Back Pain: Spondylosis, Spondylolysis, and Spondylolisthesis

Back pain is a common complaint in people of all ages. Whether it be due to old age, athletics, or a random accident, back pain can significantly impact an individual’s life. Another frustration that is common when dealing with back pain is the potentially confusing medical terms that are used to diagnose the pain. It is particularly difficult when trying to understand and differentiate spondylosis, spondylolysis, and spondylolisthesis. While they may all have “spondy” in the name, they are in fact all different. The aim of this article is to aid in the differentiation of the diagnoses, and understand what the likely course is if you are given one of these as your diagnosis for back pain.

Spondylosis: What is it? And how is it caused?

The spine is a series of bones with unique joints between each. These joints allow for flexion, extension, rotation, and side bending. However, just like any other joint, this can lead to degeneration and the development of arthritis. In spondylosis, the degeneration and arthritis that can cause compression of the spinal cord or of the nerves as they leave the spinal column. This will often present with sensory loss, difficulty with movement, pain, numbness, or muscle weakness. Spondylosis most commonly occurs in the neck region, so often the symptoms are most apparent in the neck, shoulder and arms.

Just like other forms of arthritis, spondylosis is primarily caused by wear and tear, usually due to older age. While age is the greatest risk factor for developing spondylosis, any activity or force that places more stress on the spine can increase the likelihood of development. This includes sports like football, weight lifting and dancing. But, it also includes stresses such as poor posture and scoliosis.

Spondylosis Prevention and treatment

While young, avoiding risk factors can be very helpful in preventing future onset of spondylosis. Perhaps one of the easiest ways to prevent spondylosis is to promote correct posture. Avoiding bad posture at work may be difficult to the significant time many of us spend at a desk and computer, but maintaining good posture throughout the day can have long term positive influence. An evaluation for proper ergonomics can be helpful long before pain or other symptoms present.

When diagnosed with spondylosis, usually the medical provider will recommend non-invasive conservative therapy. This will often include NSAIDs and physical therapy. In addition, activities such as yoga or massage can be helpful. Generally, surgery is only reserved for those who have significant symptoms from the spondylosis and who are not responding to the non-invasive treatments, including injection therapy.

Spondylolysis: What is it? And how is it caused?

Spondylolysis is a stress injury, meaning that it occurs gradually over time due to chronic stress. This stress will lead to a fracture that specifically occurs at the pars interarticularis of the vertebral arch, which protects the spinal column. Due to the chronic and slow progression of the injury, the onset can be difficult to pin point and present with symptoms that may mimic muscle strain or sacroiliitis. Sometimes symptoms of pain may not present or won’t be overly symptomatic. As the injury progresses, it will often present with pain with bending backwards and pain with activity in general. These individuals will often have a “sore” back on one or both sides of the lower back.

The typical individual who will develop a spondylolysis is an athlete who has repetitive backward bending in their sport, which is common to gymnastics, dancing, football (especially linemen), wrestling, and many more. Adolescence, during which rapid growth is occurring, and inflexibility, such as tight hip flexors and hamstrings are also common risk factors for developing this injury.

Spondylolysis Prevention and Treatment

There isn’t much that can be done to prevent a spondylolysis. Maintaining good core strength and avoiding excessive backwards bending will reduce the risk of developing a spondylolysis. For example, high school athletes performing heavy squats and lunges should work on engaging the core and maintaining upright posture, preventing a backwards bend (or “excessive lordosis”) of the lower back. While there may not be much that can be done in the way of prevention, early recognition and treatment is very helpful in avoiding a long-term complications from this injury.

Despite being a fracture, spondylolysis can be treated conservatively in most cases. Treatment typically includes a period of restriction from activity and physical therapy. While the patient may still be able to participate in aspects of their sport, it is important to allow the bone to heal through rest, while at the same time strengthening the core through physical therapy to make sure the injury does not recur. Re-injury is uncommon when treated properly and taking measures to build core strength and improve flexibility.

Bracing can be used in more acute injuries, or in chronic injuries that have not been able to heal as would be desired. The most typical brace is the “Boston Overlap Brace” or BOB. It is a rigid plastic custom-fit brace and will immobilize the spine in a neutral position so that it is able to heal without aggravating movements that would prevent the back from healing. Some people will transition into a soft flexible brace, but will only be used initially during transition back to sport and occasionally with intermittent episodes of back pain. Avoiding full-time use will prevent the core muscles from becoming weak.

