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    Spondylolisthesis

    Spondylolisthesis Grades and Physical Therapy

    by User_01 Sortino Marketing

    What Is Spondylolisthesis? 

    Spondylolisthesis is a disorder in which one vertebral body slips from the adjacent vertebral body. As an effect, there might appear radicular or mechanical symptoms. An affected person can feel pain and discomfort. The cause can be acquired, idiopathic, or congenital. Depending on the degree of slippage, a doctor can grade your spondylolisthesis. To do this, medical experts use the Meyerding Classification.

    Spondylolisthesis Grades

    The Meyerding Classification divides levels of spondylolisthesis into five grades. The location of the posteroinferior corner of the vertebra above influences the grade.

    • Grade One: 0-25%
    • Grade Two: 26-50% 
    • Grade Three: 51-75% 
    • Grade Four: 76-100%
    • Grade Five, when spondylosis can be identified: >100%

    Symptoms 

    Spondylolisthesis can cause various symptoms that can help to diagnose this disorder. Some of them include: 

    • Intermittent pain localized in the lower back area. People who suffer from cervical spondylolisthesis can feel pain in the neck.
    • The pain can increase when an affected segment is flexed or extended. Mechanic pain caused by motion can appear. 
    • The pain can increase while touching the affected area. 
    • The pain can radiate to other parts of the body, for example, the legs, because the nerve roots can be under pressure.
    • The pain can be eased while lying down, as in this position the pressure on the bony elements is reduced.
    • Pain in the lower back. 
    • Muscle weakness and atrophy. 
    • Tense hamstrings. Spasm in legs. 
    • Difficulty in walking, problems with coordination and balance. 
    • Rare appearances of loss of bowel and bladder control.

    Spondylolisthesis Physical Therapy 

    Physical therapy is one of the most effective and non-invasive methods that can help you with your issue. Particular exercises performed under the eye of a professional can help you to strengthen the muscles that support the spine. You can also learn how to take care of your spine and prevent injuries in the future.

    Types of Physical Therapy

    There are two types of treatment of spondylolisthesis: passive and active. 

    Passive treatments allow patients to relax and release the muscles in the body. As the name suggests, you don’t have to actively participate in the process. It is a perfect solution for people who suffer from tremendous pain and have advanced problems. The passive treatment can prepare you and your body for further steps in the process of recovery. 

    The goal of passive treatments is to get you into the active one. Active treatments are exercises that can strengthen your body and help to prevent recurring pain from spondylolisthesis. 

    Examples of Passive Treatments 

    Hot and Cold Therapies

    This therapy uses hot and cold in intervals or uses just one of the two treatments. By using heat, you get more blood to the targeted area. Increased blood flow means that more oxygen and nutrient go to the heated area. Blood can also help with removing byproducts that were created by muscles spasm.

    Cryotherapy, cold therapy, can slow circulation. Thanks to that, inflammation, muscle spasms, and pain can be reduced. Common ways to use cold therapies are by using a cold pack on the affected area, cold spray, or massages with the use of ice. After performing cryotherapy, your physician might want you to stretch the affected area. 

    Deep Tissue Massage

    When your body readjusts to the slipped vertebra, your muscles can build up a lot of tension. A deep tissue massage allows to reach those muscles and release them. Your therapist can use direct pressure on the affected area to release the tension in soft tissues.

    Transcutaneous Electrical Nerve Stimulation (TENS)

    During this therapy, you are going to be connected to a machine that stimulates your muscles using electricity. The whole process is totally safe. TENS reduces muscle spasms and tension. Because of that, it can also trigger your organism to produce endorphins. This hormone can, in a natural way, reduce your pain. 

    TENS machines used in physical therapists’ offices are quite large, but if you would like to continue treatment at home, you can find smaller machines.

    Ultrasound 

    An ultrasound is a great way to reduce muscle cramping and spasms. It can also eliminate swelling and stiffness of the affected area, releasing pain. Ultrasound waves travel deep into your muscles and generate heat. As an effect, your blood starts circulating faster and the process of healing starts. 

    Active Treatments 

    Once your pain eases a bit, your physical therapist can show you exercises that can improve your strength, flexibility, range of motion, and stability. Your therapist is going to interview you to know more about your health and history. They are also going to consider your physical abilities before programming exercises for you. 

