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Cervical and lumbar spondylosis treatment: Cervical spondylosis – Diagnosis and treatment

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Cervical spondylosis – Diagnosis and treatment

Diagnosis

Your doctor will likely start with a physical exam that includes:

  • Checking the range of motion in your neck
  • Testing your reflexes and muscle strength to find out if there’s pressure on your spinal nerves or spinal cord
  • Watching you walk to see if spinal compression is affecting your gait

Imaging tests

Imaging tests can provide detailed information to guide diagnosis and treatment. Your doctor might recommend:

  • Neck X-ray. An X-ray can show abnormalities, such as bone spurs, that indicate cervical spondylosis. Neck X-ray can also rule out rare and more serious causes for neck pain and stiffness, such as tumors, infections or fractures.
  • CT scan. A CT scan can provide more detailed imaging, particularly of bones.
  • MRI. MRI can help pinpoint areas where nerves might be pinched.
  • Myelography. A tracer dye is injected into the spinal canal to provide more detailed X-ray or CT imaging.

Nerve function tests

Your doctor might recommend tests to determine if nerve signals are traveling properly to your muscles. Nerve function tests include:

  • Electromyography. This test measures the electrical activity in your nerves as they transmit messages to your muscles when the muscles are contracting and at rest.
  • Nerve conduction study. Electrodes are attached to your skin above the nerve to be studied. A small shock is passed through the nerve to measure the strength and speed of nerve signals.

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Treatment

Treatment for cervical spondylosis depends on the severity of your signs and symptoms. The goal of treatment is to relieve pain, help you maintain your usual activities as much as possible, and prevent permanent injury to the spinal cord and nerves.

Medications

If over-the-counter pain relievers aren’t enough, your doctor might prescribe:

  • Nonsteroidal anti-inflammatory drugs. While some types of NSAIDs are available over the counter, you may need prescription-strength versions to relieve the pain and inflammation associated with cervical spondylosis.
  • Corticosteroids. A short course of oral prednisone might help ease pain. If your pain is severe, steroid injections may be helpful.
  • Muscle relaxants. Certain drugs, such as cyclobenzaprine, can help relieve muscle spasms in the neck.
  • Anti-seizure medications. Some epilepsy medications, such as gabapentin (Neurontin, Horizant) and pregabalin (Lyrica), can dull the pain of damaged nerves.
  • Antidepressants. Certain antidepressant medications have been found to help ease neck pain from cervical spondylosis.

Therapy

A physical therapist can teach you exercises to help stretch and strengthen the muscles in your neck and shoulders. Some people with cervical spondylosis benefit from the use of traction, which can help provide more space within the spine if nerve roots are being pinched.

Surgery

If conservative treatment fails or if your neurological signs and symptoms — such as weakness in your arms or legs — worsen, you might need surgery to create more room for your spinal cord and nerve roots.

The surgery might involve:

  • Removing a herniated disk or bone spurs
  • Removing part of a vertebra
  • Fusing a segment of the neck using bone graft and hardware

Lifestyle and home remedies

Mild cervical spondylosis might respond to:

  • Regular exercise. Maintaining activity will help speed recovery, even if you have to temporarily modify some of your exercises because of neck pain. People who walk daily are less likely to experience neck and low back pain.
  • Over-the-counter pain relievers. Ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) or acetaminophen (Tylenol, others) is often enough to control the pain associated with cervical spondylosis.
  • Heat or ice. Applying heat or ice to your neck can ease sore neck muscles.
  • Soft neck brace. The brace allows your neck muscles to rest. However, a neck brace should be worn for only short periods of time because it can eventually weaken neck muscles.

Preparing for your appointment

You might be referred to a physical therapist or a doctor specializing in spine disorders (orthopedist).

What you can do

  • Write down your symptoms and when they began.
  • Write down your key medical information, including other conditions.
  • Write down key personal information, including any major changes or stressors in your life.
  • Make a list of all your medications, vitamins or supplements.
  • Find out if anyone in your family has had similar problems.
  • Ask a relative or friend to accompany you, to help you remember what the doctor says.
  • Write down questions to ask your doctor.

Questions to ask your doctor

  • What’s the most likely cause of my symptoms?
  • What kinds of tests do I need?
  • What treatments are available?
  • I have other health conditions. How can I best manage them together?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask other questions that come up during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may make time to go over points you want to discuss in-depth. You might be asked:

  • Where exactly does your neck hurt?
  • Have you had previous episodes of similar pain that eventually went away?
  • Have you experienced any changes in your bladder or bowel control?
  • Have you experienced tingling or weakness in your arms, hands, legs or feet?
  • Do you have difficulty walking?
  • What self-care measures have you tried, and have any of them helped?
  • What are your occupation, hobbies and recreational activities?
  • Have you ever had whiplash or another neck injury?


