Displaced intervertebral discs: how to recognize and treat?

Spondylolisthesis (spon + dee + lo + lis + thee + sis) is a spinal pathology in which one of the vertebrae slips forward or backward in relation to the adjacent vertebra. Slipping of the upper vertebra forward relative to the underlying one is called anterolisthesis, and slipping backward is called retrolisthesis.

Spondylolisthesis (vertebral displacement) can lead to spinal deformity, as well as narrowing of the spinal canal (central spinal stenosis) or compression of the exiting nerve roots (foraminal stenosis).

Spondylolisthesis most often occurs in the lower back (lumbar spine), but can also occur in the thoracic and cervical regions. Treatment for vertebral displacement will depend on the degree of disruption of the biomechanics of the spine and the effect on nearby nerve structures and can be either conservative or surgical.

Causes of spondylolisthesis (vertebral displacement)

Spondylolisthesis has several main causes. Doctors have developed a classification system based on the different causes of spondylolisthesis.

Type I: It is also called dysplastic or congenital spondylolisthesis. Thus, type I spondylolisthesis is a defect of the articular processes of the vertebra. This defect usually occurs at the junction of the lumbar spine and the sacrum: area L5-S1. The defect causes the L5 vertebra to slip forward relative to the sacrum.

Type II: Also called isthmic, this is the most common type of spondylolisthesis. In type II spondylolisthesis, there is a problem with the pars interarticularis, a specific area of ​​the vertebra. . Isthmic spondylolisthesis is further divided into subtypes:

• Type II A: Gymnasts, weightlifters and football players are especially susceptible to this type of spondylolisthesis. This type of vertebral displacement is caused by multiple microdestructions in the pars interarticularis area, which arise due to hyperextension and excessive loads. The vertebral arches in type II A are completely broken.
• Type II B: This type is also caused by microfractures. The difference, however, is that the arms do not break completely. Instead, bone tissue grows and the arches become longer as they regenerate. Longer arches may force the vertebra to move forward.
• Type II C: Like Type II A, this type has a complete fracture and is caused by acute trauma. For example, an impact from a car accident can destroy the temples.

A fracture of the arch can lead to the appearance of a moving part of the bone; the disconnected inferior articular process may move. This bone fragment, also called a Gill fragment, can impinge on a nerve root and often requires surgical removal of the bone fragment.

Problems with the pars interarticularis can also be called spondylolysis. The word is similar to spondylolisthesis, and the two are somewhat related. Microdestructions in the pars interarticularis - often occur in gymnasts, football players and weightlifters - are a form of spondylolysis. Fractures of the arches are called spondylolysis; If a vertebra slips forward because it is not held in place properly, it is called spondylolisthesis.

Type III: Aging can also cause spondylolisthesis. As a person ages, degeneration of the spinal structures occurs. Usually, the intervertebral discs degrade first. The older a person is, the less water and proteoglycans there are in the discs - and this leads to a decrease in the shock-absorbing functions of the discs. The discs become thinner and the load on the facet joints increases. The joints become hypermobile and the vertebra can end up sliding forward because the facet joints cannot effectively hold the vertebra in place. Typical degenerative spondylolisthesis usually develops in the L4-L5 region and is more common in women over 50 years of age.

Type IV: Similar to Type II C, Type IV involves a fracture. However, it is a fracture of any other part of the vertebra other than the pars interarticularis. For example, the facet joints may collapse, separating the front part of the vertebra from the back part.

Type V: Tumors in the spine can also cause spondylolisthesis because they weaken the bones and can cause fractures that separate the vertebrae, leading to instability and potential slippage.

Type VI: develops after surgical treatment of the spine. It is also known as iatrogenic spondylolisthesis, and is usually associated with postoperative instability of the spinal motion segments.

Risk factors, causes

A variety of reasons can cause displacement, and people who experience constant physical overload or, conversely, lead a sedentary lifestyle, are at risk.

