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Osteoarthritis
Are you suffering from arthritis pain or another spinal
condition?
Contact the specialists at United Spine & Joint
to determine what treatment option is best for you, what
your insurance will cover and any additional surgery costs.
What is Osteoarthritis?
“Arthritis”
is a general term that describes many different diseases
causing tenderness, pain, swelling, and stiffness of joints
as well as abnormalities of various soft tissues of the
body. Of the combined term, “arthros” means a joint and its
attachments, and “–itis” means inflammation. Various forms
of
arthritis affect nearly 50 million Americans
and contribute to the majority of all physical disabilities.
Although
arthritis is ultimately associated with a wearing out of
joints, nearly a
half million children are also affected.
Of the several varieties of arthritis, the most common,
the most frequently disabling, and often the most painful is
osteo- (meaning bone) arthritis, mostly
affecting the weight bearing joints (hips
and
knees) plus the hands, feet and spine. Normal joints are
hinges at the ends of bones usually covered by cartilage and
lubricated inside a closed sack by
synovial fluid.
Normally, joints have remarkably little friction and move
easily. With degeneration of the joint, the cartilage
becomes rough and worn out, causing the joint halves to rub
against each other, creating inflammation with pain and the
formation of bone spurs. The fluid lubricant may become thin
and the joint lining swollen and inflamed.
Osteoarthritis is also known as degenerative joint
disease and affects up to 30 million Americans, mostly women
and usually those over 45 or 50 years of age. All races in
the U.S. appear to be equally affected. This section focuses
on osteoarthritis of the spine,
particularly on facet joint arthritis.
Where Osteoarthritis Occurs
Cartilage is a form of usually slick, slightly elastic,
connective tissue that covers the ends of the bone joints.
In part, cartilage serves as a protective shock absorber to
minimize the impact of bouncing, jumping and other types of
daily activities on the joints – and is thus subjected to
considerable
wear and tear during life. Indeed, heavy work, sports,
repeated injuries and obesity take a heavy toll on the
joints of the limbs and spine. To be healthy, all joints
should be exercised, but if this is excessive, joint damage
may accumulate slowly.
In addition to the
hips,
knees and
lower back, arthritis commonly occurs in the neck,
small finger joints, the base of the thumb, and the big
toe. In the fingers, nodes (masses of bone and cartilage)
can form on either side of the nail bed or the margins of
joints to become reddened, tender and swollen. Cartilage
breakdown in the hips and knees can be severe enough to
require joint replacement. Osteoarthritis found in other
joints, such as the
hinge of the jaw, is often due to injury or stress.
Osteoarthritis of the Spine
Spinal
arthritis is one of the common causes
of
back pain. Spinal arthritis is the mechanical
breakdown of the cartilage between the aligning
facet joints in the back portion (posterior) of the
spine that quite often leads to mechanically induced
pain. The facet joints (also called vertebral joints
or zygophyseal joints) become inflamed and
progressive joint degeneration creates more
frictional pain. Back motion and flexibility
decrease in proportion to the progression of back
pain induced while standing, sitting and even
walking.
Over time, bone spurs (small irregular growths on
the bone also called osteophytes) typically form on
the facet joints and even around the spinal
vertebrae. These bone spurs are a response to joint
instability and are nature’s attempt to help return
stability to the joint. The enlargement of the
normal bony structure indicates degeneration of the
spine. Bone spurs are also seen as a normal part of
aging and do not directly cause pain, but may become
so large as to cause irritation or entrapment of
nerves passing through spinal structures, and may
result in diminished room for the nerves to pass (spinal
stenosis).
Osteoarthritis in the spine is anatomically
divided into:
-
Lower back (lumbar spine) osteoarthritis,
sometimes called lumbosacral arthritis,
which produces stiffness and pain in the lower
spine and sacroiliac joint (between the spine
and pelvis).
-
Neck (cervical spine) osteoarthritis,
sometimes called cervical
spondylosis (spondy- implies the spine, and
–osis is an abnormal condition), which can cause
stiffness and pain in the upper spine, neck,
shoulders, arms and head.