June 12, 2020

Show references

  1. Shen FH, et al. Cervical spondylotic myelopathy. In: Textbook of the Cervical Spine. Philadelphia, Pa. : Saunders Elsevier; 2015. https://www.clinicalkey.com. Accessed May 8, 2018.
  2. Levin K. Cervical spondylotic myelopathy. https://www.uptodate.com/contents/search. Accessed May 8, 2018.
  3. Isaac Z. Evaluation of the patient with neck pain and cervical spine disorders. http://www.uptodate.com/contents/search. Accessed May 8, 2018.
  4. Robinson J, et al. Clinical features and diagnosis of cervical radiculopathy. http://www.uptodate.com/contents/search. Accessed May 8, 2018.
  5. Cervical spondylosis (arthritis of the neck). American Academy of Orthopaedic Surgeons. https://orthoinfo.aaos.org/en/diseases–conditions/cervical-spondylosis-arthritis-of-the-neck. Accessed May 8, 2018.
  6. Daroff RB, et al. Disorders of bones, joints, ligaments, and meninges. In: Bradley’s Neurology in Clinical Practice. 7th ed. Philadelphia, Pa.: Saunders Elsevier; 2016. https://www.clinicalkey.com. Accessed May 8, 2018.
  7. Robinson J, et al. Treatment and prognosis of cervical radiculopathy. https://www.uptodate.com/contents/search. Accessed May 8, 2018.
  8. Shelerud RA (expert opinion). Mayo Clinic, Rochester, Minn. May 10, 2018.

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Associated Procedures

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Non-surgical Treatment of Spondylosis (Spinal Osteoarthritis)

Spondylosis is osteoarthritis of the spine. The symptoms may vary from mild and episodic to aggressive and painfully chronic. Spondylosis affects the spine’s joints; the facet joints in the cervical (neck), thoracic (mid back), and/or lumbar (low back) spine. Fortunately, most people with spinal osteoarthritis do not need surgery. Many of the common nonoperative treatments are featured below.
Patients with chronic back pain are urged to seek the advice of a spine specialist. Photo Source: 123RF.com.

  • Acupuncture is a popular treatment used to help alleviate back and neck pain. Tiny needles, about the size of a human hair, are inserted into specific points on the body. Each needle may be twirled, electrically stimulated, or warmed to enhance the effect of the treatment. It is believed that acupuncture works (in part) by prompting the body to produce chemicals that help to reduce pain.
  • Bed Rest: Severe cases of spondylosis may require bed rest for no more than 1-3 days. Long-term bed rest is avoided as it puts patient at risk for deep vein thrombosis (DVT, blood clots in the legs).
  • Brace Use: Temporary bracing (1 week) may help relieve symptoms, but long-term use is discouraged. Braces worn long-term weaken the spinal muscles and can increase pain if not constantly worn. Physical therapy is more beneficial as it strengthens the muscles.
  • Chiropractic: Chiropractors believe that a healthy nervous system is synonymous with a healthy body. A subluxation, or the misalignment of a vertebra, may distress the nervous system and lead to a disorder causing back and neck pain. Chiropractors do not prescribe drugs or use surgery. Their practice includes ice/heat, ultrasound, massage, lifestyle modification, and spinal adjustments — also called spinal manipulation.
  • Lifestyle Modification: Losing weight and maintaining a healthy weight, eating nutritious foods, regular exercise, and not smoking are important ‘healthy habits’ to help spine function at any age.
  • Muscle Relaxants: Muscle relaxant medication helps to alleviate muscle spasm and pain.
  • Narcotics: Narcotics (opioids) may be prescribed for short periods of time to reduce acute pain.
  • NSAIDs: Non-steroidal anti-inflammatory drugs (NSAIDs) relieve inflammation that often contributes to pain. Many NSAIDs are available over-the-counter (OTC) and others by prescription only. Do not combine OTC medications with prescription drugs without the physician’s permission. Doing so may cause a serious and adverse affect.
  • Physical therapy combines passive treatments with therapeutic exercise. Passive treatment modalities include heat/ice, ultrasound and electrical stimulation to alleviate muscle spasm and pain. Therapeutic exercises teach the patient how to increase flexibility and range of motion while building strength. Patients need not be fearful of physical therapy. Even patients experiencing pain and great difficulty moving have found that isometric exercises are beneficial.
  • Spinal Injections: There are many types of spinal injections including epidural steroid injections and facet joint injections. These injections combine a local anesthetic and steroid medication to reduce inflamed nerve tissues and thereby often help to reduce pain.

Seldom is Surgery Needed

Very few patients with spondylosis require surgery. When surgery is necessary, seldom is it an emergency. Non-operative therapy is tried first. The physician may determine that combining two or more therapies may benefit the patient to quickly resolve their symptoms. In most cases, non-surgical treatments work.

However, some patients suffer neurologic deficit; such as weakness, incontinence, or develop spinal instability. The cause of severe symptoms often determines the type of surgery needed. For example, it may be necessary to surgically remove bone spurs or disc tissue compressing spinal nerves or causing spinal cord compression. Depending on the extent of the surgery, spinal fusion to stabilize the spine may be necessary. Fortunately, newer minimally invasive spine surgical techniques greatly benefit patients. Minimally invasive spine surgery enables patients to return to normal activities sooner.

Conclusion

Patients with chronic back pain are urged to seek the advice of a spine specialist. The all-important first step to relieve back and neck pain is to obtain a proper diagnosis. Back pain can be caused by many problems including spinal stenosis, fibromyalgia, spondylolisthesis, osteoporosis, compression fractures, and bone tumors. The in-depth and specialized training spine physicians receive equips them to treat a variety of disorders causing back and neck pain.

Spondylosis Center – Spinal Osteoarthritis

Peer Reviewed

The Universal Guide to Spondylosis: Everything you ever wanted to know, straight from the experts.

