Spinal Fusion/Spondylosis

Spondylosis is a term that refers to the natural degenerative process that occurs in the spine with ageing. The term itself refers to the radiological appearance of the presence of osteophytes secondary to degenerative discs and does not imply the a particular person will be symptomatic in any way.

In fact the presence of these changes should be considered normal in that they are present in most people as they get older. The condition is different to those inflammatory conditions of the joints which result in osteophytes which collectively are referred to as arthritis.

Degenerative spondylosis may result in symptoms though and in the mildest forms this may be in the form of back or neck pain, but also may lead to more serious conditions such as myelopathy. Myelopathy is a condition which occurs when progressive pressure on the spinal cord results in damage which may not resolve.

This damage may be picked up both clinically and on special diagnostic imaging which typically includes and MRI scan of the spine and usually requires surgical management. It must be stressed that the presence of myelopathy is not common in relation to how often spondylosis may be seen but as it is an important diagnosis to make, an MRI scan will often be requested as part of the diagnostic evaluation of the spine.

In the spine there are 3 main groups of symptoms people experience in the presence of spondylosis. Pain- this may be either acute (of short duration, often severe) or of chronic duration ( long standing, often moderate or background pain).

This pain is commonly felt radiating to either the scalp, top of the shoulders or between the shoulder blades and can be very positional. The reason for this distribution of pain is that the structures of the neck and back often share a sensory neurological supply and therefore result in referred pain to regions other that the spine.

Radiculopathy - this refers to the presence of pain of nerve root origin and can be associated with other neurological symptoms such as altered sensation, pins and needles ( paraesthesia), decrease in motor power. In the lumbar spine the term sciatica is often used to describe pain in the distribution of the sciatic nerve which typically involves the lower leg down the back or outer side of the calf.

Femoralgia describes similar pain in the distribution of the femoral nerve which runs down the front of the thigh an inner aspect of the lower leg.

Brachialgia describes similar symptoms in the arms. Specific patterns of pain are associated with specific nerves which can provide a useful clue as to where pain may be arising and these dermatomal patterns can be helpful in directing treatment.

Myelopathy - this is a more serious clinical presentation resulting from compression of the spinal cord. This results in a damage to the nerves that traverse the spinal cord and this damage may be permanent and irreversible. Due to this, removal of this pressure( decompression) is commonly performed to stop deterioration in the spinal cord function although in some patients the clinical damage may improve.

This is not always the case and therefore in the presence of myelopathy, there is some urgency in relieving pressure as soon as possible and being cautious about preventing deterioration while awaiting surgery.

Imaging In Spondylosis

X-Rays: these may be a very good way of making the diagnosis but in isolation are only a part of the diagnostic workup. One major benefit of x-rays is that they may be performed in a variety of positions such as standing upright, flexion, extension and often in the position that brings on symptoms. They also give an impression of how one part of the spine moves in relation to another so form a major part of the diagnosis of deformity and instability.

MRI scanning is essential to assess the neurological structures of the spine as well as those structures not made up of bone such as nerves, spinal discs, muscles etc. They are also an excellent way of diagnosing tumours and infection.

CT SPECT scanning; This new modality is a combination of a CT scan and a specific bone scintogram which are combined together with the use of a computer. This can be a very useful modality in the assessment of back pain in that it can offer some useful information on being more specific about where the pain comes from.

This type of scan does use higher doses of radiation that standard x-rays and therefore are not used in all patients but can be a helpful way of planning surgery for spinal pain. Treatment Spinal spondylosis itself does not require treatment but in the presence of symptomatic spondylosis, treatment is tailored around the specific treatment and the appearance of the spine on special radiological investigations.

Although a number of anaesthetic and steroid injections will be of value in a number of situations, Mr Orpen will also be able to discuss the surgical options in those that have persistent pain or in the presence of Myelopathy.

His emphasis will be on conservative/ non-operative treatment if possible but in specific conditions such as Myelopathy, surgery may be the first choice. These options will be made clear in consultation.

Also see documents on

• Nerve root blocks

• Facet joint injections

• Facet joint rhizolysis

• Spinal decompression

• Spinal fusion

• Disc replacement