There are a number of reasons why some people are
particularly disposed to osteoarthritis. However, as with
nearly all abnormal conditions affecting the body, it is
likely that a combination of risk factors work together to
cause osteoarthritis.
Repetitive trauma to the spine from repetitive strains
caused by accidents, surgery, sports injuries, poor posture,
or work-related activities are common causes of
spinal arthritis.
Therefore, athletes and people with jobs that require
repetitive, and particularly heavy, motion have been found
to be at greater risk. Other known risk factors for
developing spinal arthritis include:
- Aging: steady and advanced aging of
spinal structures, beginning in the 30’s, often
work-related
- Gender: osteoarthritis being more
common in
post-menopausal women (although below age 45, it is
more common in males)
- Excess weight: causing more stress
on weight-bearing joints and the spine, particularly
during the middle age years
- Genetics: having a family history
of osteoarthritis or congenital defects of joints,
spine, or leg abnormalities
- Associated diseases: the presence
of other associated diseases, infections, diabetes, and
various other forms of circulating arthritis, such as
rheumatoid arthritis or gout
When a specific cause of the osteoarthritis is unknown,
as it is in most cases, it is referred to as primary
osteoarthritis, which appears to be mostly due to aging.
Aging leads to changes in cartilage and
synovial fluid - the tissue water content increases as
the protein content decreases. Long term repetitive joint
use has been shown to lead to joint inflammation with
associated joint pain and swelling, eventually leading to
the loss of cartilage.
When the cause of the osteoarthritis is known, it is
referred to as secondary osteoarthritis, caused by a
particular disease or condition, such as
obesity,
trauma or surgery to the joints, or abnormal joints at
birth.
Patients with osteoarthritis who take an active role in
their own treatment can prevent additional joint damage and
usually will be able to continue with most of their normal
activities. The key to managing the condition is to get an
accurate diagnosis and start early, proactive treatment.
Most osteoarthritis treatments are focused on reducing the
pain and inflammation associated with osteoarthritis and
maintaining the joint mobility and flexibility needed to
continue with necessary and desired activities. It is clear
that a combination of proper exercise, joint mobility,
weight control,
nutrition and use of appropriate medication is required
to control osteoarthritis.
Osteoarthritis is characterized primarily by stiffness
and
pain in the joints, although not everyone with
osteoarthritis actually experiences pain and disability. The
stiffness and pain tend to be worse in the morning
(particularly for about 30 minutes after waking up) and
again in the evening, often called “first movement pain”
with improvement during the day as the person carries on his
or her daily activities. Pain that awakens one during the
night is often an indicator.
Other symptoms can include:
-
Swelling and warmth in one or more joints,
particularly during weather changes (which may be
related to barometric pressure changes and cooling of
the air)
- Localized tenderness when the joint or affected area
of the spine is pressed
- Steady or intermittent pain in a joint, which is
often described as an
aching type of pain. The pain may be aggravated by
motion
- Loss of flexibility of a joint, such as inability to
bend and pick something off the floor
- A crunching feeling or sound of bone rubbing on bone
when the joint is moved (called crepitus), particularly
notable in the neck
- An abnormal curve in the spine which may be due to
unbalanced muscle spasm
- A sensation of pinching, tingling or numbness in a
nerve or the spinal cord, which can occur when bone
spurs form at the edge of the joints of the spine and
irritate the nerves
Osteoarthritis usually develops over time. Early on, a
person may only experience joint aches after physical work
or exercise, which fades and then returns as the affected
joint is used or overused. As the cartilage between the
bones gradually thins, the pain often becomes steadier,
making it difficult to walk or climb stairs.
Joint pain and stiffness can begin to occur after long
periods of inactivity, such as while sitting for long
journeys or watching a two-hour movie. With advanced
osteoarthritis and increased rasping friction between
bones, the pain often becomes substantial even at rest or
with very little movement.
