LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS

(Keywords: lumbar facet arthropathy spondylolysthesis, chiropractic, lumbar facet syndrome, spondylolysthesis arthritis, lower back and leg pain)

LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS is a not uncommon condition found at the Chiropractic Clinic. It's often associated with severe leg pain.



Spondylo-lys-thesis

Shall we start by getting this jaw breaker out the way, otherwise you my be tempted to leave this page immediately!

Spondylolysthesis is a spinal condition where one vertebra slides forwards on it's neighbour below. There are two main causes:

1. Trauma which fractures the "pars", usually in childhood, but it's also a stress fracture the sportsmen get. It's very common in cricketers. Fast bowlers get it.

2. Degenerative change (arthropathy) in the facet joints causing the shape and orientation to change, allowing the vertebra to slide forwards. It occurs in the older person.



The lumbar facet joints are subject to wear-and-tear, particularly after a hyperextension injury that was not properly cared for. The ensuing chronic fixation leads invariably to Immobilisation Arthritis and Hyaline Cartilage degeneration.

In short, the hyaline cartilage that lines the ends of bones is dependent on movement for correct nutrition. Immobilise or fixate at joint and it rapidly becomes arthritic.



CASE FILE

LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS

Mrs G is a 75-year old woman who has had pain in her left buttock for five years. Four months ago she fell down five steps on her buttocks (the staircases in the Nederlands are very steep). A month later the pain started radiating down her the back of her thigh and calf, with tingling on top of her foot.

She couldn't use any power with her left leg without severe pain in the leg. Turning her torso left and right, and straightening up after bending was very painful. The pain in her leg was constant, 24 hours per day. She could never escape it.


EXAMINATION
LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS

  • Looking for a Leg Length Inequality is always tricky. It can't be measured precisely without a special X-ray of the pelvis, which I didn't have, and sometimes it changes after adjusting the pelvis, or even adjusting the foot. However, by eye-balling her pelvis, there was no obvious low side. A mild scoliosis (curvature) however was clearly present. LEG LENGTH INEQUALITY ...
  • There was a marked fixation in the opposite (right) sacroiliac joint, and at the L5-S1 joint (the lumbo-sacral joint). L4 was tender on palpation.
  • Forward bending caused moderate pain in her back and buttock but did not radiate to the leg. Sideways bending, right and left, were mildly uncomfortable.
  • The test of Lasegue for a pinched nerve was very mildly positive at 60 degrees, with pain in the buttock, but not the leg. The Slump test too was mildly positive. SLUMP TEST ... for a pinched nerve.
  • There was no numbness, no muscle weakness and the reflexes were normal.
  • The piriformis muscle was very tender with active trigger points. PIRIFORMIS SYNDROME ...
  • Her right hip shows signs of early hip arthritis. Limited flexion, adduction and internal rotation with pain in the groin. HIP ARTHRITIS ...

LUMBAR STENOSIS

LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS


The radiological report reads:

"Forward slip of the body of L4 in relation to L5, spondylolisthesis, grade 1.

At L4-5 a canal stenosis is seen with facet arthropathy and hypertrophy (thickening) of the Ligament Flavum. Reduced intervertebral foramena right more than links.

At L5-S1 there is also relative canal stenosis, also on the basis of advanced facet arthropathy and hypertrophy of the Ligament Flavum. There is possibly a small synovial cyst at the left facet joint."

Certainly there is a very small, tight spinal canal, consistent with our case history and findings. Chronic low back pain, buttock pain and radiating pain to the left foot.

Can Chiropractic possibly help? Does chiropractic help have a spinal stenosis explanation and solution...?



DISCUSSION LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS

Something didn't quite fit. With such severe pain in the leg, I would in the first place have expected pain in the leg when she bent (either forwards, or sideways, backwards) and that the tests for a pinched nerve would be strongly positive. But no, this is not a "pinched" nerve in the normal sense, but irritated nerves, severely inflammed by the complex toxins exuded by fixated joints.


We had to wait a week, before starting the treatment, for the X-rays and scan which brought forth the explanation. Extremely degenerate facet joints at L4-5 that had allowed the fourth lumbar vertebra to slide forwards: SPONDYLOLYSTHESIS.

Interestingly her symptoms were partly from the S1 nerve root (from the L5 fixated joint) and partly from the L5 nerve root (tingling on top of her foot): from the Spondylolysthesis.

The severe fixation in the right sacroiliac joint anatomy was central to the whole problem.

TREATMENT

The first three treatments involved the sacroiliac joints and L5 using the Thompson drop protocol, and gentle drop treatments on L5 with her in the side-lying posture. The pain increased after the first two treatments. She was dubious, but I assured her that was normal for a chronic condition.

I modified the treatment to include the very degenerate L4-5 joint. From the case notes:

"Flex iets Li bil. Kemp R en L > Links L5. L5R vast. ZSLR L licht in L bil. L4R, L5L roll drops. Steeds pijn, dus: Prone: R sac hard, L si AS hard. Supine R en L Si, ant bekken. Active release therapie aan de linker hamstring, piriformis en Iliotibial band."

Within five treatment she had 50% less pain, and after seven the pain has completely gone.

We are now busy with rehab, still concentrating on the right hip arthritis which is still tender, though also improving, and I'm pondering the need for a heel lift.

Next week we start with a full examination of her neck, which is also stiff and painful.


PROGRESS

LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS

Mrs G came in today for her seventh treatment. She's smiling, me too. She played tennis twice this week, with no ill effect. I'm no longer smiling! that wasn't allowed, but it seems with no negative results. She added a sentence about the loneliness of growing older. The tennis club is her solution. So be it, she's not just a back.

