After age thirty, your discs become less effective cushions; they start to resemble pancakes. In addition, loss of spacing puts more pressure on the facet joints at the back of the vertebrae, a process that results in lumbar spondylosis. These degenerative changes occur in all of us as we age, but in some of us they happen sooner.
Facet joints normally allow motion forward and backward and do not carry weight, but as the cushioning of the discs lessens, more and more body weight is placed on the facet joints. When the facet joints begin bearing weight, they start wearing out. These changes eventually lead to osteoarthritis, the most common form of arthritis; osteoarthritis often also involves the knee or hip.
Narrowing discs and changes in the facet joints may be a painless process, but it may also cause severe localized back pain. Individual differences are the rule, and we can’t predict who will have pain associated with lumbar spondylosis. X rays and MRIs can detect changes in the joints and the degenerative discs, but these tests are unable to predict future pain. This is important because many patients come to me with MRIs demonstrating disc degeneration, but these changes may be inconsequential. In the past, a number of studies have shown that people with no complaints or history of back pain may show significant disc degeneration when given radiographic tests. On the other hand, osteoarthritis of the facet joints can cause significant back pain that requires attention in order to improve.
Almost everybody with lumbar spondylosis improves with nonsurgical therapy. Appliances—artificial discs—designed to replace discs in the spine remain in a developmental and experimental stage. We need many more years of testing before disc replacements will be available to the small group of patients with intractable back pain related to degenerative disc disease.
Treatment with Exercise and Medications
Disc degeneration and osteoarthritis are primarily treated with exercises. If you limit the motion of your spine, stiffness and fatigue often result. Range-of-motion exercises help maintain movement of the spine. Add medication if physical function is limited by increasing local back pain.
Osteoarthritis of the lumbar spine is treated with analgesics, NSAIDs, and muscle relaxants in varying combinations.
Facet Joint Injection for Osteoarthritis
If you have osteoarthritis, you will likely respond to oral drugs and will not need additional therapies. But you may be one of the few who have increased pain when bending to the side. The location of this side-bending pain does not change and is just off to the side of the middle of the back. These symptoms are characteristic of arthritis that affects the facet joints. When other therapies are ineffective, facet joint injections help decrease the pain.
The chance for success is increased when the injections are done with the help of X rays so that the needle can be placed exactly in the joint. Under fluoroscopic guidance, the injection of anesthetic and corticosteroid decreases the inflammation of the joint and the nerves supplying sensation to this area. The beneficial effect of the injection can last from days to months.
A more permanent, but more invasive, method to decrease pain in the facet joint is the use of heat (radiofrequency) or cold (cryoablation) to damage nerves supplying sensation to the facet joints. The point of the therapy is destruction of the nerves to the facet joint by searing or freezing them. We expect that the procedure will destroy all the nerves that cause the pain, without damaging any of the nerves supplying the muscles.
These procedures require you to be awake while the injections are given. Even when the procedure is done properly, all the sources of pain may not be reached. In addition, the procedure itself has the potential to cause increased low back pain. Therefore, I add these procedures as part of a complete prescription in only the most severe cases of facet syndrome that have been resistant to NSAIDs, muscle relaxants, exercises, and long-acting narcotics.
Osteoarthritis of the Hip
Arthritis of any type that affects the hip can cause groin pain. Nerves that supply sensation to the hip also innervate the muscles in the low back and thigh. Pain from the hip may also radiate down to the knee, and hip disease may show up as low back or thigh pain. If you have hip arthritis, you may have difficulty walking and you may attribute this to your back.
At fifty-five, Ellen, an attorney, had had difficulty walking for about six months. Her pain was localized to the right buttock and low back, and although she couldn’t remember when her pain had started, she’d noticed a gradual increase in the severity of her symptoms. She had been to two other physicians who had focused attention on her lumbar spine as the cause of her symptoms, although X rays and an MRI scan of her spine did not reveal abnormalities. Despite lack of lumbar spine difficulties, her back pain increased and she had more and more trouble getting out of a chair or out of bed in the morning. Ellen’s pain also had a detrimental effect on her sexual relationship with her husband because she had trouble finding a comfortable position during sex, one that did not cause more right buttock pain.
She had normal range of motion in her back, but when her right hip was moved by rotating her foot away from the center of her body, she experienced her “back” pain. An X ray taken of the pelvis, as opposed to the lumbar spine, revealed significant joint space narrowing and extra bone formation. When asked if she’d had trauma to this hip in the past, this limping lawyer remembered a horseback riding accident in which she had fallen on that hip but had only a bad bruise and no fracture. This old injury was the probable source of her current problems. I suggested treatment with exercises to strengthen her leg and anti-inflammatory medications. Currently, Ellen is walking without a limp, but she may be a candidate for hip replacement in the future.
- Understanding Back Pain, Your Spine and its Cause
- Ask the Expert About Back Pain
- Mechanical Disorders of the Spine
From Back in Control by Dr. David Borenstein