With progressive
osteoarthritis, a single joint may at first be affected,
but with time and further activities, many joints of the
body may be affected—in the base of the neck, or in the
knees,
hips,
hands and/or
feet. Although less common, some patients may experience
severe deformities of certain joints over time.
Osteoarthritis differs from systemic forms of arthritis
because it only affects joints (although it may lead to an
entrapment of a nerve at any level in the spine or the
spinal cord in the neck) and does not affect organs or soft
tissue areas of the body.
Osteoarthritis is Sometimes Confused with
Other Conditions Causing Pain
Because other conditions seem similar to osteoarthritis
of the spine, particularly when symptoms are at their worst,
it is important to receive an accurate clinical diagnosis
from a doctor who specializes in spinal medicine or
spinal surgery.
Rheumatoid Arthritis
(RA) usually affects multiple joints in a symmetrical
pattern (both sides of the body being affected).
Rheumatoid arthritis is an
autoimmune disease that causes chronic inflammation of
the joints and may involve other tissues or organs of the
body. Therefore, when
rheumatoid arthritis flares up, symptoms can include
fatigue, poor appetite,
low grade fever, muscle and joint aches, and stiffness,
again usually most notable in the morning and after periods
of inactivity. Joints, usually in the
hands, wrists and
feet, frequently become red, swollen, painful, and
tender.
Osteoarthritis is also sometimes confused or may be
associated with
degenerative disc disease (or spondylosis), a gradual
deterioration of the disc(s) between the vertebrae of the
spine. This is because osteoarthritis and degenerated discs
are commonly found together. However, they are separate
conditions and it is important to know which anatomical
changes in the spine are the actual cause of the patient’s
pain or disability.
An x-ray will show degenerative disc disease as a
narrowing of the normal disc space between adjacent
vertebrae. An
MRI scan may show the early changes of a loss of water
content in the disc. Degeneration of the disc tissue
increases its susceptibility to
bulging or
herniation. Disc degeneration can occur at any level of
the spine and can cause local pain in the affected area with
radiation of pain along the nerves emerging from the spinal
canal at that level. Symptomatic lumbar disc degeneration is
most common in people of working age, usually between 30 and
50. After the age of 50 or 60, the affected area of the
spine actually tends to stabilize and degenerative disc
disease is less likely to cause pain. In general, one cannot
equate disc degeneration or bone spur formation with pain
and disability, since about 85% of persons with such
findings on an x-ray or scan do not have a clinically
significant back problem.
Osteoporosis, or low calcium content of the
bones, is another condition that does not cause but can lead
to chronic back pain. With
osteoporosis, particularly more common in
post-menopausal women, bone mineral (calcium) loss may
weaken bones in several parts of the body, particularly in
the hip and the spine.
Spinal fractures with compression (wedging) of vertebral
bodies may occur. The pain from an osteoporotic spinal
fracture can last for several weeks as the bone heals, and
then typically turns into more of a chronic, achy pain
concentrated in the area of the back where the fracture
occurred. This aching may be similar to the sensation
reported by those with osteoarthritis. A bone density test,
which measures bone mass, preferably taken of both a long
bone and a vertebral body, is used to diagnose osteoporosis.
An x-ray can usually identify a compression fracture in the
spine. Since the treatments for osteoarthritis and
osteoporosis are very different, it is critical to get an
accurate diagnosis.
Osteoarthritis Diagnosis
Any patient experiencing back pain or stiffness in a
joint or joints for more than two weeks should see his or
her physician for an evaluation. The evaluation usually
consists of a discussion of symptoms and a detailed medical
history, a physical examination and—if
osteoarthritis is suspected—a series of x rays. Other
tests (blood tests,
MRI or CT scans) may be performed to confirm the
presence of spinal arthritis or to rule out other conditions
that can cause similar symptoms, such as a
spinal tumor, infection, fracture, or
other types of arthritis.
Diagnosing Spinal Osteoarthritis
Typically, the physician will use a combination of findings
from a patient’s medical history, physical exam and medical
tests to accurately diagnose whether a patient has
osteoarthritis. An accurate diagnosis is very important for
guiding the selection of treatment options—and for actually
helping relieve the pain and discomfort associated with the
patient’s condition.