Should non-invasive therapies including activity restriction, bracing and physical therapy not work, surgery may be indicated in people with significant symptoms. Pedicle screws can be placed to close the gap of the fractured bone, which prevents future progression and in most cases treats pain. Before considering surgery it is important to make sure pain is due to the fracture, and not to facet joints (“facet arthropathy”), sacroiliitis, interspinous impingement or other cause.

In most cases, conservative treatment will be sufficient in allowing the individual to return to the full level of activity.

Spondylolisthesis: What is it? And how is it caused?

A spondylolisthesis is a spondylolysis injury that has progressed and resulted in the higher up vertebral body slipping forward in reference to the vertebral body below. This is often called a “step-off” or “slip” by the medical provider. The degree to which the slippage occurs will result in a grading of the spondylolisthesis. This is measured by how much of the vertebral body has slipped. The following scale is used, with reference to how much of the vertebral body overlaps the level below, with higher grade having a worse prognosis:

  • Grade I: 0-25%
  • Grade II: 25-50%
  • Grade III: 50-75%
  • Grade IV: 75-100%
  • Grade V: greater than 100%

Spondylolisthesis Prevention and Treatment

Prevention and treatment for a spondylolisthesis is the same for spondylosis with conservative and surgical options. Even with a step-off, most patients can be conservatively treated and return to full activity. Surgery can be considered in cases of recalcitrant pain or failed conservative management.

By Zac Taylor & Jon Minor, MD

References

Cervical Spondylosis Prevention. (n.d.). Retrieved from https://my.clevelandclinic.org/health/diseases/17685-cervical-spondylosis/prevention

Dubousset, J. (1997). Treatment of Spondylolysis and Spondylolisthesis in Children and Adolescents. Clinical Orthopaedics and Related Research,337, 77-85. doi:10.1097/00003086-199704000-00010

Kim, R., Singla, A., & Samdani, A. F. (2015). Classification of Spondylolisthesis. Spondylolisthesis,95-106. doi:10.1007/978-1-4899-7575-1_7

Pathogenesis of myelopathy in cervical spondylosis. (1975). Injury,7(2), 161. doi:10.1016/0020-1383(75)90022-4

Images:
https://www.bonati.com/conditions/spondylosis/causes/
https://corewalking.com/spondylosis-spondylolysis-and-spondylolisthesis/
https://www.bio4me.co.za/2015/11/spondylolysis/

Back pain is a common complaint in people of all ages. Whether it be due to old age, athletics, or a random accident, back pain can significantly impact an individual’s life. Another frustration that is common when dealing with back pain is the potentially confusing medical terms that are used to diagnose the pain. It is particularly difficult when trying to understand and differentiate spondylosis, spondylolysis, and spondylolisthesis. While they may all have “spondy” in the name, they are in fact all different. The aim of this article is to aid in the differentiation of the diagnoses, and understand what the likely course is if you are given one of these as your diagnosis for back pain.

Spondylosis: What is it? And how is it caused?

The spine is a series of bones with unique joints between each. These joints allow for flexion, extension, rotation, and side bending. However, just like any other joint, this can lead to degeneration and the development of arthritis. In spondylosis, the degeneration and arthritis that can cause compression of the spinal cord or of the nerves as they leave the spinal column. This will often present with sensory loss, difficulty with movement, pain, numbness, or muscle weakness. Spondylosis most commonly occurs in the neck region, so often the symptoms are most apparent in the neck, shoulder and arms.

Just like other forms of arthritis, spondylosis is primarily caused by wear and tear, usually due to older age. While age is the greatest risk factor for developing spondylosis, any activity or force that places more stress on the spine can increase the likelihood of development. This includes sports like football, weight lifting and dancing. But, it also includes stresses such as poor posture and scoliosis.

Spondylosis Prevention and treatment

While young, avoiding risk factors can be very helpful in preventing future onset of spondylosis. Perhaps one of the easiest ways to prevent spondylosis is to promote correct posture. Avoiding bad posture at work may be difficult to the significant time many of us spend at a desk and computer, but maintaining good posture throughout the day can have long term positive influence. An evaluation for proper ergonomics can be helpful long before pain or other symptoms present.

When diagnosed with spondylosis, usually the medical provider will recommend non-invasive conservative therapy. This will often include NSAIDs and physical therapy. In addition, activities such as yoga or massage can be helpful. Generally, surgery is only reserved for those who have significant symptoms from the spondylosis and who are not responding to the non-invasive treatments, including injection therapy.

Spondylolysis: What is it? And how is it caused?

