Lumbar Spondylolisthesis - Nitin Bhatia, MD

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have with me, Dr. Nitin Bhatia. Dr. Bhatia is a spine surgeon, who is the Chief of Spine Surgery, at the University of California Irvine. Dr. Bhatia did his undergraduate training at Stanford. He then went on to Baylor College of Medicine where he completed his M.D. degree. From there, he did orthopaedic surgery training at UCLA. From there, he finished a spine fellowship at the University of Miami. Today, he practices complex spine surgery at University of California Irvine. Good day, Dr. Bhatia.

Dr. Nitin Bhatia: Thank you for having me.

Dr. Sechrest: Dr. Bhatia, today what I would like to turn to now to discuss is a concept that I don't think a lot of people are familiar with, but spine surgeons are familiar with it obviously. It's called spondylolisthesis. Define what that long word means.

Dr. Nitin Bhatia: Spondylolisthesis is our fancy medical term for when the bones in the spine slip a little on each other. We classically see it in the low back or lumbar spine. Most commonly, not at the very bottom level, but one level up, lumbar 4 or lumbar 5, although it can occur anywhere through there and it can even occur somewhat in the neck. What happens is, with time, the joints wear out much like the hinges on a door may wear out, and instead of holding the bones immediately on top of each other, the bones start to slip with the top bone, in the case L4 sliding in front of L5.

Dr. Sechrest: Why 4 on 5? Why is that the one that occurs most commonly?

Dr. Nitin Bhatia: That's a great question. Probably that the level that sees the most wear and tear and has the most motion and forces upon it in the lumbar spine. So its joints, both the disc in the front which is the big shock absorber in the front of the spine as well as the two smaller joints in the back of the spine called the facet joints, wear out faster than the areas where they don't see as much motion and wear and tear.

Dr. Sechrest: Now, there's another term that's commonly confused with spondylolisthesis and that's spondylosis. We think of these two terms together, but define for me the difference between those two.

Dr. Nitin Bhatia: Sure. Spondylosis is 'spondy' which is essentially 'spine' and then 'lysis', which means 'break' or 'fracture'. So spondylosis is actually a small fracture in the back of the spine. That we see more commonly in our teenage patients especially high level athletes who do a lot of hyperextension – so, gymnasts, football linemen who have to come up and block a lot. Nowadays, especially in my practice in southern California, I see surfers and snowboarders because they do a lot of extension. At a point in their teenage years the bones are slightly weaker than they are in the rest of our lifetimes and they can have a small fracture there. That can also lead to a spondylolisthesis, which is a slippage of the bones although usually if it's associated with the fracture, it's one level below the degenerative type that I was talking about before. So, the spondylosis, which is an isthmic spondylolisthesis, is at L5-S1.

Dr. Sechrest: Yeah, and I just wanted that clear because I think it's easily confused. I think that a lot of physicians confuse the two and seem to think that they're one and the same. The difference, as I understand, is that one because of a wear and tear phenomenon, and the slippage still occurs; you still see it on the x-ray, but for totally different reasons and in different areas.

Dr. Nitin Bhatia: That's exactly right.

Dr. Sechrest: Today, what we're really going to talk about, I think, is the adult, the one with the wear and tear spondylolisthesis. How that differs from the other one, and it's different not only in its causes, but how you treat it.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: Tell me what symptoms a person have who has a degenerative spondylolisthesis? How old are they? How do they present?

Dr. Nitin Bhatia: A degenerative spondylolisthesis occurs as we age from the wear and tear and degeneration of the joints. So it's a problem that we see usually in patients over the age of 50 or 60. Sometimes it can occur in patients in their 40s but rarely are they younger than that. What we see is that the patients gradually develop some back pain, but more importantly, they may have some compression on their nerves causing pain shooting down the legs like a sciatica type pain.

Dr. Sechrest: Why is that? Where does the pressure come from?

