Lumbar Facet Arthropathy Spondylolysthesis

Keywords; lumbar facet arthropathy spondylolysthesis.



This is a not uncommon condition found at the chiropractic clinic. It's often associated with severe leg pain.

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 a joint and it rapidly becomes arthritic.



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.



Lumbar facet syndrome


Lumbar Facet Arthropathy Spondylolysthesis

CASE FILE

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 limb 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 and severely inflamed by the complex toxins exuded by fixated joints.



We had to wait a week, before starting the treatment, for the xrays and scan which brought forth the explanation. Extremely degenerate facet joints at L4 on 5 that had allowed the fourth lumbar vertebra to slide forwards; spondylolysthesis.

Interestingly her symptoms were partly from the S1 nerve root from the fixated L5 joint and partly from the L5 fibre causing 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: lower back and leg pain

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 and so am I. She played tennis twice this week, with no ill effect. I'm no longer so happy; 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, by the way. 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 museum 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




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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the pain is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Mrs T looked like the leaning tower of Pisa; she had a slipped disc at L5 making her lean towards the opposite side. It's called the postero lateral disc hernia; she's much better after two weeks of treatment and will go back to work next week, part time. Lateral discs are more difficult; both take a minimum of six weeks to heal. In my opinion, antalgic patients need what I call exercising bed rest. Sit and it won't get better.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months. He has a pincer deformity in the hip causing the groin pain, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your lower back is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her hip, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Hypermobility is more difficult that too stiff in my opinion. Chiropractic is for kids too.

8. This 65 year old lady is a serious gardener; every day is bending, lifting, digging for 2-3 hours a day; it regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs 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. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

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



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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