In This Article: What Is Spondylosis?   |    Bone Spurs   |    Symptoms    |    Risk Factors    |    Diagnosis   |    Nonoperative Treatments  |    Surgery Options    |    Complementary and Alternative Treatmens   |    Lifestyle Changes   |    Sources

Spondylosis can feel like a metaphor for the aging process. That slow march of wear and tear is happening to us all, whether we feel it or see it. One day you look in the mirror and think, “Where’d all this salt-and-pepper hair come from?” Spondylosis can be sneaky like that, except instead of grey hairs you get back pain. Yay.

Spondylosis is a degenerative condition that may worsen as a person grows older. It can affect any region of the spine. Photo Source: 123RF.com.Technically, spondylosis is a form of arthritis—spinal osteoarthritis (osteoarthritis is the most common type of arthritis) to be exact. We tend to think of arthritis as something you get in your hands and knees, but the spine, and all of its bones and joints, can fall victim to its grip as well. And yes, while it’s most likely to affect people in the 60+ range, patients typically report their first symptoms between the ages of 20 and 50 years (massive range, right?).

More than 80% of people older than 40 years show evidence of the condition on X-rays. Lumbar, or lower back, spondylosis is especially common in people older than 40 years. According to the Arthritis Foundation, spinal osteoarthritis may affect as many as 75% of everyone over the age of 60.

Nobody (except little kids) wants to get older, but you have to. But you don’t have to get spondylosis, and if you do get it, you don’t have to let it destroy your quality of life. Here’s everything you need to know about spondylosis: Its causes and symptoms, how it’s diagnosed, and maybe most important, how to manage and prevent it.

What is Spondylosis?

Spondylosis describes the general degeneration of the spine that can occur in joints, discs, and bones of the spine as we age.

“Arthritis” is an umbrella term for more than 100 conditions that cause painful joints, and in the case of spondylosis, the spine is full of joints that can be affected. Osteoarthritis—which is what spondylosis is—is the most common type.

Bones in a joint need to glide smoothly together. Articular cartilage, which is cartilage that wraps the ends of bones in a joint, allows that smooth gliding and helps prevent painful and damaging bone-on-bone contact. Osteoarthritis is the gradual breakdown of this cartilage. It’s also known as wear-and-tear arthritis, because it just sort of happens naturally over a lifetime of joint movement.

Your spine is a column made of 33 bones called vertebrae. Cushion-like pads called discs are tucked between most vertebrae, which protects the spine and makes it flexible. And within this column of vertebrae lies the spinal cord. Vertebrae are connected by facet joints, which are the victims in spondylosis.

Spondylosis is common, but it is usually not serious. Many who have it experience no pain, though it can be painful for some. Most patients with spinal osteoarthritis will not need surgery. However, it is a degenerative condition that may worsen as a person grows older, and can affect any region of the spine, including:

  • Cervical — neck
  • Thoracic — upper, mid-back
  • Lumbar — low back
  • Lumbosacral — low back/sacrum

How Does Spondylosis Affect Discs and Cause Bone Spurs to Form?

To better understand the implications of spondylosis, it helps to learn about the challenges that can arise. Intervertebral discs serve as the cushion between the bone and function as a major shock absorber by retaining water. As we age, the discs begin to dry out and, as a result, can lose their shock-absorbing capability, transmitting more load to the vertebrae, sometimes resulting in bone spur formation (that’s degenerative disc disease, or DDD). Our bodies respond to stress by forming bone in an attempt to stabilize the segment.

Bone spurs can pinch a spinal nerve root and cause inflammation and pain. Photo Source: SpineUniverse.com.Spinal osteoarthritis also affects the facet joints of the vertebrae — which is why it is also known as facet joint syndrome, facet joint arthritis, or facet disease. And, DDD may contribute to the problem. As the discs between the vertebrae become thinner, more pressure is placed on the facet joints, leading to more friction and, subsequently, damage to the cartilage.

Barrett Woods, MD, a board certified orthopedic surgeon with Rothman Orthopaedic Institute at AtlantiCare, and assistant professor of spine surgery at Thomas Jefferson University Hospital, says that in facet joints, just like a knee or hip, “the cartilage surfaces breaks down, causing bones to rub together, which can form bone spurs or enlarge the joint (hypertrophy) in an attempt to stabilize the segment.

What Are Spondylosis Symptoms?

The most common symptoms of spondylosis.

While spondylosis can affect the joints anywhere along the spine, it occurs more commonly in the neck and low back. The neck is susceptible because it supports the head’s weight throughout a wide range of movement—according to the American Academy of Orthopaedic Surgeons, more than 85% of those over the age of 60 have cervical spondylosis. The low back is at risk because it manages and distributes most of the body’s weight and related structural stresses. More than 80% of those over the age of 40 may have lumbar spondylosis in the United States, though the majority are asymptomatic (have no symptoms and feel no pain).

Although many with the condition do experience varying levels of discomfort, the positive news is that spondylosis does not always cause pain. According to Dr. Woods, “when spondylosis of the spine does result in pain, it is non-radiating, but can affect range of motion. If the spondylosis progresses to compressing the nerves in the neck or lower back, it will likely result in pain numbness or weakness in the arms and legs.”