Spondylolysis is a stress injury, meaning that it occurs gradually over time due to chronic stress. This stress will lead to a fracture that specifically occurs at the pars interarticularis of the vertebral arch, which protects the spinal column. Due to the chronic and slow progression of the injury, the onset can be difficult to pin point and present with symptoms that may mimic muscle strain or sacroiliitis. Sometimes symptoms of pain may not present or won’t be overly symptomatic. As the injury progresses, it will often present with pain with bending backwards and pain with activity in general. These individuals will often have a “sore” back on one or both sides of the lower back.

The typical individual who will develop a spondylolysis is an athlete who has repetitive backward bending in their sport, which is common to gymnastics, dancing, football (especially linemen), wrestling, and many more. Adolescence, during which rapid growth is occurring, and inflexibility, such as tight hip flexors and hamstrings are also common risk factors for developing this injury.

Spondylolysis Prevention and Treatment

There isn’t much that can be done to prevent a spondylolysis. Maintaining good core strength and avoiding excessive backwards bending will reduce the risk of developing a spondylolysis. For example, high school athletes performing heavy squats and lunges should work on engaging the core and maintaining upright posture, preventing a backwards bend (or “excessive lordosis”) of the lower back. While there may not be much that can be done in the way of prevention, early recognition and treatment is very helpful in avoiding a long-term complications from this injury.

Despite being a fracture, spondylolysis can be treated conservatively in most cases. Treatment typically includes a period of restriction from activity and physical therapy. While the patient may still be able to participate in aspects of their sport, it is important to allow the bone to heal through rest, while at the same time strengthening the core through physical therapy to make sure the injury does not recur. Re-injury is uncommon when treated properly and taking measures to build core strength and improve flexibility.

Bracing can be used in more acute injuries, or in chronic injuries that have not been able to heal as would be desired. The most typical brace is the “Boston Overlap Brace” or BOB. It is a rigid plastic custom-fit brace and will immobilize the spine in a neutral position so that it is able to heal without aggravating movements that would prevent the back from healing. Some people will transition into a soft flexible brace, but will only be used initially during transition back to sport and occasionally with intermittent episodes of back pain. Avoiding full-time use will prevent the core muscles from becoming weak.

Should non-invasive therapies including activity restriction, bracing and physical therapy not work, surgery may be indicated in people with significant symptoms. Pedicle screws can be placed to close the gap of the fractured bone, which prevents future progression and in most cases treats pain. Before considering surgery it is important to make sure pain is due to the fracture, and not to facet joints (“facet arthropathy”), sacroiliitis, interspinous impingement or other cause.

In most cases, conservative treatment will be sufficient in allowing the individual to return to the full level of activity.

Spondylolisthesis: What is it? And how is it caused?

A spondylolisthesis is a spondylolysis injury that has progressed and resulted in the higher up vertebral body slipping forward in reference to the vertebral body below. This is often called a “step-off” or “slip” by the medical provider. The degree to which the slippage occurs will result in a grading of the spondylolisthesis. This is measured by how much of the vertebral body has slipped. The following scale is used, with reference to how much of the vertebral body overlaps the level below, with higher grade having a worse prognosis:

  • Grade I: 0-25%
  • Grade II: 25-50%
  • Grade III: 50-75%
  • Grade IV: 75-100%
  • Grade V: greater than 100%

Spondylolisthesis Prevention and Treatment

Prevention and treatment for a spondylolisthesis is the same for spondylosis with conservative and surgical options. Even with a step-off, most patients can be conservatively treated and return to full activity. Surgery can be considered in cases of recalcitrant pain or failed conservative management.

By Zac Taylor & Jon Minor, MD

References

Cervical Spondylosis Prevention. (n.d.). Retrieved from https://my.clevelandclinic.org/health/diseases/17685-cervical-spondylosis/prevention

Dubousset, J. (1997). Treatment of Spondylolysis and Spondylolisthesis in Children and Adolescents. Clinical Orthopaedics and Related Research,337, 77-85. doi:10.1097/00003086-199704000-00010

Kim, R., Singla, A., & Samdani, A. F. (2015). Classification of Spondylolisthesis. Spondylolisthesis,95-106. doi:10.1007/978-1-4899-7575-1_7

Pathogenesis of myelopathy in cervical spondylosis. (1975). Injury,7(2), 161. doi:10.1016/0020-1383(75)90022-4

Images:
https://www.bonati.com/conditions/spondylosis/causes/
https://corewalking.com/spondylosis-spondylolysis-and-spondylolisthesis/
https://www.bio4me.co.za/2015/11/spondylolysis/

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