they are designed to absorb stress. The bony architecture is similar to the Greek Pantheon. The bone has columns which support the roof and floor. With time, as we lose mineral, our vertebra lose columns and the roof is more at risk of collapse. If the spine sees a significant stress, you are at risk of sustaining a compression fracture. These injuries are extremely painful and may take weeks to months to heal.

Patients with back pain secondary to degeneration usually respond to conservative treatments which include physical therapy (P.T.), anti-inflammatories (Ibuprofen) and steroid shots. P.T. is important to strengthen our trunk, neck and shoulder girdle musculature, which helps to minimize the wear and tear to which our spine is exposed. The increase in muscular endurance and strength from P.T. is similar to getting new shocks on the car. The speed bumps you encounter in life are not as significant. Anti-inflammatory medication helps break the pain cycle and minimizes the effects of the arthritic change. Steroid shots are used to decrease the irritability of the nerve roots. The shots also can decrease the swelling that nerve roots may exhibit from being "pinched". The effects are similar to being stuck in Phoenix traffic, without an air conditioner, and taking a valium. You are still in traffic but you are less angry about your situation.

If symptoms do not improve with conservative management then a surgical consultation may be needed. Surgical intervention should be viewed as a last resort and usually involves "altering" your anatomy to alleviate the pain source. This can be anywhere from a decompression (making the foramen bigger and relieving the "pinching" the nerve is experiencing) to a fusion (stopping moving parts which are causing pain from moving). There are new techniques which focus on minimizing the physical insult of surgery by using smaller incisions (minimally invasive surgery) to "Kyphoplasty". Kyphoplasty involves using a balloon to expand a compression fracture and fill the bone with bone cement to stabilize the fracture. All these techniques involve fewer days in the hospital and more rapid recovery.

To conclude, conservative measures and surgery do not "turn back the odometer". These treatments are attempting to improve quality of life and increase function. Everybody has some back discomfort and degeneration of the spine is a fact of life. Our goal at Sonoran Spine is to do whatever is needed to get your "car" running as efficiently as possible for the rest of your life.