L5-S1 Disc Degeneration – Causes and Treatments

A lumbosacral joint (L5-S1) comprises of 5 vertebrae in the lumbar segment of the spine (L1 to L5) and the sacrum (S1). Sacrum connects to two iliac bones of the pelvis forming a sacroiliac joint. It bears the load of the entire cervical, thoracic, and lumbar segments. Coccyx lies below sacrum. Nerve roots branching from the spinal cord in L1-S1 region travels down to the legs. This nerve is known as sciatic nerve. The intervertebral disc between the fifth lumbar and first sacral vertebrae (L5 and S1) is known as the L5-S1 disc.

L5-S1 Anatomy

To understand a lumbosacral joint (L5-S1) we need to first know the anatomy of a spine. Spine is also known as vertebral column, spinal column or backbone. In an adult, a vertebral column is constituted of 26 bones or vertebra. It attaches the base of the skull to pelvis, protects the spinal cord, and supports body weight. Intervertebral discs are present in the spaces between vertebrae, throughout the column. They cushion the bones during movements of the spine.

Each vertebra has a hollow portion (vertebral foramen) and is arranged on top of each other such that the hollows coincide to form a tube (central canal). The spinal cord is contained in this tube of the vertebral column. Spinal cord is made of nerves, which branch out from the canal and transmit messages between the brain and muscles.

The spine is naturally curved to form an “S” shape. This curvature of spine facilitates even distribution of body’s weight along its length and assists in providing optimum body balance. The spine curvature changes at this location makes the lower back susceptible to an additional strain.

Anatomically, the vertebral column is divided into five main segments, which are:

• Cervical Vertebrae – 7 vertebrae in the neck region. 
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• Thoracic Vertebrae – 12 vertebrae in the chest region.
• Lumbar Vertebrae – 5 vertebrae in the lower back region.
• Sacral Vertebra – or sacrum is a single bone which is formed by the fusion of 5 vertebrae during adolescence.
• Coccygeal Vertebra – or coccyx is a bone which is formed by the fusion of 4 vertebrae during adolescence.

Sacrum and coccyx are the last two vertebrae in the spinal column. Each vertebra is named after the segment to which they belong and are numbered in sequence from top to bottom such as, C1, C2 or L4, L5 (where C stands for cervical and the first cervical vertebra is denoted by C1, and so on).

Having a brief idea of the structure of a spine, let us now discuss a lumbosacral joint.

Diseases and Conditions Associated with L5-S1 region

Degenerative disc disease

Degenerative disc disease is the shrinking or complete collapse of intervertebral discs, with age; hence also known as disc desiccation. This causes friction in the facet joints between vertebrae leading to pain and stiffness.

The wear and tear of intervertebral disc are known as osteoarthritis; it may result in spinal stenosis. Our body may respond to osteoarthritis by growing new bones in the facet joints (joints between vertebrae) called bone spurs or osteophytes to help support the vertebrae. This overgrowth can cause narrowing of the spinal canal.

Osteoarthritis can also cause thickening of ligaments, leading to narrowing of the spinal canal.

Spinal stenosis

Spinal stenosis occurs when the space around a spinal column becomes narrow resulting in pressure on the spinal cord and its nerves. 

Disk tear

Aging can cause small tears on the outer surface of intervertebral discs (annulus). Disc tears may not be symptomatic; however, in certain cases, pain due to a disc tear may last for weeks, months or more.

Disk herniation

Also known as slipped disc, prolapsed disc bulged disc or herniated nucleus pulposus is most prevalent (approximately 95%) in L4-L5 and L5-S1 regions of the spine.

A herniated disc in the lower back often exerts pressure on the sciatic nerve (nerve root leading to the leg and foot). This causes sciatica, which is characterized by constant pain on only one side of the buttock or leg accompanied by weakness and numbness.

Cauda equina syndrome

Although rare, this condition is a serious manifestation of a ruptured disc in which compression of the bundle of lumbar and sacral nerve roots causes loss of bladder and bowel control along with pain and numbness in the buttocks, groin, and leg.