The main reasons for the development of spondylolisthesis:

• 
  Often it is spinal trauma that is a factor in its deformation, congenital pathologies of the spinal column, leading to the development of dysplastic displacement;

• age-related degenerative changes in the vertebral structure;
• mechanical injuries of the spine (fractures, bruises, cracks and dislocations);
• ever undergone spinal surgery;
• oncological diseases of the spinal joints, muscle atrophy;
• constant excessive loads on the spine.

In adolescence, displacement may be caused by insufficient development of the muscular corset . The main risk group includes professional athletes (weightlifters, gymnasts) and people engaged in heavy physical labor.

Consequences

At the initial stage of development, the patient is prescribed conservative treatment, which is highly effective. In advanced cases, the patient will definitely need surgical intervention, for example, artificial fusion of the vertebrae, removal of excess scar tissue.

If the disease is diagnosed in an elderly patient, then most often the therapy ends with the assignment of disability . Displacement is often accompanied by damage to internal organs, the development of arthritis and arthrosis, and radiculitis.

Symptoms of spondylolisthesis

Symptoms of spondylolisthesis with minor mechanical disturbance of the location of the vertebra may be limited to discomfort after physical activity.

As the vertebra moves, conditions arise for a compression effect on the spinal cord (with anterolisthesis) and on the nerve roots (retrolisthesis). Mechanical impact on nerve structures can lead to symptoms of compression of the spinal cord or roots.

With severe compression of the spinal cord, serious complications such as cauda equina syndrome may occur, which requires emergency surgical intervention.

Most often, the following symptoms appear with spondylolisthesis:

• Pain in the lower back (neck) increases when turning or bending
• Pain in arms or legs
• Pain that runs down the back of the leg, pain in the buttocks
• Weakness in legs, arms
• Tingling or numbness in the extremities
• Muscle discomfort
• Muscle spasms
• Difficulty walking
• Bladder and bowel dysfunction (cauda equina syndrome)

Features of preparation

Initially, an MRI is performed, the results of which determine the degree of displacement, the percentage of deformation and narrowing of the intervertebral discs. It is also necessary to perform an X-ray of the cervical or lumbar region in two standard projections with functional tests in the lateral projection. Based on this, it is chosen which spine surgery will be performed for spondylolisthesis.

As part of the preoperative examination, the following is prescribed:

• UAC and OAM;
• Doppler ultrasound of the vessels of the lower extremities;
• CT;
• electromyography.

Diagnosis of vertebral displacement

As a rule, it is impossible to obtain visual signs of spondylolisthesis (vertebral displacement) based on the examination of the patient.

Patients usually complain of back pain and occasional pain in the legs or arms. Misalignment of the vertebrae (spondylolisthesis) can often cause muscle spasms or stiffness in the harness tendons.

The diagnosis of vertebral displacement is easily made using simple radiographs. A lateral x-ray can clearly show the presence of slippage of one vertebra in relation to another.

Spondylolisthesis is measured as the percentage of displacement of a vertebra compared to the adjacent vertebra.

• Grade I is a displacement of up to 25%.
• Grade II ranges from 26% to 50%.
• Grade III ranges from 51% to 75%.
• Grade IV ranges from 76% to 100%.
• Grade V or spondyloptosis occurs when a vertebra has completely fallen out of the underlying vertebra.

If the patient complains of pain, numbness, tingling or weakness in the legs, the doctor may order additional tests. These symptoms may be caused by stenosis or narrowing of the foramina and compression of the nerve roots. A CT scan or MRI may help identify nerve compression associated with vertebral misalignment. Sometimes a PET scan can help determine whether the bone at the defect site is active. This may help in choosing treatment tactics.

Types and degrees of displacement

Depending on the direction of the displacement, it is customary to distinguish:

• ventrolisthesis - anterior displacement;
• retrolisthesis - posterior displacement.