Common symptoms can include:

  • Stiffness, particularly after periods of inactivity or rest, such as waking up after a nap.
  • Paresthesias, or abnormal sensations, may develop — such as numbness or tingling.
  • Limited range of motion in affected joints.
  • Pain can result from a bulging or herniated disc that impinges or pinches a spinal nerve (see diagram below). Nerves compressed in the neck can cause neck pain to radiate down into the shoulder, arm, and hand. Similarly, if the low back is affected, the patient may experience buttock pain and sciatica, a type of nerve-related leg pain.

While not as common, Dr. Woods pointed out that “spondylosis can affect the alignment of the back, which can make it difficult to stand upright.

What Are Risk Factors for Developing Spondylosis?

While spondylosis is often associated with aging, certain genetic predispositions, and injuries may increase a person’s risk of developing spinal osteoarthritis. Aside from normal wear and tear and specific autoimmune triggers, in many cases of spondylosis, the cause remains unknown.

According to Dr. Jacob LaSalle, board certified anesthesiologist and pain medicine specialist at Hudson Medical, common risk factors include:

  • Being overweight or obese
  • Having certain conditions like diabetes, gout, psoriasis, tuberculosis, irritable bowel syndrome (IBS), and Lyme disease

How Do Doctors Diagnose Spondylosis?

To diagnose spinal osteoarthritis, a doctor will need to conduct a physical and neurological examination — and look closely at a patient’s spine and range of motion when bending forward, backward, and side-to-side. The physician will note the shape of the spine, including any abnormal curvatures, and will palpate or feel the spine to detect any tender spots, muscle tightness, spasms, bumps, or areas of inflammation.

Your physician will evaluate your pain level, along with other symptoms such as weakness or paresthesias, and take X-rays to detect bone spurs or loss of disc height, which can be a sign of degenerative disc disease. Your doctor may also order a CT (computerized tomography) or MRI (magnetic resonance imaging) to view degenerative changes and abnormalities in the spine’s soft tissues. Depending on your symptoms, you may undergo other diagnostic tests.

X-rays can show bone spurs, while other types of imaging can depict soft tissue changes.What Are Some Common Nonoperative Spondylosis Treatment Options?

“Spondylosis is treated with a multi-modal therapeutic approach, which best addresses the multi-faceted nature of the disease,” said Dr. LaSalle. “Physical therapy is a cornerstone of treatment in most cases, which helps to protect and strengthen the vulnerable areas of the spine. Complementary and alternative treatments such as massage and acupuncture can also be utilized as part of a holistic treatment approach.

The overall goal of nonoperative treatment is to improve the strength and coordination of the muscles that surround the spine so they can act like the world’s greatest back and neck brace. Luckily, most patients respond favorably to nonsurgical treatments like anti-inflammatory medication, physical therapy, and injections.

  • Radiofrequency ablation of the nerves that innervate the painful and arthritic joints of the spine (usually facet joints) can provide pain relief for three to six months by stopping nerves from transmitting pain signals to the brain.
  • Strengthening exercises can help improve spinal flexibility, build strength, and endurance.
     
  • No-impact aerobic exercie improves overall circulation, resting muscle tone (which leads to better posture), and decreases inflammation

What Are Common Surgery Options for Spondylosis?

If you are diagnosed with spondylosis, we want you to know that spine surgery is seldom needed to treat spinal osteoarthritis that develops in the neck or back. However, in some cases, spondylosis symptoms can become progressively worse to the point that first-line therapies and middle-of-the-road treatments do not provide adequate pain or symptom relief.

Dr. Woods shared that “common reasons for surgery include nerve or spinal cord compression, which, if it becomes severe, can lead to significant arm or leg weakness and numbness. In some of these cases, back or neck surgery may be recommended.”

Surgery for spondylosis has two main components—removing what is causing pain and fusing the spine to control movement—and are respectively known as decompression and stabilization surgery.

Dr. Woods added, “if there is mechanical instability or misalignment due to the degenerative changes, surgery may be indicated.” He emphasized that the goal of surgery for spondylosis is to remove pressure from the nerves or spinal cord, which can be accomplished in several ways, but most commonly looks to remove bone spurs or herniated discs.

Some of the more common surgical interventions for spondylosis include:

  • Decompression surgeries to remove bones spurs (foraminotomy), herniated discs (discectomy), or part of the vertebra (facetectomy)
  • Stabilization surgery like spinal fusion to stabilize vertebral segments using bone graft and hardware if they are moving abnormally.
  • In some patients, disc replacement may be a good option, especially if you want to avoid fusion and spare motion.

Often, a decompression and fusion are done simultaneously. If a spinal surgical procedure is being considered, your doctor will look at many different factors, like your overall health,  to evaluate if you are a good candidate for surgery and decide on the best type of surgery for your situation.

What Are Some Complementary and Alternative Treatment Options for Spondylosis?

“While generally lacking robust clinical studies to support their efficacy, many complementary and alternative treatments have been used effectively to relieve pain related to spondylosis and degenerative conditions of the spine,” shared Dr. LaSalle.  Some of these treatments include chiropractic manipulation, massage therapy, hypnotherapy, cryotherapy, and psychological interventions such as cognitive-behavioral therapy and biofeedback.  

Newer treatments include platelet-rich plasma (PRP) injections, stem cell injections, and laser endoscopic annuloplasty surgery. However, these treatments need to be studied more before they’re adopted into widespread use. They’re also not typically covered by insurance, meaning the whole cost will be on you to pay. Proceed with caution. 