Dr. Nitin Bhatia: The pressure comes from, not only now, the abnormal motion of the bones; so as the bones move forward, the nerves which lie behind the bones get kind of pinched in that abnormal alignment. But, as the body tries to stop this abnormal motion, it creates extra tissue, both bony osteophytes or bone spurs, as well as extra ligaments particularly called the ligamentum flavum, which then pushes on the sensitive nerves in that region, and that's where the pressure on the nerves comes from.

Dr. Sechrest: So those nerves that are leaving the spine at that point just get trapped.
They don't have enough room to get out.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: How does that present? What does the patient feel from that standpoint?

Dr. Nitin Bhatia: Usually the patient feels a combination of pain, numbness, or tingling shooting down the legs most commonly in the side of the legs and side of the thighs and calves, or the back of the legs in the buttock, back of the thighs, back of the calves, and into the feet.

Dr. Sechrest: When you see this person, and let's say they've have some x-rays, their primary care physician has seen this slippage, became alarmed, sent them to you. How are you going to begin the process of trying to figure out, first what's going on with the back, because we're not certain that that slippage is causing their pain. How are you going to work that person up? What do you need to do?

Dr. Nitin Bhatia: Well, the number one thing we have to do is figure out is the slippage causing their pain; and that involves getting to know the patient and their problem and seeing where their pain really is, making sure it fits the picture of the spondylolisthesis or the slipped vertebra. We can do a physical exam to check for any strength problems, numbness, or nerve irritability, and then we can also check x-rays to see if the bones are moving. One particular x-ray that's useful in this case are flexion-extension x-rays, or x-rays with the patient bending forward and then bending backward to see how much those bones are really moving. Sometimes you see that they move very little. Sometimes you see them almost dislocate they move so much. Finally, we can get a test called an MRI scan which shows us the nerves and can show how much pinching there is of those nerves at that area as well as other areas above and below it.

Dr. Sechrest: Now, you mention the flexion-extensions and you mention some folks move a lot. I'm assuming more is worse.

Dr. Nitin Bhatia: That's correct. More is definitely worse.

Dr. Sechrest: So if they're not moving a lot when they're moving forward and backwards, we're less concerned about that spondylolisthesis and think that may not be causing the pain?

Dr. Nitin Bhatia: Well, it still could be causing the pain and I'm concerned about any spondylolisthesis with pain coming from it, but I'm much more concerned about people who have a lot of motion because that tells me that their joints are so worn out that every time they move like that they're just beating up those poor nerves. Now even with a little spondylolisthesis, you have those extra bone spurs and that ligament causing the nerve compression and causing the patient's symptoms. So we're concerned but it's probably not going to get worse as rapidly as the person who's moving a lot.

Dr. Sechrest: Define for me this problem of spondylolisthesis. Is this primarily a leg pain problem or primarily a back pain problem or is it balance? Or are we seeing both?

Dr. Nitin Bhatia: You can see them both. You see people who have the back pain from the mechanical problem of the bones moving and the associated degenerative arthritic changes of the joints. You can also see significant leg pain from the nerve pinching from the motion and the bone spurs and the other things that form from it.

Dr. Sechrest: Okay. You mentioned that essentially what you want to see as a spine surgeon is, I want to see the MRI scan, I want to see what's happening to the soft tissues, I want to see what's happening to those nerves, and I want to see a dynamic test, the flexion-extension x-rays, to see how much it's moving. Any other tests you want to see?

Dr. Nitin Bhatia: Usually those are ample for what we need to see.

Dr. Sechrest: Okay. So, after you've made this diagnosis, what's next? How are you going to treat it?

Dr. Nitin Bhatia: One of the questions is: How severe are your symptoms? Hopefully the symptoms aren't so bad in which case we can try a course of physical therapy specifically focused on what we call core strengthening to make the muscles in the abdomen and low back stronger, to theoretically stabilize the slipping area somewhat. Now it can't fully stabilize it, but perhaps by providing a little more support, can decrease some of the pain. Some of the other treatments include oral medicines like anti-inflammatories or low dose narcotics, as well as possibly injections into the arthritic facet joints or even epidural steroid injections to calm the nerves down a little.