Depending on the area of ​​displacement, five degrees of pathology are distinguished:

• First degree - the displacement area does not exceed 25%, there are practically no pain symptoms, it manifests itself with intense movements and loads;
• Second degree - the displacement area ranges from 25% to 50%, pain occurs more often and lasts longer;
• Third degree - the displacement area ranges from 50% to 75%, severe pain occurs, limited movement, subsidence of the spine, pain radiating to the leg;
• Fourth degree - the displacement area exceeds 75%, is characterized by incessant pain, the inability to walk, sit, stand for a long time, numbness and weakness of the feet and hands appear;
• Fifth degree - there is complete displacement and prolapse of the vertebra.

Treatment of vertebral displacement

• Initial treatment for spondylolisthesis (displacement of the vertebrae) is conservative and based on symptoms.
• A short period of rest or avoidance of activities such as heavy lifting, bending, and athletics may help reduce symptoms.
• Physical therapy can help increase range of motion in the lumbar or cervical spine, relieve muscle spasms, and strengthen core muscles.

A physical therapy program is one of the most effective treatments for spondylolisthesis for two main reasons: (1) It can help strengthen the muscles that support the spine, and (2) it can teach the patient how to maintain spinal function and prevent further progression of vertebral misalignment.

Physical therapy includes both passive and active treatment methods.

• Passive treatments help relax the body. They are called passive because the patient does not actively participate. A physical therapy program may begin with passive treatment to allow the body to heal, especially if the patient has pars interarticularis fractures.
• But the main goal of physical therapy is active treatment. These are therapeutic exercises that strengthen the body and help prevent the recurrence of possible pain associated with a misaligned vertebra.

Passive treatment

The doctor may prescribe passive procedures such as:

• Deep tissue massage: This method aims to relieve spasm and chronic muscle tension that occurs due to the body's adaptation to biomechanical disorders associated with vertebral misalignment.
• Hot and cold therapy: alternating hot and cold therapy. By using heat, blood flow can be achieved to a specific area and the increased blood flow brings more oxygen and nutrients to that area. Blood is also needed to remove the byproducts created by muscle spasms and also aids in healing.

• Cold therapy, also called cryotherapy, slows blood circulation and helps reduce inflammation, muscle spasms and pain. Ice packs can be used for cryotherapy, but currently a special physiotherapeutic hardware technique called cryotherapy is used to cool tissues.
• TENS (transcutaneous electrical nerve stimulation): TENS helps reduce muscle spasms and it can also increase the production of endorphins, natural pain relievers.
• Ultrasound: By increasing blood circulation, ultrasound helps reduce muscle spasms, swelling, stiffness and pain. The sound waves penetrate deep into muscle tissue, creating heat that enhances circulation and healing.

Complex conservative treatment:

prescribing painkillers, muscle relaxants and antispasmodics to relieve tension in the back muscles and relieve pain.

• local blockades of the spine in places of displacement of the vertebrae with injections of hormonal drugs.
• therapeutic massage (not prescribed during periods of acute pain)
• acupuncture
• use of chondroprotectors
• physiotherapy (electrophoresis, paraffin, salt or radon baths)
• physiotherapy

After eliminating the displacement of the vertebrae, the doctor may recommend wearing a specialized corset or belt to fix the spine. This will significantly reduce muscle tension and pain.

Active treatments

In the active portion of physical therapy, the physical therapy therapist will teach the patient various exercises to improve flexibility, strength, stability of the spinal column and restore range of motion. The physical exercise program (physical therapy) is individualized, taking into account health and medical history. Exercises for one person may not be suitable for another person with spondylolisthesis. Thus, the exercise therapy doctor selects an individual exercise program for each patient and the task of the set of exercises is to create a muscle corset that will compensate for biomechanical disorders associated with vertebral displacement.

If necessary, the patient receives information from a physical therapy doctor on how to correct his posture and incorporate ergonomic principles into daily activities. This is all part of the physical self-care or self-medication aspect: through physical therapy, the patient learns good habits and principles to better care for the body.