Medical history. The patient will be asked to describe his
or her symptoms, such as a description of the pain,
stiffness and joint function, when and how the symptoms
started, and how the symptoms have changed over time. The
patient should also discuss how the symptoms affect his or
her everyday life and work activities. The doctor also needs
to know about the patient’s other medical conditions,
current medications, past experience with other treatments,
family history, and general lifestyle habits (such as
alcohol intake, smoking, etc.). When dealing with pain
problems, the doctor is likely to ask key questions related
to those things that reliably cause or aggravate the pain
and those that
reliably bring relief or prevent the pain. Other
questions may relate to certain lifestyle topics, such as
exercise,
nutrition and activities for diversion, sports, etc.
Physical examination. The doctor will conduct a physical
exam to assess the patient’s overall general health,
musculoskeletal status,
nerve function, reflexes and direct evaluation of the
problematic joints in the back. The doctor will be looking
at muscle strength, flexibility, and the patient’s ability
to carry out daily living activities such as walking,
bending, and reaching. The patient may also be asked to
perform some exercises to test range of motion and determine
whether pain worsens during any particular type of movement.
X-rays. The doctor will likely
order an
x-ray to see if there is joint damage and how much
joint damage has occurred. The x-ray can show cartilage
loss, bone damage, and the presence and location of bone
spurs. X-rays are also useful in helping to exclude
other causes of pain and to better inform possible
considerations about surgery. However, it is important
to keep in mind that what shows up in an x-ray may not
correlate to the presence or absence of osteoarthritis
and associated pain. For example, most people over age
60 have degenerative changes in their spine consistent
with osteoarthritis, but for perhaps 85% of them there
is no pain or stiffness. Conversely, an x-ray conducted
during the early stages of
osteoarthritis may not yet show any visible damage
to the joints. For all these reasons, the clinical
history and physical examination are essential to
arriving at an accurate clinical diagnosis and plan of
treatment.
Other tests may also be used to rule out conditions other
than osteoarthritis that may be causing the patient's
symptoms. For example, blood tests are used to exclude
diseases that can cause secondary osteoarthritis or other
types of arthritis that simulate osteoarthritis.
Joint aspiration, where fluid is drawn from the joints
through a needle for examination, can help rule out
conditions such as infections or gout.
Additional tests that may be needed to rule out other
causes of pain or to identify the presence of arthritis with
more sophistication than an x-ray can include:
- A
radioactive bone scan, used to rule
out inflammation, a
tumor, infection or a small fracture. With a bone
scan, the radioactive 'tracer' material is injected
intravenously and then is concentrated by the body where
there is high metabolism or bone turnover. If something
suspicious is found on the bone scan, it is usually
followed by a CT or MRI scan to distinguish what the
bone lesion might represent, since the bone scan alone
cannot distinguish among tumors, infections or
fractures.
- A CT scan may be used to better
show the adequacy of the spinal canal and surrounding
structures. A CT scan may also include myelography,
where an x-ray contrast dye is injected into the spinal
column to show structures such as a
bulging disc or bone spur possibly pressing on the
spinal cord or nerves.
- The
MRI or magnetic resonance imaging scan,
is a very sophisticated imaging method that can show
great anatomic details of the spinal cord, nerve roots,
discs, ligaments and surrounding tissues and spaces.
Most MRI studies require the patient to lie flat in a
tube for about 40 minutes, although open frame and even
standing MRI scanners exist and seem particularly
appropriate for patients having claustrophobia (fear of
tight spaces). MRI scans can be adjusted to show
different tissues including their water content,
important in determining disc degeneration, infections
or tumors. The goal of all diagnostic studies is to
discover patterns or confirmations between the various
tests that point to a clear diagnosis among various
possible ones.
The key is to diagnose the condition causing the
patient's pain and disability and to guide appropriate
treatment, including psychological, physical, medical and/or
surgical. Diagnosis is a detective hunt for causes and
effects with the goal of improved treatment.
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