Dr. Sechrest: Are you expecting those injections to fix the problem or is this just treatment?

Dr. Nitin Bhatia: Unfortunately, they don't fix the problem. We know that the problem is truly a structural problem in the spine. Those joints have essentially fallen apart and, in fact, sometimes on the MRI scans we see much the joints have so much wear and tear on them that they even have fractures through them and the joints, instead of being nice sandwiched together, they've splayed apart so there's really no more control of that level. So the injections can't fix that, all they can really do is give the patient some symptomatic relief.

Dr. Sechrest: When do you make the decision that this is not going to work? That conservative care has failed and it's time to consider surgical options?

Dr. Nitin Bhatia: When the patient's, when we've tried appropriate options and they just haven't gotten better or, in patients whose pain is so significant that it's not worth it to spend 3 months or 6 months trying nonsurgical options, probably because we know the nonsurgical options for this, provide only temporary relief. Really, most patients who symptoms from this at some point or the other, will require surgery.

Dr. Sechrest: It's interesting because this is an instability problem. Do you think there's any place for bracing in these patients? Do these patients respond to braces? Is there any need to try a back brace or anything like that?

Dr. Nitin Bhatia: There's not, and the reason is, this problem can't heal even if we put it in a brace. If you broke your arm and I put you in a cast or a brace, the bones would heal and would go back to normal so we could maybe avoid surgery. But this isn't that kind of problem so, even if I put you in a brace or a whole body cast, or I put you on bed rest for three months, it would not heal and it would not stop this abnormal motion. So there's no role in bracing and, in fact, bracing can be somewhat problematic because it can make the muscles weaker by making the body rely on the brace rather than its own internal muscles, which are our internal brace, and then allow more of the abnormal motion when you're not in the brace.

Dr. Sechrest: Now are we still talking about an elective procedure from the standpoint is it still the choice of the patient whether to pursue surgery or not or is there any reason you would say, "It's really in your best interest to have surgery and that's what you need".

Dr. Nitin Bhatia: In general, it's an elective procedure, and what I tell patients who come in I say, "We do surgery when you're sick of the pain and when you don't have it anymore". But it's not a problem that's going to paralyze the patient. It's not a problem where all of the sudden, one day, they're going to wake up and not be able to move their leg. Sometimes patients come in and it's really bad and they're having trouble walking because they have severe weakness and that's a different story; but that's, luckily for this problem, quite rare. Most patients come in and they're uncomfortable and they have significant pain, but when they decide they want to get rid of the pain is when we do surgery.

Dr. Sechrest: So, if they're willing to put up with the pain, willing to put up or decrease or their activity, then it's okay for them to opt to let this go as long as possible?

Dr. Nitin Bhatia: Correct.

Dr. Sechrest: If they want to be more active or they want to lead a more active life, then surgery is a good option for them.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: What are our surgical options? How do you treat this surgically?

Dr. Nitin Bhatia: The options really encompass the two main goals of spine surgery and those two goals are 1) decompression, or opening up the space for the nerves to stop the sciatica and leg pain; and 2) stabilization, or in stopping the abnormal motion. So the first part involves opening up the space for the nerves and the classic procedure for that in the low back is called the laminectomy; and there's a variety of different options based around that that we can use that are tailored to each patient's particular needs. In order to stop the abnormal motion we actually have to do what's called a fusion, when you put screws and rods in to lock the bones in place. Now fusions sometimes get a bad name because of horror stories that I'm sure everybody's heard. I've heard a lot of them. I'm sure you have, too. But for this problem it's very clear that patients who have a fusion, especially a fusion with screws and rods, have a better long-term outcome than patients who don't because, otherwise, the motion keeps going and likely keeps getting worse and worse.
Dr. Sechrest: Yeah, I think you're right. The fusion has a bad name because I think it's being used inappropriately; or it's used for reasons that aren't going to necessarily respond to fusion. Pain we don't really know where it's coming from.