The effect of massage of different parts of the spine and the main contraindications

Various pathologies of the back lead to incorrect anatomical location of the vertebrae and muscles.

spine massage

Massage can have a restorative effect and form the correct bends and shapes of the areas of the spinal column. Only a qualified doctor can perform a proper spinal massage. It is especially important to choose a professional, because treatment is aimed at the rehabilitation of the musculoskeletal system, which is important for the body.

Massaging the thoracic vertebrae is usually prescribed to reduce the symptoms of neuralgia and degenerative tissue damage (osteochondrosis). Massaging the collar part of the body will help relieve severe headaches, restore blood circulation and reduce adynamia. As a pain reliever, massage is used when a hernia is detected between the vertebrae as an additional treatment.

Who needs a spinal massage

A sedentary and inactive lifestyle, so common in our modern world, has a very negative effect on the entire body. Also, due to heavy loads on the back, a person begins to feel pain in the lower back, cervical and thoracic areas, and incorrect posture develops. Therefore, negative manifestations in the back and even just tension are an important reason for massage effects.

Spinal massage will also be useful for those who have the following ailments:

1. Curvature of the vertebrae (kyphosis, scoliosis), inferiority of the ligamentous apparatus;
2. It will improve the process of maintaining the cartilage tissue of the spine in case of various herniated intervertebral discs, protrusions and various types of osteochondrosis;
3. When it is necessary to strengthen the muscle group of muscles that support the spinal column;
4. Lumbodynia – painful sensations in the lower back that are chronic;
5. Thoracalgia is a painful deformation of different parts of the back;
6. When the spinal roots are pinched;
7. After surgery or serious injuries, massage will increase blood circulation in pinched tissues and strengthen them;
8. Post-stroke and neuralgia
   ;
9. Swelling of body tissues after long periods of sitting or standing;
10. Passing to the groin and thighs - pain in the gluteal muscles.

Restrictions on massage

A preliminary consultation with your doctor is required before performing the procedure. After all, this is not just a pleasant and relaxing procedure, it is one of the methods of treating and preventing problems of the spinal column. Everyone should remember about contraindications that arise temporarily or, as happens quite often, are permanent.

Temporary limiting factors:

• various bleedings (from the nose, uterus, intestines);
• for acute respiratory infections, flu, sore throat;
• complication of pathologies of internal organs;
• purulent diseases affecting the body;
• skin rash;
• sudden increase in blood pressure;
• osteoporosis – acute infection of the spinal column and joints;
• vomiting and nausea.

The permanent group includes:

• varicose veins;
• respiratory failure;
• the presence of a malignant tumor without initiation of treatment;
• active degree of tuberculosis;
• poor blood clotting syndrome;
• pathological dilatation of the aorta and heart vessels;
• STD;
• cardiovascular diseases;
• AIDS.

Next, let's talk about massage on various areas of the spinal column. The main thing you need to know: the impact should be carried out at a distance of three to ten cm on the right and left sides of the spinal column. The movements should be directed upward from the lower back to the beginning of the hair.

Massage of the lumbosacral region

The greatest load is placed on the lumbosacral region; it is almost never relaxed. That is why, in order to relieve severe and frequent pain in this area, a specialist must pay special attention to its treatment.

First you need to stretch the muscles of the buttocks and only then begin to work on the problem area. Stroking movements warm up the muscles in the pelvic area. Squeezing, kneading, shaking and stroking again - all actions alternate. Repeat two or three times.

At the next stage, squeezing is performed, and the massage therapist moves his fingers, folded into a fist, along the spine with kneading movements. Finally, stroking and shaking are done to calm the tissues.

Cervicothoracic massage

The neck is the most unprotected part of the human body, because it contains a large number of channels with nerves and blood vessels. Therefore, massage has an excellent effect in relieving neck movement restrictions.