    During therapy, your physician might teach you how to keep a correct posture and incorporate it into your daily life. Through the practice, you not only get better but also learn good habits that can help you to prevent injuries in the future. 

    Your therapist can recommend a set of exercises to you that you should follow even after therapy. This way, the risk of getting recurring back pain is lower. Moreover, you improve your overall health. If you suffer from spondylolisthesis, you can expect exercises that strengthen your abdominal and hamstring. Those two muscle groups are very important for low back support and can prevent lumbar spondylolisthesis from developing. 

    Isotonic and isometric activities can strengthen the main muscles of the chest. The stronger is the trunk, the better is the spine’s stability. Those types of exercises are also for reducing pain. Another great way to get rid of pain is performing endurance training of muscles.

    Core exercises are useful in easing pain. They can reduce chronic pain in patients with spondylolisthesis. A stable core also means more support for the spine. 

    Stretching and strengthening exercises can help to decrease the force which the lumbar spine has to carry. Activities that involve hamstrings, lumbar paraspinal muscles, and hip flexors are crucial to improving the patient’s mobility. 

    Some of the other most common active exercises recommended for spondylolisthesis are:

    • balance training: sensomotoric exercises on unstable ground, coordinative skills, walking,
    • hydrotherapy, 
    • Gailt training,
    • anitlordotic movement patterns of the spine, 
    • Elastic band exercises

    Remember that some exercises can be great for some people, but not necessarily good for you. Before performing any of the mentioned activities, consult your doctor or physical therapist to verify if you can benefit from them and if they are safe for you. 

    Depending on the grade of your spondylolisthesis, you might need to adjust the level of exercise. The best way is to seek the help of a professional. After a few sessions, you might be able to perform all the exercises on your own, without the risk of hurting yourself.

    Surgery

    In case the physical therapy is not effective, you might need spondylolisthesis surgery

    There is no one type of surgical treatment that suits all patients. Some of the most common treatments include decompression, fusion with instrumentation or without it, and interbody fusion. In some cases, these treatments can be combined.

    Some surgeons recommend reducing spondylolisthesis. This way, the foraminal narrowing can be decreased. Moreover, spinopelvic sagittal alignment can improve. All of this creates a lower risk of further spinal changes. The higher the grade of spondylolisthesis, the bigger is the risk of the operation. 

    Slipped Vertebrae Treatment Options

    by User_01 Sortino Marketing

    Slipped vertebrae are also called Spondylolisthesis. That is a severe spinal condition that frequently causes low back pain. It can happen when one of the vertebrae (bones in the spine) slips out of place and hits the vertebra below. Many times, you can use nonsurgical treatments to relieve the symptoms. However, some people may require spondylolisthesis surgery.

    What Is It? 

    Spondylolisthesis is a spinal condition. When one of the vertebrae moves too much, it slips out of place. That often occurs at the base of your spine (lower back). Usually, the slipped vertebrae in the lower back put too much pressure on the nerves, so you can experience pain in the legs or low back.

    Are Spondylolysis and Spondylolisthesis the Same?

    Both conditions can cause low back pain, and they are related but not the same.

    With spondylolysis, the spine defect is caused by a crack or stress fracture in the spinal bones. Young athletes often get it.

    Spondylolisthesis happens when your vertebra slips out of place to rest on the bones below. Sometimes, spondylolysis can cause slipped vertebra if a stress fraction is a cause for the slippage. Alternatively, the vertebra could slip out because of disc degeneration. The discs between the facet joints (the back parts of the vertebrae linking it together) and the vertebrae could wear down. 

    Bone-in the facet joints could grow back and over-grow, which causes an unstable and uneven surface area. This makes your vertebrae less likely to stay where they should. Regardless of the cause, if a vertebra slips out of place, more pressure is put on the bone below. 

    Most spondylolisthesis cases don’t have any symptoms. If you feel any leg pain, it might be caused by pinched nerve roots in the spinal canal. The compression happens because the vertebrae slip out of position and narrows the space needed for the nerves.

    What Types of Spondylolisthesis Are There?