One of the safest and viable treatment options for anyone suffering from spondylosis is acupuncture. “While high-quality clinical trials have not definitively shown a benefit, copious anecdotal reports and case series have demonstrated positive clinical outcomes, which given its low-risk profile, render it an intervention worth considering as part of a multi-modal treatment approach for degenerative conditions of the spine,” added Dr. LaSalle. “Potential therapeutic mechanisms include modulation of local blood flow and modulation of the body’s endogenous opioid and analgesic mechanisms.”

Acupuncture is an effective complementary and alternative treatment for many people with spondylosis.What Lifestyle Changes Can Help Prevent Spondylosis?

“Osteoarthritis, spondylosis, and softening happen to us all as we age,” commented Dr. Woods, “but being active and living a healthy lifestyle can help slow the onset of them or make them less severe.” You know what that means because you’ve read it a million times, but we’ll say it again: eat a balanced diet and do regular physical activity to maintain a healthy weight. Dr. Woods added that “there is some solid data which supports that an anti-inflammatory diet might decrease pain.”

Dr. LaSalle advises that “ reducing emotional and physical stress through mindfulness and stress-reduction strategies” is key to mitigating or preventing spondylosis. Smoking? Stop. Seriously.

Finally, you need to keep your mind right. Part of that is being proactive with your treatment strategies. If you’re not doing much besides watching your condition degenerate, that takes both a physical and emotional toll, which can accelerate your disease. It’s a feedback loop: Your back hurts, your feel lousy, you get stressed and depressed, your back hurts more, et cetera, et cetera, et cetera.

Luckily, though, the reverse is also true. When you’re taking charge of your treatment and it’s starting to take some of your pain away—or you’re proactively ruling out ineffective treatment strategies and trying new therapies—your body and your mind benefit. You have more physical and mental resources to put toward your recovery, so your back feels better and you feel less stressed and more hopeful.  

Bottom line: You got this!

 

Sources

Gower T. Is It Back Pain or Is It OA? Arthritis Foundation. www.arthritis.org/about-arthritis/types/back-pain/articles/oa-and-back-pain.php. Accessed August 17, 2020.

Rubin Dl. Epidemiology and Risk Factors for Spine Pain. Neurol Clin. 2007; May;25(2):353-71.

Laxmaiah Manchikanti, Epidemiology of Low Back Pain, Pain Physician, Volume 3, Number 2, pp 167-192, 2000 (level of evidence 5).

Spinal Arthritis (Arthritis in the Back or Neck). Spinal Arthritis (Arthritis in the Back or Neck) | Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/spinal-arthritis. Accessed August 17, 2020.

When Back Pain May Mean Arthritis: Arthritis Foundation. When Back Pain May Mean Arthritis | Arthritis Foundation. http://www.arthritis.org/about-arthritis/where-it-hurts/back-pain/treatment/back-pain-relief-injections.php. Accessed August 16, 2020.

Frymoyer, J. W., J. Geen, M. E., Andersson, G. B., J. Dillane, J. F., HI. Andersson, G. E., MW. Tulder, B. W. K., … JN. Katz, S. J. L. (1988, January 1). Lumbar spondylosis: clinical presentation and treatment approaches. Current Reviews in Musculoskeletal Medicine. https://link.springer.com/article/10.1007/s12178-009-9051-x. Accessed August 18, 2020.

Binder, A. I. (2007, March 8). Cervical spondylosis and neck pain. The BMJ. https://www.bmj.com/content/334/7592/527. Accessed August 18, 2020.

Theodore, N. (2020). Degenerative Cervical Spondylosis. New England Journal of Medicine, 383(2), 159–168. https://doi.org/10.1056/nejmra2003558. Accessed August 28, 2020

Lee, S. Y., Cho, N. H., Jung, Y. O., Seo, Y. I., & Kim, H. A. (2017). Prevalence and Risk Factors for Lumbar Spondylosis and Its Association with Low Back Pain among Rural Korean Residents. Journal of Korean Neurosurgical Society, 60(1), 67–74. https://doi.org/10.3340/jkns.2016.0505.007. Accessed August 28, 2020.

Binder, A. I. (2007). Cervical spondylosis and neck pain. Bmj, 334(7592), 527–531. https://doi.org/10.1136/bmj.39127.608299.80. Accessed August 29, 2020.

Cervical Spondylosis (Arthritis of the Neck) – OrthoInfo – AAOS. OrthoInfo. https://orthoinfo.aaos.org/en/diseases–conditions/cervical-spondylosis-arthritis-of-the-neck/. Accessed September 1, 2020.

Gellhorn, A. C., Katz, J. N., & Suri, P. (2012). Osteoarthritis of the spine: the facet joints. Nature Reviews Rheumatology, 9(4), 216–224. https://doi.org/10.1038/nrrheum.2012.199. Accessed September 1, 2020.

Middleton, K., & Fish, D. E. (2009). Lumbar spondylosis: clinical presentation and treatment approaches. Current Reviews in Musculoskeletal Medicine, 2(2), 94–104. https://doi.org/10.1007/s12178-009-9051-x. Accessed September 1, 2020.