Spondylolisthesis

It is a condition in which a vertebra in the lower spine dislocates from its anatomical position leading to pressure on nerves exiting the spinal canal. 

Scoliosis

It is a spinal deformity resulting in an abnormal curve in their spine and can be observed in some teenagers and in older, arthritis patients. Scoliosis may cause back pain if it involves pressure on nerves.

Sciatica

Is caused by compression of sciatic nerve from a herniated disc or sometimes from a tumor or a cyst resulting in pain and numbness of one leg along with muscle weakness.

Osteomyelitis

Is characterized by infections involving the vertebrae.

What can cause these conditions?

The risk factors of acquiring L5-S1 syndrome are:

• Ageing
• Overactivity
• Trauma
• Genetics
• Birth defects
• Obesity
• Repetitive stress
• Sports involving weight bearing.
• Smoking – may lead to an accelerated aging of joints.
• Developmental anomalies in the spine due to a birth defect.
• Tumors causing compression on the spine.
• Infections involving the spinal cord.

When should you visit a doctor?

Mild back pain can be treated by application of topical pain medications. But if your pain lasts longer than a week or two it is advisable to consult a physician.

Although conditions related to L5-S1 region usually manifests as a backache, sometimes, numbness and pain in buttocks radiating towards a leg or loss of bladder and bowel control may also indicate a spine problem.

Symptoms associated with L5-S1 abnormalities are:

• Muscle spasm in the back.
• Stiffness of the spine.
• Excruciating pain during movements, such as sitting or bending – which relieves while lying down.
• Discomfort while sitting for prolonged durations.
• Pain after standing for a long time.
• Backache radiating towards buttocks or behind the knee and leg.
• Changes in reflexes or body balance.

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Diagnosis

Medical history: a complete medical history is essential to find out the occurrence of trauma in the past or presence of a developmental anomaly.

Your doctor will need to have knowledge of all your past and existing ailments, along with the medications that you have been taking.

Physical Examination

The doctor may inquire in detail about all your symptoms and whether you have noted any changes in your reflexes or balance, recently.

Clinical examination includes assessing back mobility and flexibility. Examination of neurological reflexes is essential to determine nerve damage.

• SLR (straight leg raise) test is done to detect nerve irritation.
• Dermatomal sensory loss/myotome deficit is done to check for root compression/damage.
• Musculoskeletal maneuvers (e.g. facet loading, sacroiliac joint and hip maneuvers, low back palpation) ­­is carried out for anatomic localization of pain

Other diseases and conditions that may mimic the symptoms of an L5-S1 abnormality are:

• Kidney stones
• Abdominal aortic aneurysms: an abnormal enlargement of a large blood vessel supplying abdomen, pelvis, and legs.
• Osteoporosis: a metabolic disease causing reduced bone mineral density.
• Endometriosis: an abnormal growth of uterine tissues.
• Fibromyalgia: a chronic muscle pain syndrome.

Investigations

• X-ray of spine helps in localizing any abnormalities in the structure of a spine. X-rays are used to rule out fractures, bony malformations, developmental anomalies, and tumors. However, soft tissues cannot be visualized in X-rays.

• Myelogram is a process of injecting a dye in the spinal canal to improve the visibility of tissues in X-rays.
• Computed tomography scan (CT scan) is another imaging technique which can produce horizontal and axial images of the body and is preferred to X-rays.
• Magnetic resonance imaging (MRI) makes images of internal tissues and can help in detecting a disc disease, for instance, disc herniation and other soft tissue anomalies. An MRI can create images of the disc, nerve roots, and spinal cord.
• Electromyography (EMG) measures muscle response to nerve stimulation and can help in the diagnosis of altered neurological responses.
• Bone scans may be used to diagnose infections or fracture of the spine or bone disorders.
• Ultrasound also known as ultrasonography are used for imaging of soft tissues, like ligaments, tendons, and muscles.
• Blood tests can help in ruling out the presence of infections, inflammation, and arthritis.
• Bone density test is recommended in cases of osteoporosis.
• NCS/EMG (Nerve Conduction Studies/Electromyogram) is done to check for the presence of neuropathy (neurological disorder).
• QST (Quantitative Sensory Testing Technique) helps in indicating the pain mechanism.