    Before you consider an appropriate spondylolisthesis treatment, you need to know what types are out there. They include:

    • Degenerative spondylolisthesis – This is the most common type and is caused by aging. With time, the discs cushioning the vertebrae lose water and thin. They can then slip out of place more easily.
    • Isthmic spondylolisthesis – This happens from spondylolysis because the fracture or crack weakens the bones.
    • Congenital spondylolisthesis – This happens when the baby’s spine doesn’t form correctly before birth. That person has a higher risk for slippage later because of the misaligned vertebrae.

    Those are the most common reasons for spondylolisthesis, but here are some less common ones:

    • Post-surgical spondylolisthesis – This is a slippage resulting directly from spinal surgery.
    • Pathological spondylolisthesis – That happens when a tumor or disease (osteoporosis) causes it.
    • Traumatic spondylolisthesis – You get this type if an injury causes your vertebrae to slip.

    How Common Is It?

    It is quite common to have slipped lumbar vertebrae, and it affects about 4 to 6 percent of the population. Many people have spondylolisthesis for years and don’t know it because they have no symptoms.

    Degenerative spondylolisthesis happens because of age with normal wear and tear on your spine. It’s most common in women over 50 than in men.

    Typically, isthmic spondylolisthesis is caused by spondylolysis and comes in the form of back pain in teens.

    Who’s Most at Risk for Slipped Vertebrae?

    You could be more at risk to get spondylolisthesis because of:

    • Age – As you get older, you can develop degenerative spinal conditions. That causes more wear and tear on your spine to weaken the vertebrae. Older adults tend to be at a higher risk of spondylolisthesis if they have degenerative spinal problems, which becomes more common after you turn 50.
    • Genetics – Some people have isthmic spondylolisthesis and are born with thin sections of the vertebra (pars interarticularis). That thin bone piece connects with the facet joints and links the vertebrae above and below, forming a working unit so that you can move your spine. Ultimately, those thin vertebrae areas are likely to slip and fracture.
    • Athletics – Young athletes (teens and kids) who participate in certain sports could develop spondylolisthesis. Typically, football and gymnastics are the top contenders. Vertebra slippage often happens when children have a growth spurt. It’s one of the most common causes of back pain in teenagers.

    Slipped Vertebrae Symptoms

    Slipped vertebrae lower back symptoms can be severe, but some people don’t experience any issues. You may notice:

    • Buttock pain
    • Low back pain
    • Muscle stiffness and tightness
    • Tight hamstrings
    • Pain that is worse with activities
    • Pain that spreads down the leg (nerve root pressure)
    • Trouble walking or standing
    • Weakness, numbness, and tingling in the feet

    Typically, the cause of spondylolisthesis is an overextension of the spine. However, genetics can play a role, and age can be problematic, too.

    Diagnosis

    Your doctor is likely to do a physical exam and might ask about your symptoms. It’s important to be honest and forthright here. Then, he or she is going to request an imaging scan to confirm.

    A spinal X-ray is often done to help the doctor tell if your vertebrae are out of place. However, you may also need an MRI or CT scan so that the doctors can see the spine in better detail or to check the soft tissue for nerves and discs.

    Slipped Vertebrae Treatment

    Getting the right slipped vertebrae lower back treatment can be a challenge, and you may have to use trial and error to find the right one(s). Nonsurgical spondylolisthesis treatment options can include:

    • Rest – You may have to stop doing sports and other activities so that the back feels better.
    • Injections – Your doctor might recommend an injection of different steroid medicines right in the affected area.
    • Medication – Over-the-counter NSAIDs (Nonsteroidal anti-inflammatory drugs) like naproxen (Aleve) or ibuprofen (Motrin) can help bring relief. If they don’t work, you may be prescribed something stronger.
    • Bracing – A brace could stabilize the spine. This limits movement so that the cracks and fractures heal. However, braces can’t be used by adults.
    • Physical therapy – Your physical therapist may give you some exercises for slipped vertebrae. They focus on strengthening the back and belly. You may need to perform these slipped vertebrae exercises each day to relieve the pain. However, it could take a couple of weeks to see results.

    Is Surgery Needed?

    If you’ve tried all the other spondylolisthesis treatment options and nothing has worked (or they quit working), you might need surgery. It might also be necessary if the pain is severe. Surgery can help:

    • Restore function
    • Stabilize the spine where the vertebrae have slipped
    • Pain relief for the irritated nerves

    Spondylolisthesis surgery requires spinal decompression. During this procedure, the surgeon removes discs and bone from your spine. That way, the nerves have more space, and the pain is relieved.

