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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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