Dr. Nitin Bhatia: Exactly. I agree wholeheartedly.

Dr. Sechrest: But this problem is a true orthopaedic problem, if you would. It's a problem with too much motion, where there's instability.

Dr. Nitin Bhatia: Right.

Dr. Sechrest: Something we probably understand fairly well. Define for me again, though, we banter about this term fusion and we talk about putting screws in, but what are we really trying to accomplish. What is a fusion?

Dr. Nitin Bhatia: A fusion is just having the bones that are moving abnormally heal together. In the past, we didn't use screws or rods before we had that technology, and we'd take bone from another part of the body. Previously we used to use bone from the iliac crest, which is part of the pelvis or hip, and put it around the bones which we're trying to heal together; and it creates kind of a bony bridge between the two. Nowadays, the technology is very different. We do have the screws which increase the rate and success of the fusions, as well as we have other technologies like bone morphogenic proteins, which are manmade proteins made in the lab that replicate human body proteins, that can make bone instead of having to take bone from the pelvis so it allows faster recovery.

Dr. Sechrest: Yeah, I think you're analogies are very useful. We're orthopedists, so we're used to putting casts on things, holding things in place. Then we had plates and screws, so we take away the cast, put a plate and a screw on the inside of the skin so you don't have to wear the brace on the outside. For years we put people in body casts to try to brace a fusion to get it to heal more reliably. Now, with those screws and the rods, we can brace it internally so that the patient doesn't have to wear a body cast and get a better healing leg.

Dr. Nitin Bhatia: Exactly. In fact, in my practice, when we put the screws and rods in for a procedure like this, the patient doesn't get any sort of rigid brace at all, because the screws and rods are so strong on the inside it provides better bracing and better healing than any sort of body cast you can be in.

Dr. Sechrest: I think the other term you used, and I think you explained it very succinctly, and that is the concept of decompression. But elaborate on that a little bit. To my sort of thinking is what we're really trying to do is give those nerves as much breathing room to take pressure off; whatever is pressing on them we just take it away. We call it a laminectomy but that's just a term. What we're really doing is trying to chip away those bone spurs and take away all the pressure on the nerves.

Dr. Nitin Bhatia: Exactly. Normally we live our whole lives with the nerves nicely protected by the fluid that's around them and the fat that's around them and that's a nice soft bed for nerves to line and that's what nerves like to be in. So when, all of the sudden, you get bone spurs pushing on it or a really tough ligament pushing on it, the nerves don't like it and that's when you get the shooting pain down the legs. So the goal of the decompression is just to take that pressure off and wherever those bone spurs are we go in and just shave them away and open up the space for those nerves once again and make it more normal.

Dr. Sechrest: Well, let's go back to from the patient's perspective, what does this whole procedure look like? How long are we in the hospital? How long does it take to recover? What are my expectations before I'm completely well?

Dr. Nitin Bhatia: There's two ways we can do it. One way, is a kind of a classic, what I call, a mini-open way through a small, couple inch incision in the middle of the back. Sometimes the patients have really, really tight nerve compression or, for a variety of other reasons, that's the preferable way to do the surgery. Usually they're in the hospital, the surgery itself takes a couple of hours with very low blood loss, they're in the hospital for 3 days, give or take a day. Some patients may go home 2 days after surgery, some patients stay and extra day; up and walking the same day as surgery or maybe the next morning. Usually within 6 weeks back doing almost all activities that they want to be doing and within 3 months definitely doing all activities that they want to be doing. The other option is a minimally invasive surgery. We make two smaller incisions to the outside area of the spine, and that can be really beneficial for patients who've got problems mainly on one side, either the left or the right. We do the exact same kind of procedure through these small incisions. The small incisions may allow a little faster recovery in the short term, but probably long-term-wise the results are the same as the mini-open procedure.