    Generally, decompression therapy isn’t done alone. Fusion is often the next step. When that happens, the surgeon connects the two vertebrae together and fuses them. They heal and form into a single bone. This eliminates any movement from those two vertebrae. Most people have limited flexibility because of that.

    There is another option, though. The TOPS implant can be used after decompression therapy. Instead of fusing the vertebrae together, a motion-preserving implant device is used. You can often walk around the next day and still have movement within the spine.

    Conclusion

    There are plenty of slipped vertebrae treatment options, and they work well for most people. It might be time to consider spondylolisthesis surgery if you find that exercises for slipped vertebrae don’t reduce your slipped vertebrae lower back symptoms. With decompression therapy and the TOPS implant, you could restore your quality of life.

    What is Spondylolisthesis?

    by admin

    If you’re struggling with persistent back pain along with numbness, tingling, or weakness, you may have a spinal condition. Spondylolisthesis is one possible condition that can trigger these symptoms and ultimately compromise your quality of life. 

    In this article, we’ll dive into the topic of spondylolisthesis and explain what patients can expect from a spondylolisthesis diagnosis. While the prospect of managing this condition may seem intimidating, rest assured that there are numerous effective treatment options for spondylolisthesis. 

    What is Spondylolisthesis?

    With spondylolisthesis, one of the vertebrae in the spine becomes displaced due to instability. As a result, it moves downward in relation to its proper position, settling on the vertebra beneath it.

    This malpositioning can put pressure on the spinal cord, as well as the nerves that emanate from the spinal column. This pressure can lead to pain in the lower back and leg.  

    Spondylolisthesis of the lumbar region (meaning that it occurs in the lower back) is the most common. Specifically, the L5-S1 level of the spine is most frequently affected by spondylolisthesis, followed by the L4-5 level. 

    Is Spondylolisthesis The Same As a Slipped Disc?

    You’ve probably heard the common medical term, “a slipped disc”. While this may seem to indicate the slippage involved in spondylolisthesis, it’s an entirely different condition. 

    Spondylolisthesis affects the spinal bones, which are known as vertebrae. A slipped disc is an injury involving an intervertebral disc, which is a cushion of shock-absorbing tissue. There’s an intervertebral disc located in between each of the vertebrae in the spine. 

    Given that spondylolisthesis and a slipped disc affect different parts of the spine and develop differently, it’s crucial to distinguish them. A spinal specialist can give you an accurate diagnosis of back pain. 

    Spondylolisthesis vs. Spondylolysis

    As another spinal condition that’s commonly confused with spondylolisthesis, you may have heard of spondylolysis. This condition, unlike a slipped disc, is related to spondylolisthesis. However, they’re still different conditions. 

    Spondylolysis is a stress fracture that runs through the pars interarticularis, a small segment of bone that connects two vertebrae. When the pars interarticularis is fractured, patients may experience back pain that worsens with physical activity. However, not all spondylolysis patients have symptoms. 

    Approximately one out of 20 people have spondylolysis, making it a relatively common condition. Additionally, spondylolysis can lead to spondylolisthesis. This is because the pars interarticularis fracture can diminish the stability of the spine and potentially lead to slippage. 

    What Are The Most Common Causes of Spondylolisthesis?

    Spondylolisthesis has several possible causes, the most common of which include:

    • Spinal degeneration

    The most common cause of spondylolisthesis is degenerative changes in the vertebral joints and cartilage due to aging. When spondylolisthesis is caused by age-related spinal changes, it’s known as degenerative spondylolisthesis.

    • Birth defects

    Younger individuals may experience spondylolisthesis caused by a birth defect in the facet of the vertebra. The defect, which is present at birth, can cause the vertebra to slip out of position. This is referred to as dysplastic spondylolisthesis. 

    • Spinal trauma

    Spondylolisthesis can also result from sudden trauma, such as a sports injury or car accident. This is known as traumatic spondylolisthesis and can occur in people of all ages. 

    • Sports injury

    In athletes that repetitively strain and overstretch the spine, spondylolisthesis is a relatively common injury. This is especially true in younger athletes, given that their spines haven’t fully developed.  

    Key Spondylolisthesis Symptoms 

    Lower Back Pain

    The most frequent symptom of lumbar spondylolisthesis is lower back pain. The pain typically worsens after exercise and abates when you sit or bend forward.

