Spinal degeneration

Causes of sciatica

What is spinal degeneration?

Spinal degeneration is a condition characterised by gradual wear and tear to the discs, joints and bones of the spine that typically occurs in older patients.

The spine comprises of many bones known as vertebrae each of which has a large hole in its centre (figure 1). Because these bones are situated on top of each other, their holes line up, forming the spinal canal. This canal provides protection and space for the spinal cord and nerves to travel from the brain to the rest of the body. Each vertebra connects with the vertebra above and below via two types of joints: the facet joints on either side of the spine and the disc centrally (figure 2). There are also small holes on each side of the spine known as intervertebral foramen. These are located between adjacent vertebrae and allow nerves to exit the spinal canal (figure 2).

Over time, wear and tear to the discs, joints and bones can occur resulting in degenerative changes to the spine. These degenerative changes may include decreased disc height, loss of joint cartilage, bony spurring (osteophytes) and thickening of bone. This condition is known as spinal degeneration. As this condition progress the spinal canal and intervertebral foramen can begin to narrow (leading to spinal canal stenosis) and may eventually place pressure on the spinal cord and nerves resulting in a variety of symptoms.

Figure 1 - Vertebral Anatomy

 

Figure 2 - Relevant Anatomy for Spinal Degeneration

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Causes of spinal degeneration

Spinal degeneration is a condition that typically occurs over time due to gradual wear and tear associated with overuse or aging. It may be particularly common in patients with a history of lower back pain or trauma to the spine or in those with lifestyles that have involved large amounts of lifting, bending, twisting or sitting activities.

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Signs and symptoms of spinal degeneration

Spinal degeneration is usually seen in older patients. Minor cases of degeneration may cause little or no symptoms. As the condition progresses patients may experience low back pain, loss of spinal movement and general lower back stiffness. In more severe cases involving spinal cord or nerve compression, pain, pins and needles, weakness or numbness may be experienced in the lower back, buttocks, groin, legs or feet.

Patients who experience pain due to this condition generally experience an increase in symptoms during activities that repetitively or continuously straighten or extend the spine (figure 3). Symptoms may also increase during activities that place weight on the spine (e.g. lifting, prolonged standing, walking etc.). Symptoms tend to ease during activities that bend the spine (e.g. sitting) or take weight off it (e.g. lying down).

Figure 3 - Spinal Extension

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Diagnosis of spinal degeneration

A thorough assessment from a physiotherapist combined with appropriate investigations is usually required to diagnose spinal degeneration. An X-ray of the spine will typically demonstrate changes associated with degeneration. Other investigations such as CT scan, bone scan or MRI may also be indicated to assess the severity and to determine the exact structures that are affected.

Prognosis of spinal degeneration

Although little can be done to reverse the degenerative changes to the spine associated with this condition, most patients can have a good outcome with appropriate management. Many patients with mild to moderate degenerative changes to the spine can often experience little or no symptoms with appropriate management and remain active with some lifestyle modifications. Patients with more severe degeneration can also demonstrate significant improvements with appropriate management, although typically, they may require more significant lifestyle modifications and often experience more severe symptoms and functional limitations.

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Physiotherapy for spinal degeneration

Physiotherapy treatment for patients with spinal degeneration is important to assist with pain relief, improve flexibility and strength, and to ensure an optimal outcome. This may comprise:

• soft tissue massage
• electrotherapy (e.g. ultrasound)
• mobilization
• traction
• dry needling
• ice or heat treatment
• the use of a back brace or back taping
• education
• activity modification advice
• prescription of walking aids
• clinical Pilates
• hydrotherapy
• exercises to improve flexibility, strength and core stability

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Contributing factors to the development of spinal degeneration

There are several factors that may contribute to the development of this condition. These factors need to be assessed and where possible, corrected with direction from a physiotherapist and may include:

• age (> 40 years)
• a lifestyle that has involved large amounts of lifting, sitting, bending or twisting
• history of injury or trauma to the lower back
• being overweight
• excessive or inappropriate activity
• inadequate recovery periods from activity
• poor posture
• lumbar spine stiffness
• poor core stability
• muscle weakness or tightness
• muscle imbalances
• inappropriate lifting technique
• biomechanical abnormalities
• genetics

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Other intervention for spinal degeneration

Despite appropriate physiotherapy management, some patients with spinal degeneration continue to deteriorate. When this occurs, other intervention may be required. This may include pharmaceutical intervention, corticosteroid injection, the use of supplements such as fish oil, glucosamine and chondroitin, investigations such as an X-ray, CT scan, bone scan or MRI, or assessment from a specialist. The treating physiotherapist can advise on appropriate management and can refer to the appropriate medical authority if it is warranted clinically. In more severe cases of spinal degeneration involving spinal canal stenosis or nerve compression, surgery may be required to relieve the pressure on the spinal cord or nerves.

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Exercises for spinal degeneration

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.

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Initial Exercises

Transversus Abdominus Retraining

Slowly pull your belly button in "away from your belt line" and breathe normally. Your rib cage should remain relaxed and should not elevate during this process. You should be able to feel the muscle contracting if you press deeply 2cm in from the bony process at the front of your pelvis (figure 4). Practise holding this muscle at one third of a maximal contraction for as long as possible during everyday activity (e.g. when walking etc.) provided it is pain free. Repeat 3 times daily.

Figure 4 – Transversus Abdominus Retraining

Rotation in Lying

Begin this exercise lying on your back as demonstrated (figure 5). Slowly take your knees from side to side as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Repeat 10 times provided there is no increase in symptoms.

Figure 5 – Rotation in Lying

Hip Flexion

Slowly take your knee towards your chest as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 6). Use your hands to gently bring your knee closer to your chest. Repeat 5 - 10 times on each leg provided there is no increase in symptoms.