Kolenkiewicz, M., Włodarczyk, A., & Wojtkiewicz, J. (2018). Diagnosis and Incidence of Spondylosis and Cervical Disc Disorders in the University Clinical Hospital in Olsztyn, in Years 2011–2015. BioMed Research International, 2018, 1–7. https://doi.org/10.1155/2018/5643839 

Continue Reading …. What Causes Spondylosis?

Updated on: 03/30/21

Spondylosis Center – Spinal Osteoarthritis

Peer Reviewed

The Universal Guide to Spondylosis: Everything you ever wanted to know, straight from the experts.

In This Article: What Is Spondylosis?   |    Bone Spurs   |    Symptoms    |    Risk Factors    |    Diagnosis   |    Nonoperative Treatments  |    Surgery Options    |    Complementary and Alternative Treatmens   |    Lifestyle Changes   |    Sources

Spondylosis can feel like a metaphor for the aging process. That slow march of wear and tear is happening to us all, whether we feel it or see it. One day you look in the mirror and think, “Where’d all this salt-and-pepper hair come from?” Spondylosis can be sneaky like that, except instead of grey hairs you get back pain. Yay.

Spondylosis is a degenerative condition that may worsen as a person grows older. It can affect any region of the spine. Photo Source: 123RF.com.Technically, spondylosis is a form of arthritis—spinal osteoarthritis (osteoarthritis is the most common type of arthritis) to be exact. We tend to think of arthritis as something you get in your hands and knees, but the spine, and all of its bones and joints, can fall victim to its grip as well. And yes, while it’s most likely to affect people in the 60+ range, patients typically report their first symptoms between the ages of 20 and 50 years (massive range, right?).

More than 80% of people older than 40 years show evidence of the condition on X-rays. Lumbar, or lower back, spondylosis is especially common in people older than 40 years. According to the Arthritis Foundation, spinal osteoarthritis may affect as many as 75% of everyone over the age of 60.

Nobody (except little kids) wants to get older, but you have to. But you don’t have to get spondylosis, and if you do get it, you don’t have to let it destroy your quality of life. Here’s everything you need to know about spondylosis: Its causes and symptoms, how it’s diagnosed, and maybe most important, how to manage and prevent it.

What is Spondylosis?

Spondylosis describes the general degeneration of the spine that can occur in joints, discs, and bones of the spine as we age.

“Arthritis” is an umbrella term for more than 100 conditions that cause painful joints, and in the case of spondylosis, the spine is full of joints that can be affected. Osteoarthritis—which is what spondylosis is—is the most common type.

Bones in a joint need to glide smoothly together. Articular cartilage, which is cartilage that wraps the ends of bones in a joint, allows that smooth gliding and helps prevent painful and damaging bone-on-bone contact. Osteoarthritis is the gradual breakdown of this cartilage. It’s also known as wear-and-tear arthritis, because it just sort of happens naturally over a lifetime of joint movement.

Your spine is a column made of 33 bones called vertebrae. Cushion-like pads called discs are tucked between most vertebrae, which protects the spine and makes it flexible. And within this column of vertebrae lies the spinal cord. Vertebrae are connected by facet joints, which are the victims in spondylosis.

Spondylosis is common, but it is usually not serious. Many who have it experience no pain, though it can be painful for some. Most patients with spinal osteoarthritis will not need surgery. However, it is a degenerative condition that may worsen as a person grows older, and can affect any region of the spine, including:

  • Cervical — neck
  • Thoracic — upper, mid-back
  • Lumbar — low back
  • Lumbosacral — low back/sacrum

How Does Spondylosis Affect Discs and Cause Bone Spurs to Form?

To better understand the implications of spondylosis, it helps to learn about the challenges that can arise. Intervertebral discs serve as the cushion between the bone and function as a major shock absorber by retaining water. As we age, the discs begin to dry out and, as a result, can lose their shock-absorbing capability, transmitting more load to the vertebrae, sometimes resulting in bone spur formation (that’s degenerative disc disease, or DDD). Our bodies respond to stress by forming bone in an attempt to stabilize the segment.

Bone spurs can pinch a spinal nerve root and cause inflammation and pain. Photo Source: SpineUniverse.com.Spinal osteoarthritis also affects the facet joints of the vertebrae — which is why it is also known as facet joint syndrome, facet joint arthritis, or facet disease. And, DDD may contribute to the problem. As the discs between the vertebrae become thinner, more pressure is placed on the facet joints, leading to more friction and, subsequently, damage to the cartilage.

Barrett Woods, MD, a board certified orthopedic surgeon with Rothman Orthopaedic Institute at AtlantiCare, and assistant professor of spine surgery at Thomas Jefferson University Hospital, says that in facet joints, just like a knee or hip, “the cartilage surfaces breaks down, causing bones to rub together, which can form bone spurs or enlarge the joint (hypertrophy) in an attempt to stabilize the segment.”

What Are Spondylosis Symptoms?

The most common symptoms of spondylosis.

While spondylosis can affect the joints anywhere along the spine, it occurs more commonly in the neck and low back. The neck is susceptible because it supports the head’s weight throughout a wide range of movement—according to the American Academy of Orthopaedic Surgeons, more than 85% of those over the age of 60 have cervical spondylosis. The low back is at risk because it manages and distributes most of the body’s weight and related structural stresses. More than 80% of those over the age of 40 may have lumbar spondylosis in the United States, though the majority are asymptomatic (have no symptoms and feel no pain).