    Reduced Mobility

    Decreased range of motion and tightness of the hamstring muscles are common spondylolisthesis symptoms.

    Neurological Symptoms

    The nerve compression may also result in pain, numbness, tingling, or weakness in the legs, and in cases of severe compression, loss of bowel or bladder control.

    Spinal Stenosis

    Spinal stenosis isn’t exactly a symptom of spondylolisthesis. However, degenerative spondylolisthesis is a prevalent cause of spinal stenosis, which is an abnormal narrowing of the spinal canal. 

    How Is Spondylolisthesis Diagnosed?

    A physician specializing in spinal disorders can diagnose spondylolisthesis using radiographs and x-ray imaging, as well as a comprehensive physical exam. You’ll likely stand sideways as the x-rays are taken so your physician can see the vertebra’s slippage clearly.

    After your physician has examined the imaging test results, the severity of your spondylolisthesis case will be graded. The grading scale is based on the degree of slippage from the vertebra’s normal position.

    Upon making a diagnosis, a physician can recommend appropriate treatments for spondylolisthesis.

    What Are Spondylolisthesis Grades?

    As aforementioned, spinal specialists use a grading system to determine the severity of spondylolisthesis cases. Spondylolisthesis grades include:

    • Grade I: 1% to 25% slippage
    • Grade II: 26% to 50% slippage
    • Grade III: 51% to 75% slippage
    • Grade IV: 76% to 100% slippage
    • Grade V or Spondyloptosis: Over 100% Slippage

    What Makes Spondylolisthesis Worse?

    Several factors can worsen spondylolisthesis, including:

    • High-intensity physical activities
    • Heavy lifting
    • Poor posture
    • Being involved in an auto accident

    If you’ve been diagnosed with spondylolisthesis, your physician likely recommended lifestyle adjustments to help you avoid the factors listed above. 

    Spondylolisthesis Exercises To Avoid

    Any exercises that involve heavy lifting and excessive twisting or bending should be avoided with spondylolisthesis. If you enjoy a specific sport, you should talk to your physician about whether it’s safe to participate in that sport while you’re struggling with spondylolisthesis symptoms.  

    Sports that tend to exacerbate spondylolisthesis symptoms include:

    • Weightlifting and powerlifting
    • Running
    • Football
    • Soccer
    • Diving
    • Competitive swimming
    • Gymnastics
    • Certain types of dance, including ballet

    Spondylolisthesis Treatment

    Treatments for spondylolisthesis include physical therapy, exercises for relieving pressure on the affected spinal nerves, medication, and epidural steroid injections. In many patients, these treatments are sufficient to alleviate the symptoms of spondylolisthesis.

    What Does Physical Therapy For Spondylolisthesis Involve?

    Physical therapists can help patients manage spondylolisthesis in several ways.

    For one, your PT can offer valuable insights and education about how your lifestyle is affecting your symptoms. From your exercise regimen to your footwear to your posture, your physical therapist can identify areas for improvement. In making the recommended adjustments, you can likely reduce the pressure on your spine, leading to an improvement in spondylolisthesis symptoms. 

    Additionally, your PT can implement various non-invasive methods of pain management. Targeted heat and cold therapy can help alleviate inflammation and pain. Electrical stimulation is another popular method among physical therapists to gently reduce the transmission of pain signals to the brain. 

    Physical therapists can also recommend stretching and strengthening exercises for spondylolisthesis. By stretching to reduce muscle tension, you can gain greater back flexibility. By strengthening various muscle groups, you can gain greater stability in the lumbar spine, hips, and pelvis. 

    Does Chiropractic Care Help With Spondylolisthesis?

    Many spondylolisthesis patients find that chiropractic care is a helpful tool for alleviating their symptoms. Chiropractors specialize in spinal manipulation to treat issues involving the musculoskeletal system.

    Key goals of chiropractic care for spondylolisthesis include improving spinal mechanics, restoring spinal function, and improving posture. In achieving these goals, your chiropractor may alleviate compression on the spinal nerves, which often leads to reduced symptoms. 

    One of the main benefits of chiropractic care for spondylolisthesis is that it’s non-invasive. Chiropractors focus on methods including manual and instrument-assisted manipulation to adjust the spine, making it a safe back pain treatment option. 