Treatment

Treatment is based on the extent and severity of ailment and its chronicity. Treatment modalities may also vary with patient’s age, health, and underlying diseases or conditions.

What are the steps to prevention of L5-S1 dysfunction?

Acute pain can be treated with rest and pain medication, such as anti-inflammatory drugs, followed by weight management and physical therapy to prevent recurrence and worsening of symptoms. Physical therapy helps in strengthening muscles and relieving spasms.

Lifestyle changes, posture improvement, nutritious diet, and physical exercises may help in relieving symptoms in certain patients with acute pain. However, exercises should be attempted only under the supervision of a trainer or a physiotherapist.

Counseling is an essential step to educate patients towards pain management and avoiding additional stress.

In the case of trauma, application of ice packs within 24 hours followed by warm compress may help in alleviating pain and muscle spasm. Severe injuries involving the spine require immediate medical attention.

Acquiring a healthy lifestyle is essential to prevent L5-S1 disorders. Some measures for prevention are:

• Exercising: Aerobic exercises, like walking or swimming, strengthens the muscles in the back and abdomen.
• Maintaining a healthy weight: Excess body weight exerts the lower back.
• Quitting Tobacco: Smoking accelerates the aging process of the spine.
• Improve Posture: Keeping the spine straight, while standing, sitting and even lifting, is important.
• Avoiding a sedentary lifestyle.
• Learning the right way to bend and avoiding bending or stooping too often can help in relieving strain.

How to manage chronic pain due to L5-S1 dysfunction?

Conventional therapy:

Medications:

• Your physician may prescribe medications, such as Paracetamol 500 mg and other anti-inflammatory drugs for acute pain; these help in short-term pain relief. Muscle relaxants may be prescribed to reduce muscle spasm.
  
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• Steroids administered orally can help reduce inflammation.
• Counter-irritants or topical analgesics that reduce inflammation can help in stimulating blood flow.
• Antidepressants
• Chiropractic or manipulation therapy is used in cases with subluxation and help in increasing the range of motion and physical function.
• Traction is often used but lacks scientific evidence for long-term effectiveness.
• Other exercise-based programs such as pilates or yoga may be helpful in certain cases.

Counseling: Cognitive behavioral therapy (CBT) can be recommended to help patients manage their pain better.

Epidural Steroid Injections: Although temporary, this approach provides enough pain relief to allow patients to move, exercise and heal. They are prescribed to reduce localized inflammation. They are also known as corticosteroid injections, nerve blocks, facet blocks or epidural blocks.

Physiotherapy:

• Transcutaneous electrical nerve stimulation (TENS) stimulates the nervous system and can modify the perception of pain.
• Spinal decompression procedure involves enlarging the space between the discs to reduce pressure on the nerve root.

Braces are sometimes recommended in a chronic backache.

Lumbo Sacral Belt

Surgical Treatment:

In case your pain lasts longer than a week or if the ice packs, rest, and topical ointment regime has been of little or no help you must visit a physician or a spine specialist.

Your doctor may suggest a surgical intervention for a permanent cure after conservative methods of treatment have failed to provide adequate pain relief.

Surgery in L5-S1 region is done under general anesthesia. Usually, surgeries are recommended in conditions, like:

• Disk herniation
• Nerve root compression due to a tumor.
• Lumbar canal stenosis
• Advanced spondylosis (degeneration of the spine).
• When the primary cause of dysfunction or pain in L5-S1 region is a tumor or an infection of the spinal cord, elimination of causative factor is the chief goal.