Although many with the condition do experience varying levels of discomfort, the positive news is that spondylosis does not always cause pain. According to Dr. Woods, “when spondylosis of the spine does result in pain, it is non-radiating, but can affect range of motion. If the spondylosis progresses to compressing the nerves in the neck or lower back, it will likely result in pain numbness or weakness in the arms and legs.”

Common symptoms can include:

  • Stiffness, particularly after periods of inactivity or rest, such as waking up after a nap.
  • Paresthesias, or abnormal sensations, may develop — such as numbness or tingling.
  • Limited range of motion in affected joints.
  • Pain can result from a bulging or herniated disc that impinges or pinches a spinal nerve (see diagram below). Nerves compressed in the neck can cause neck pain to radiate down into the shoulder, arm, and hand. Similarly, if the low back is affected, the patient may experience buttock pain and sciatica, a type of nerve-related leg pain.

While not as common, Dr. Woods pointed out that “spondylosis can affect the alignment of the back, which can make it difficult to stand upright.”

What Are Risk Factors for Developing Spondylosis?

While spondylosis is often associated with aging, certain genetic predispositions, and injuries may increase a person’s risk of developing spinal osteoarthritis. Aside from normal wear and tear and specific autoimmune triggers, in many cases of spondylosis, the cause remains unknown.

According to Dr. Jacob LaSalle, board certified anesthesiologist and pain medicine specialist at Hudson Medical, common risk factors include:

  • Being overweight or obese
  • Having certain conditions like diabetes, gout, psoriasis, tuberculosis, irritable bowel syndrome (IBS), and Lyme disease

How Do Doctors Diagnose Spondylosis?

To diagnose spinal osteoarthritis, a doctor will need to conduct a physical and neurological examination — and look closely at a patient’s spine and range of motion when bending forward, backward, and side-to-side. The physician will note the shape of the spine, including any abnormal curvatures, and will palpate or feel the spine to detect any tender spots, muscle tightness, spasms, bumps, or areas of inflammation.

Your physician will evaluate your pain level, along with other symptoms such as weakness or paresthesias, and take X-rays to detect bone spurs or loss of disc height, which can be a sign of degenerative disc disease. Your doctor may also order a CT (computerized tomography) or MRI (magnetic resonance imaging) to view degenerative changes and abnormalities in the spine’s soft tissues. Depending on your symptoms, you may undergo other diagnostic tests.

X-rays can show bone spurs, while other types of imaging can depict soft tissue changes.What Are Some Common Nonoperative Spondylosis Treatment Options?

“Spondylosis is treated with a multi-modal therapeutic approach, which best addresses the multi-faceted nature of the disease,” said Dr. LaSalle. “Physical therapy is a cornerstone of treatment in most cases, which helps to protect and strengthen the vulnerable areas of the spine. Complementary and alternative treatments such as massage and acupuncture can also be utilized as part of a holistic treatment approach.”

The overall goal of nonoperative treatment is to improve the strength and coordination of the muscles that surround the spine so they can act like the world’s greatest back and neck brace. Luckily, most patients respond favorably to nonsurgical treatments like anti-inflammatory medication, physical therapy, and injections.

  • Radiofrequency ablation of the nerves that innervate the painful and arthritic joints of the spine (usually facet joints) can provide pain relief for three to six months by stopping nerves from transmitting pain signals to the brain.
  • Strengthening exercises can help improve spinal flexibility, build strength, and endurance.
     
  • No-impact aerobic exercie improves overall circulation, resting muscle tone (which leads to better posture), and decreases inflammation

What Are Common Surgery Options for Spondylosis?

If you are diagnosed with spondylosis, we want you to know that spine surgery is seldom needed to treat spinal osteoarthritis that develops in the neck or back. However, in some cases, spondylosis symptoms can become progressively worse to the point that first-line therapies and middle-of-the-road treatments do not provide adequate pain or symptom relief.

Dr. Woods shared that “common reasons for surgery include nerve or spinal cord compression, which, if it becomes severe, can lead to significant arm or leg weakness and numbness. In some of these cases, back or neck surgery may be recommended.”

Surgery for spondylosis has two main components—removing what is causing pain and fusing the spine to control movement—and are respectively known as decompression and stabilization surgery.

Dr. Woods added, “if there is mechanical instability or misalignment due to the degenerative changes, surgery may be indicated.” He emphasized that the goal of surgery for spondylosis is to remove pressure from the nerves or spinal cord, which can be accomplished in several ways, but most commonly looks to remove bone spurs or herniated discs.

Some of the more common surgical interventions for spondylosis include:

  • Decompression surgeries to remove bones spurs (foraminotomy), herniated discs (discectomy), or part of the vertebra (facetectomy)
  • Stabilization surgery like spinal fusion to stabilize vertebral segments using bone graft and hardware if they are moving abnormally.
  • In some patients, disc replacement may be a good option, especially if you want to avoid fusion and spare motion.

Often, a decompression and fusion are done simultaneously. If a spinal surgical procedure is being considered, your doctor will look at many different factors, like your overall health,  to evaluate if you are a good candidate for surgery and decide on the best type of surgery for your situation.

What Are Some Complementary and Alternative Treatment Options for Spondylosis?

“While generally lacking robust clinical studies to support their efficacy, many complementary and alternative treatments have been used effectively to relieve pain related to spondylosis and degenerative conditions of the spine,” shared Dr. LaSalle.  Some of these treatments include chiropractic manipulation, massage therapy, hypnotherapy, cryotherapy, and psychological interventions such as cognitive-behavioral therapy and biofeedback.  