    Which Medications Are Used To Treat Spondylolisthesis?

    Physicians often recommend over-the-counter medications to help spondylolisthesis patients manage pain and inflammation. In more advanced cases that don’t improve with over-the-counter options, physicians may instead suggest prescription medications. 

    There are a few different types of drugs that may help with spondylolisthesis. The main types include:

    • Analgesics

    In simpler terms, analgesics are painkillers. These over-the-counter medications’ primary function is to relieve pain. The most common analgesic is acetaminophen, or Tylenol. 

    • NSAIDs (non-steroidal anti-inflammatory drugs)

    NSAIDs alleviate inflammation along with pain. There are numerous over-the-counter NSAIDs, such as aspirin, Aleve, and Advil (ibuprofen), as well as prescription NSAIDs. 

    • Neuropathic agents

    This type of prescription medication can be helpful for patients suffering from spondylolisthesis nerve pain. Neuropathic agents target nerve pain directly and can help with spondylolisthesis symptoms including tingling, numbness, and weakness.

    Gabapentin and pregabalin (Lyrica) are two of the most commonly prescribed neuropathic agents for spondylolisthesis. 

    • Muscle relaxants

    Some spondylolisthesis patients experience chronic back pain caused by muscle spasms in the back. In these cases, physicians may prescribe a muscle relaxant to stop the spasms. Soma, Flexeril, Baclofen, Tizanidine, and Robaxin are among the most widely prescribed muscle relaxants. 

    Will I Need Spondylolisthesis Surgery?

    For patients with moderate to severe spondylolisthesis who don’t respond to conservative therapies, physicians may recommend spinal decompression surgery. The idea of undergoing surgery can be daunting, but note that most patients’ symptoms improve with non-surgical treatment.

    If you and your physician determine that surgery is the right route of treatment, you’ll likely discuss the spinal decompression procedure. 

    What is Spinal Decompression?

    Spinal decompression involves removing portions of the vertebrae that impinge on the spinal cord and nerve roots. There are several different approaches to spinal decompression, including laminectomy, foraminotomy, discectomy, and corpectomy. For spondylolisthesis, surgeons often opt for laminectomy. 

    Laminectomy involves removing some or all of the lamina. This is the small section of bone that covers the back of the spinal canal. By removing it, your surgeon can create more space for the spinal nerves and alleviate nerve impingement. 

    Spinal decompression can have a dramatic effect, relieving pain and other spondylolisthesis symptoms. However, removing portions of the lamina reduces the stability of the spinal column. So, after decompression surgery, spinal stability remains a key concern for spondylolisthesis patients.

    This is why surgeons traditionally perform spinal fusion after spinal decompression. 

    What is Spinal Fusion?

    Spinal fusion involves placing bone graft material in between the affected vertebrae. Then, screws and rods are implanted to secure the graft in place and provide additional stability.

    In the period following spinal fusion surgery, the bone graft material will spur the permanent joining of the affected vertebrae. This prevents all movement between the fused vertebrae, which can prevent instability in spondylolisthesis patients. 

    Unfortunately, in stabilizing the vertebrae, spinal fusion eliminates the natural independent motion that gives the spine flexibility. This diminishes patients’ ability to carry out certain movements, namely those that require the bending or twisting of the spine. Fusion has also been shown to promote the deterioration of adjacent vertebrae.

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    The TOPS™ System For Spondylolisthesis

    In a seven-year study for patients with degenerative spondylolisthesis and lumbar spinal stenosis, the TOPS™ System maintained clinical improvement and stability. Additionally, in a five-year study of the TOPS™ System for 10 patients with degenerative spondylolisthesis and lumbar spinal stenosis, the clinical outcome scores “improved significantly across all scoring systems”. In this study, there were no failures at five years and no patients required revision surgery.   

    The TOPS™ device is approved for use in Europe and many other countries. In the United States, the FDA granted Premia Spine approval to begin an IDE investigation of the TOPS™ System. 

    TOPS™ Testimonials

    Patient and surgeon testimonials are highly encouraging for the TOPS™ System as a spondylolisthesis treatment. Many patients note that they’re able to return to their favorite activities after the TOPS™ procedure, as it preserves spinal mobility. 

    We encourage anyone with persistent back problems to consult a physician who specializes in spinal disorders and learn about the latest available treatment options.