Dr. Sechrest: And you're doing the same, it's just smaller incisions. You're still trying to relieve the pressure for the nerves and fuse that segment.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: What are the implications long-term? If I've got a spondylolisthesis at L4-5, for example, you fix it. Am I good to go from now on? Do I see some problems with the fusion? What should I expect long-term from this?

Dr. Nitin Bhatia: Fortunately, nowadays with our technologies, the rates of healing of fusions are very, very high, and so it's fairly rare to see a fusion not heal well. Once you've healed, and especially, once you've got out of the first 3-6 months after surgery, you're pretty much good to go. You can do almost any activity that you want to do, or essentially any activity that you want to do. The one thing that we do keep in mind is that people who have spine problems, such as the spondylolisthesis, probably have some genetic predisposition to spine problems, and so we have to keep an eye open for other problems at other levels in the future.

Dr. Sechrest: So that degeneration is occurring at multiple levels not just the one 4 on 5, it's just the first one you see it at.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: Complications. What do you worry about, as a spine surgeon, when you do this type of a fusion? What can happen that you're not expecting?

Dr. Nitin Bhatia: The complications that we worry about are, even if the surgery goes technically perfectly, sometimes the fusion doesn't heal, because the fusion is not the process of putting the screws and rods in; the fusion is process of having the bone heal and bridge those two bones so that they stop moving, and that depends not only on the technology I use in the surgical process, but in the patient's own body healing potential. Some patients are a little higher risk – patients who smoke, patients who are diabetic, patients who are significantly, significantly overweight – but that's why we use all of the new technology that we have including the screws, including the bone-forming proteins, everything we need to give the patient the highest rate of success possible.

Dr. Sechrest: Now, some of those things are under my control. If I'm a diabetic, the best I can probably do is control my blood sugars better. If I'm overweight, I can lose weight. Does that increase the success of this procedure?

Dr. Nitin Bhatia: Losing weight before surgery not only increases the rate of success but also improves the postoperative outcomes and recovery.

Dr. Sechrest: What about smoking, same thing? If I stop the day before surgery am I still better off?

Dr. Nitin Bhatia: We want you to stop usually 4 weeks to 6 weeks before so it all gets out of your system. But if you can stop, say 6 weeks before and keep it off until you're healed for maybe one year after surgery, probably your results are the exact same, even if you say, okay, "One year and a day I'm going back to smoking". It won't affect your spine; it will affect everything else, but just not that spine.

Dr. Sechrest: Any other comments or anything that you would like patients to know that are afflicted with spondylolisthesis; anything that we haven't covered in our discussion that you would like your patients to know?

Dr. Nitin Bhatia: Now this is a very common problem – the spondylolisthesis, or slipped vertebra. We're seeing it more and more because it is a problem of our older patients. It occurs more commonly when you're over the age of 50 or 60 and occurs more commonly in women. It's so common now that the government even funded a multimillion-dollar study looking at treatments for patients with spondylolisthesis and sciatica pain from it. What they found was that, the physical therapy, medicines, and injections, or the conservative treatments, probably provided some temporary relief, but nothing permanent; and the patients who had for surgery for it did statistically significantly better than the patients who didn't, and they were much happier years down the road. Now, not everybody needs surgery for it, but for people whose lives are being affected by it, surgery provides a great option for this with a very rapid recovery. I essentially expect complete pain relief in the legs as soon as patients wake up from surgery with a minimal risk and great outcomes.

Dr. Sechrest: I think the take-home message there is that not all back pain is the same.

Dr. Nitin Bhatia: Right.

Dr. Sechrest: That there are specific areas, and to sort of paint all back pain with the same brush; and, if you've had this fear of surgery or even if you're notion is that the spine fusion is a bad operation and should never be done, maybe that's not the case with this procedure, or with this condition, and a spine fusion applied to this condition; but you might want to rethink it a little bit.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: Thank you very much.

Dr. Nitin Bhatia: Thank you.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.