Surgery for spinal arthritis

Although osteoarthritis tends to be chronic, the symptoms are rarely progressive and rarely require surgery on the painful spinal joints. Surgery may be needed for certain patients with severe cases of spinal arthritis that leads to instability of the joint (degenerative spondylolisthesis) or nerve root pinching (spinal stenosis). Often both conditions run together as unstable joints tend to get bigger over time, eventually creating spinal stenosis of the canal.

Spine fusion surgery for osteoarthritis
For spinal arthritis, the only effective surgical treatment is spine fusion surgery to stop the motion at the painful joint. Spinal fusion may also be referred to as “arthrodesis”. Currently, total disc replacement surgery (artificial discs) is contraindicated for patients with osteoarthritis of the facet joints, as artificial discs maintain motion through the painful degenerated facet joints. Artificial disc surgery is only indicated for those individuals with degenerative disc disease without facet joint pathology, and it should be considered an experimental procedure at this point.

Because motion in the joint is causing the pain, the goal of a fusion surgery is to stop the motion and thereby stop the pain. However, spine fusion surgery is generally not recommended for spinal osteoarthritis since the arthritic condition tends to affect multiple vertebral levels in the spine (initially or over time) and multi-level fusions are generally not advisable. The spine is designed to move, and if motion is stopped along multiple adjacent levels of the spine, the significantly limited motion in the spine can in and of itself stress the spine and potentially cause pain. In cases where osteoarthritis of the facet joint leads to spinal instability (degenerative spondylolisthesis), fusion surgery can be considered to stop the instability for that particular joint. This generally occurs at L4-L5, and sometimes at L3-L4, levels of the lower back.

Spinal stenosis and laminectomy for spinal arthritis
If the arthritis is affecting the nerves in the spine, then surgical decompression of the nerve roots may be an option. As mentioned earlier, spinal arthritis may lead to the formation of bone spurs (osteophytes), which are boney growths in the spine that form in response to the friction in the arthritic joint. A bone spur may then intrude into the neuroforamen, which is the space where spinal nerves branch off from the spine and exit the spinal canal. When nerve impingement happens, the patient may experience symptoms such as pain, numbness, tingling, or weakness that radiates into the arms and/or legs (depending on where the nerve is affected). The general diagnosis for this problem is called spinal stenosis.

The type of surgery to remove bone spurs is usually a laminectomy. The goal of a laminectomy is to relieve the pain and neurological symptoms by removing the bones spurs and any thick ligaments that are causing symptomatic nerve compression. This type of spine surgery is usually only considered for patients who are experiencing severe, chronic pain and/or loss of function due to the bone spurs. The compression of the nerve roots causes the patient to experience leg pain with walking or standing (pseudoclaudication). Standing and walking narrows the spinal canal, and sitting will open the canal again. Generally, patients are quite comfortable either sitting or leaning forward (i.e. they can walk better leaning over a shopping cart).

The majority of patients who have a laminectomy surgery to remove bone spurs experience good relief of their symptoms that often lasts for many years, although the bone spurs may return at any time. If a significant amount of bone is removed, then the spine is not stable and a fusion surgery will likely also be required. As always, the risks and benefits of surgery should be thoroughly researched and discussed with one’s treating physician prior to making a decision about the procedure. Decompression surgery alone without a fusion is only indicated for those patients with pseudoclaudication (leg pain), and it is not indicated for patients with back pain due to osteoarthritis. Removing pressure on the nerve roots can improve walking/standing leg pain, but surgically removing some of the arthritis does not remove the pain generator for back pain.

By: Vert Mooney, MD
May 25, 2005