Surgical Techniques

Surgery should be the last approach when all nonsurgical options have failed to provide pain relief for around 6 months to a year. Commonly used surgical techniques are:

• Vertebroplasty and kyphoplasty are surgical techniques to repair compression fractures caused by osteoporosis.
• Spinal laminectomy is performed in cases of spinal stenosis, to remove pressure on the nerves.
• Discectomy or microdiscectomy is recommended in cases of herniated disc or bone spur.
• Foraminotomy is done to enlarge the foramen and to relieve pressure on the nerve.
• Intradiscal electrothermal therapy (IDET) is a treatment for degenerative disc disease.
• Nucleoplasty also called plasma disc decompression (PDD) uses radiofrequency energy to treat low back pain associated with mildly herniated discs.
• Radiofrequency denervation causes a localized destruction of the target nerves.
• Spinal fusion prevents painful movements and is recommended for degenerative disc disease or spondylolisthesis (following laminectomy).
• Artificial disc replacement is an alternative to spinal fusion for treatment of severely damaged discs.

How do you prepare for L5-S1 surgery?

Being prepared before you undergo a surgery may prove to be of great help. Apart from a physical and mental preparation in which your surgeon should guide you, it is good to have a complete idea about the costs involved in your surgery and other miscellaneous charges that you will need to bear.

Do not hesitate to inquire in detail about the surgical procedure and the materials used. In case of a doubt you must clarify; being well informed will boost your confidence.

Lifestyle and posture changes may be a part of your preparation which may include alterations in diet, habits, and activity levels.

Your doctor may change or add certain medications to prepare you for the operation. Sometimes, a pre-operative physiotherapy may also be suggested.

You may have to alter your workstation or furniture at home and rearrange domestic items to facilitate easy movements and to prevent trauma during recovery. These changes may add up to your overall expense.

Furthermore, it is important to find out whether your surgery could be covered by your medical insurance; how much of the cost would they reimburse; and which hospital can provide such facility.

How long will you need to be hospitalized?

Usually, a spine surgery requires one to three days of hospitalization. However, the duration may vary with the surgical intervention involved, for instance, a complex surgical procedure to correct scoliosis (which is a developmental defect of the spine) may require a patient to be hospitalized for more than six days.

Recovery

After surgery, as the anesthesia wears off, a feeling of soreness along with mild pain in the back is expected. It takes around six weeks for the pain to disappear, after which you will slowly regain muscle strength.

Stitches or staples will need to be removed after 5 to 10 days. In case your surgeon uses resorbable sutures, then stitch removal will not be necessary as those get absorbed by your body.

A plaster may be used to cover the stitches while they heal. This is applied as a measure to protect the stitches and care must be taken to keep it dry.

Some patients may find it difficult to pass urine post-surgery. Although such complications are temporary, it is prudent to inform your surgeon immediately, in case you observe any such side-effect.

You will be allowed to walk, a few days after surgery. However, it usually takes around six weeks to acquire complete mobility.

Duration of the recovery period depends on the level of your fitness, your general health, the condition of your spine before surgery, and the surgical technique. In most cases, a physiotherapy regime is recommended post-surgery.

It is advisable to attempt activities (initially with assistance) during the recovery period to regain strength and function, but you must avoid excessive strain, for instance, lifting heavy objects; awkward body posture; sitting on the floor or bending forward. Furthermore, sitting or standing for more than 15-20 minutes should be avoided to prevent joint stiffness.

It is essential that you follow only a physiotherapist’s advice regarding the type and duration of exercises to be undertaken.

Medications like opioids, NSAIDs (non-steroidal anti-inflammatory drugs), and local anesthetics may be prescribed for pain management. Although these medicines help in making recovery more comfortable, they will need to be discontinued as per your doctor’s advice.

Periodic follow-up visits are required after the surgery so that your doctor can assess your recovery and progress.

Resuming work will depend on whether your job involves physical strain. It is best to heed your surgeon’s advice in this aspect.

Besides, it is very important to inform your surgeon immediately, in case you notice any unexpected changes in your body, post-surgery.

During the healing period, some patients feel certain emotional changes; usually, these originate from a sudden lack of movements and function and patient post-surgical expectations. Counseling, family support, and optimism are of utmost benefit in such situations. If patients are encouraged their progress and the outcome of surgery improve.

What are the risks?