The pain in her left leg has completely stopped and the Slump test is negative. She still has a little discomfort in the right sacroiliac joint, something she has had for years, which is connected to the arthritis in her right hip. The right groin is still a little painful when she rotates her hip. We're working on it, Rome wasn't built in a day. Nor were Aachen or Cologne as we say in Europe. (They are both worth a visit. Especially the Dom in Aachen which is where you'll see the remains of Charlemagne; and the Christmas fair in Cologne is generally acknowledged as the best in Europe. And the chocolate factory is to die for!)

Managing these complex cases successfully means addressing each and every part of the syndrome. A mixture of symptoms and signs, in this case the

  1. Muscular condition in her left buttock, the Piriformis.
  2. The fixation at L5.
  3. The spondylolysthesis at L4.
  4. The hip arthritis on the other side.
  5. Thinking about the Leg Length Inequality, and would a heel lift help, or hinder.
  6. Convincing the patient of the need to do daily rehab exercises, to start walking more and sitting less. Tennis, mm???
  7. Persuading them to accept that some things belong to the past. Can they still garden, play tennis, golf, work in a bookshop where lifting boxes of books is required...


LOWER BACK AND LEG PAIN

LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS

Lower back and leg pain is an every-day-event in chiropractic clinics. It's our bread and butter. Sometimes it's routine and straightforward, sometimes it can be extremely complex. Occasionally we have to refer patients for surgery. Occasionally!

More often it's we who are trying to cope with very unhappy patients after Failed Back Surgery (FBS) as it's known in the literature, or the complications of surgery. LOWER BACK AND LEG PAIN ...

COMPLICATIONS OF SURGERY

Today I had a new patient in her upper fifties with a not dissimilar history, but she went for the surgery. Immediately after the operation she developed a severe foot drop, and could only move about with a walker for two months.

And she still has disabling numbness and tingling in her lower leg. The X-ray reveals another LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS ... I wonder what we can do for her, if anything.

My point? These serious cases of degenerative lumbar spines are an every day affair in chiropractic clinics. Each has to be managed carefully, thoroughly, mostly fairly gently though periodically a good "pak sla" is necessary. A good hiding!

Do we chiropractors always win with these difficult cases? No, of course not, but isn't conservative treatment always worth a try before going for surgery?

It's never far from my mind that a favourite relative died (literaly) after her seventh lumbar surgery, aged forty-two. And it all started with a routine, uncomplicated lower back strain. You can do a lot more damage with a knife in your hand, than just a plain hand!

Plus the risk of infection, not to mention Anaesthetic Alzheimers ...


IMPORTANT CONSIDERATIONS @ LUMBAR FACET ARTHROPATHY SPONDYLOLYSTHESIS




The search this site function in the navigation bar on the left enables you to find stuff on this site.

Google has gone through an enormous shakeup in the last year, giving webmasters much grief.

Meantime, use that search function to find more information about subject material mentioned on the page where links have probably been removed.  There are over 360 pages at chiropractic help; it's become a veritable encyclopedia dedicated to better health.


Did you find this page useful? Then perhaps forward it to a suffering friend. Better still, Tweet or Face Book it.


Interesting challenges of the day

1. Mr B  came initially for a painful and stiff neck and then asked whether chiropractic could help the cold numb feeling running down the side of his thigh for six months. Meralgia paresthetica is a double crush syndrome with the nerve affected in the back and groin. He's 80% improved after five treatments.

2. Mrs C has a long history of severe, disabling migraine headaches since having her wisdom teeth removed. She clenches her teeth at night. After six treatments she has no migraines but some jaw joint discomfort remains; a bite plate is in the offing.

3. Mrs U has the trophy for the worst back this year. After major surgery with plates and screws two years later she still had paresis in the lower leg and severe disabling back pain. She's doing far better than expected, in no little part due to a lift in her shoe for a very short leg.

4. Mr V is 86 years old and hurt his back helping his wife into the car. Just one treatment of the sacroiliac joint and he's eighty percent better. It's not always like that.

5. Mr W lay on his back knocking down a pillar. Turning his head causes severe vertigo. He needs the Epley exercises, not pills, research shows. Update, he's fine.

6. Mrs X, a young mother has severe lower back pain, with numbness down the posterior thigh, calf and side of her foot. It started after a long drive in the car. After six treatments she is 60 percent better, but it's slow and is going to take the full 6 weeks to heal.

And now a setback, after lifting her child she now has leg pain. It's going to the be difficult.

7. This lady is a 70 year old woman, is on maintenance care for a nasty lumbar stenosis despite having to do everything at home. Her husband has a hospital acquired infection after a total shoulder replacement. After four operations he is incapacitated.

8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.

9. This man is a 73 year old engineer, still working, is doing fine after a long episode of lower back pain. Some pain on the side of the hip remains after five treatments. I reassured him it's not hip arthritis.

10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.

11. Mr C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.

13. Both Mrs E and I can't believe how much better her lower back and leg pain are. Surgery for a scoliosis and spondylolysthesis three years ago helped greatly for one year. But then her leg went lame and weak. He was responded extremely well despite all expectations.

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.



Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?


Interesting questions from visitors

CLS writes:

Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.

Your own unresolved problem. Pose a question

Knowing that up to 70% of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there's a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong! Give plenty of detail if you want a sensible reply.


You visited this chiropractic help site no doubt because you have a problem that is not resolving and want to know more about what chiropractors do.

The quickest and most interesting way is to read one of my ebooks of anecdotes. Described by a reader as gems, both funny and healthful, from the life and work of a chiropractor, you'll love them. Priced right at $2.99, though Kindle fiddles the price without telling me.

LOW BACK and LEG PAIN


Falls

Bending and twisting


Sitting

Short leg?


Lower back and leg pain


Lumbar facet syndrome


Slipped disc


Sacro-Iliac Joint


Spondylolysthesis


Examination