The techniques used in this type are kneading, stroking, shaking, squeezing and rubbing. The right and left areas of the spine, reflexogenic zones and places of the spinal cord roots deserve special attention.

It is worth starting massage from the healthy side, that is, the opposite side to the one in which pain is present. The back and neck muscles should be in a state of complete relaxation - this is very important. The massage can be performed both in a sitting position and in a lying position.

DIY cervical massage

You can massage your cervical spine yourself while at home. It doesn't take long - less than 15 minutes. While sitting, you need to move from the fourth vertebra of the sternum to the beginning of the hair.

In self-massage, the same movements are used as in classic cervical massage.
You can make movements with two palms at the same time or just one. All actions must be correct and careful. It's better to see a doctor if you can't. This will reduce the risk of self-harm. Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr

Surgical treatment of vertebral displacement (spondylolisthesis)

Surgical treatment may be recommended if there is severe displacement of the vertebra or there is no effect of conservative treatment.

The type of surgery depends on the type of spondylolisthesis. Patients with isthmic spondylolisthesis may undergo surgical reconstruction of the defective part of the vertebra. If an MRI scan or PET scan shows that the bone is active at the site of the defect, then it will be restored when the arches are reconstructed. This surgery involves removing any scar tissue from the defect and placing a bone graft in the area, followed by screw fixation.

If there are signs of compression of nerve structures, surgery may include decompression to create more space for the nerve roots to exit the spine. Decompression is often combined with vertebral fusion, which can be performed either with or without screws. In some cases, the vertebrae are returned to their normal position before fusion is performed, and in other cases, only fusion can correct the misalignment of the vertebra. Outcomes and recovery after surgery depend on a comprehensive rehabilitation program.

Causes and types of pathology

Spondylolisthesis most often begins after injury, but congenital forms of this pathology are also diagnosed. Modern medicine knows six types of the disease.

• Dysplastic. The cause is a congenital anomaly of the facet joints of the fifth lumbar or, less commonly, the sacral vertebrae. The first symptoms appear in childhood and progress with the growth of the spinal column.
• Degenerative. Most often it is the result of arthritis and osteochondrosis. Displacement of the lumbar vertebrae occurs; if not treated in a timely manner, the risk of manifestations of disturbances in the functioning of the lower extremities and internal organs increases, as well as restriction of freedom of movement in old age.
• Isthymic. The reason is a defect in the development of the interarticular part of the vertebra. Until the age of five, it does not manifest itself at all, the peak of development is 7–18 years. It is considered the most common form.
• Pathological. Consequence of metabolic disorders in bone.
• Postoperative. The reason is injuries received as a result of surgical intervention in the spine.
• Traumatic. Develops as a result of regular overload. Even frequent visits to a chiropractor to treat spinal disc displacement (although this is a separate disease that requires its own therapy) leads to deformation of the spinal joint.

Complications and prognosis of spondylolisthesis

Complications of a misaligned vertebrae (spondylolisthesis) include chronic pain in the lower back or legs, and numbness, tingling, or weakness in the legs. Severe nerve compression can cause problems with bowel or bladder control, but this complication is very rare.

The prognosis for patients with spondylolisthesis is good. Most patients respond well to conservative treatment.

If severe symptoms are present, surgery may help relieve symptoms by decompressing nerve structures.

Etiology

Signs of vertebral displacement are observed for various reasons. As already mentioned, one of them is a disease such as spondylolysis, nonunion or defect of the vertebral arch, which leads to a fracture of the vertebral pedicle. As for other factors, they are presented as follows:

• spinal injuries;
• spinal surgery;
• spinal stretch;
• osteochondrosis;
• sharp contraction of the spinal muscles;
• congenital pathology in the form of bone weakness;
• pathological changes in the intervertebral joints that appear with age.

In the case of children, displacement of the vertebrae can be observed due to birth trauma or sudden movement.

In addition, displacement can occur as a result of:

• traffic accident;
• falling on your back;
• intense loads;
• lifting weights.