Most surgical procedures have known risks. Apart from the general complications associated with surgical procedures and anesthesia, the complications involved in L5-S1 surgeries are:

• Herniated disk
• Nerve damage
• Post-surgical infection in the joint
• Persistent pain
• Lack of function
• Blood clots in the leg
• Sexual dysfunction
• Transitional syndrome – more stress in the adjacent segment of the spine due to a non-functional segment (after spinal fusion).
• Pseudoarthrosis – failure in joints to fuse after a surgical fusion.
• Lung problems

Let’s check what research says about L5-S1 surgeries

A study in 2016, assessed the treatments and outcomes of disc herniation in children and adolescents. It was concluded that both conservative and surgical methods of treatments were applicable to this group. However, surgical treatments were recommended for patients with low back pain accompanied by lack of function, recurring pain, and neurological deficits for more than 6 weeks despite medications.

Another study in 2016 examined the safety and efficacy of mini open transforaminal lumbar interbody fusion (a surgical technique for lumbar degenerative disc disease). Apart from the advantages, like less soft tissue damage, minimal blood loss, and shorter period of hospitalization, this approach was found to be efficient and safe for the treatment of instability in the lumbar spine due to degenerative diseases.

A recent study in 2017 examined the changes in ligaments of the spine and remodeling of spinal canal after spinal fusion procedures, in 10 patients. It was observed that stabilization induced by this procedure resulted in remodeling of the spinal canal and sustained changes in its ligaments, 10 years post-surgery. These modifications accounted for the long-term pain relief in all patients.

An interesting study in 2017 rendered percutaneous transforaminal endoscopic surgery (a surgical technique for correction of lumbar disc herniation) an effective and safe method. Furthermore, in this study, out of 209 cases assessed, none were reported to have any major complication, such as permanent nerve damage.

A study in 2017 evaluated spontaneous regression in lumbar herniated discs with conservative approach and rest. It was observed that all the patients showed clinical and radiological improvement after approximately 14 to 19 months with medications and bed rest. This study showed that conservative methods of treatment should be considered as the first option in disc herniation.

Another study in the same year analyzed lumbar spine alignments in various common postures. It was found that lumbar flexion was greater during slump sitting and lying down as compared to forward bending; whereas, lumbar extension was greater while backward bending than while standing. This study also confirmed that there is a loss of flexibility in the spine after spinal fusion procedures.

Cost of surgery

In India, a surgery involving the lumbosacral joint may cost anywhere between 1.3 and 5 lakh rupees. The prices may vary with the type of surgery and complication of the procedure.

Hence this price range is not absolute but is meant as a guide for patients before they plan a surgery.

Additional costs like pre-operative tests and medications; post-operative rehabilitation and medications; follow-up visits; cost of physiotherapy, and miscellaneous expenditures like crutches, canes or braces should be considered.

Some government and charitable hospitals in India have provisions for surgery at a subsidized rate.

If you have a medical insurance, you will need to find out whether your policy covers the recommended surgery, well in advance. Medical insurance companies do not cover certain expenditures, such as the cost of disposables. Additional charges may incur, in spite of the reimbursement. Hence, you will also need to enquire about how much of the amount could be covered by your policy.

For more information, do get in touch with us through email at help@healthclues.net or message us on WhatsApp at +91-9640378378, or submit your question below.

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References

1. http://www.innerbody.com/image/skel05.html
2. http://umm.edu/programs/spine/health/guides/anatomy-and-function
3. http://www.orthoinfo.org/topic.cfm?topic=A00575
4. http://www.innerbody.com/image/skel05.html

Dr Kaleem Mohd

Dr. Kaleem Mohammed graduated as a Bachelor of Physiotherapy in 2014 from Deccan College of Physiotherapy, affiliated to Dr. N.T.R. University of Health Sciences, Vijayawada, India. Dr. Kaleem is an expert at handling physiotherapy needs of patients suffering from orthopedic and spinal conditions and post-surgery rehabilitation. Dr. Kaleem is associated with HealthClues since its inception where he facilitates diagnosis and advanced consultation with senior doctors. He is also a medical researcher and prolific writer who loves sharing insightful commentaries and useful tips to educate the patient community about fitness, treatment options, and post-treatment recovery.