Newer treatments include platelet-rich plasma (PRP) injections, stem cell injections, and laser endoscopic annuloplasty surgery. However, these treatments need to be studied more before they’re adopted into widespread use. They’re also not typically covered by insurance, meaning the whole cost will be on you to pay. Proceed with caution. 

One of the safest and viable treatment options for anyone suffering from spondylosis is acupuncture. “While high-quality clinical trials have not definitively shown a benefit, copious anecdotal reports and case series have demonstrated positive clinical outcomes, which given its low-risk profile, render it an intervention worth considering as part of a multi-modal treatment approach for degenerative conditions of the spine,” added Dr. LaSalle. “Potential therapeutic mechanisms include modulation of local blood flow and modulation of the body’s endogenous opioid and analgesic mechanisms.”

Acupuncture is an effective complementary and alternative treatment for many people with spondylosis.What Lifestyle Changes Can Help Prevent Spondylosis?

“Osteoarthritis, spondylosis, and softening happen to us all as we age,” commented Dr. Woods, “but being active and living a healthy lifestyle can help slow the onset of them or make them less severe.” You know what that means because you’ve read it a million times, but we’ll say it again: eat a balanced diet and do regular physical activity to maintain a healthy weight. Dr. Woods added that “there is some solid data which supports that an anti-inflammatory diet might decrease pain.”

Dr. LaSalle advises that “ reducing emotional and physical stress through mindfulness and stress-reduction strategies” is key to mitigating or preventing spondylosis. Smoking? Stop. Seriously.

Finally, you need to keep your mind right. Part of that is being proactive with your treatment strategies. If you’re not doing much besides watching your condition degenerate, that takes both a physical and emotional toll, which can accelerate your disease. It’s a feedback loop: Your back hurts, your feel lousy, you get stressed and depressed, your back hurts more, et cetera, et cetera, et cetera.

Luckily, though, the reverse is also true. When you’re taking charge of your treatment and it’s starting to take some of your pain away—or you’re proactively ruling out ineffective treatment strategies and trying new therapies—your body and your mind benefit. You have more physical and mental resources to put toward your recovery, so your back feels better and you feel less stressed and more hopeful.  

Bottom line: You got this!

 

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When Back Pain May Mean Arthritis: Arthritis Foundation. When Back Pain May Mean Arthritis | Arthritis Foundation. http://www.arthritis.org/about-arthritis/where-it-hurts/back-pain/treatment/back-pain-relief-injections.php. Accessed August 16, 2020.

Frymoyer, J. W., J. Geen, M. E., Andersson, G. B., J. Dillane, J. F., HI. Andersson, G. E., MW. Tulder, B. W. K., … JN. Katz, S. J. L. (1988, January 1). Lumbar spondylosis: clinical presentation and treatment approaches. Current Reviews in Musculoskeletal Medicine. https://link.springer.com/article/10.1007/s12178-009-9051-x. Accessed August 18, 2020.

Binder, A. I. (2007, March 8). Cervical spondylosis and neck pain. The BMJ. https://www.bmj.com/content/334/7592/527. Accessed August 18, 2020.

Theodore, N. (2020). Degenerative Cervical Spondylosis. New England Journal of Medicine, 383(2), 159–168. https://doi.org/10.1056/nejmra2003558. Accessed August 28, 2020

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Middleton, K., & Fish, D. E. (2009). Lumbar spondylosis: clinical presentation and treatment approaches. Current Reviews in Musculoskeletal Medicine, 2(2), 94–104. https://doi.org/10.1007/s12178-009-9051-x. Accessed September 1, 2020.

Kolenkiewicz, M., Włodarczyk, A., & Wojtkiewicz, J. (2018). Diagnosis and Incidence of Spondylosis and Cervical Disc Disorders in the University Clinical Hospital in Olsztyn, in Years 2011–2015. BioMed Research International, 2018, 1–7. https://doi.org/10.1155/2018/5643839 

Continue Reading …. What Causes Spondylosis?

Updated on: 03/30/21

clinical presentation and treatment approaches

Curr Rev Musculoskelet Med. 2009 Jun; 2(2): 94–104.

1 and 2

Kimberley Middleton

1Department of Physical Medicine and Rehabilitation, University of Washington Medical Center, Seattle, WA USA

David E. Fish

2Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250 16th Street, 7th Floor Tower Building Room 745, Santa Monica, CA 90404 USA

1Department of Physical Medicine and Rehabilitation, University of Washington Medical Center, Seattle, WA USA

2Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250 16th Street, 7th Floor Tower Building Room 745, Santa Monica, CA 90404 USA

Corresponding author.

Received 2007 Nov 26; Accepted 2009 Feb 25.

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

This article has been cited by other articles in PMC.

Abstract

Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable. Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine. Back pain has been termed as “an illness in search of a disease.” Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative. We will elaborate on these degenerative processes and their clinical implications. We will further discuss diagnostic approaches and the efficacy of existing treatment options.

Keywords: Low back pain, Spondylosis, Osteophyte, Degenerative disk disease, Intervertebral osteochondrosis

Introduction

Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives [1–3]. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks [4]. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population [5, 6]. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable [7].

Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country [8]. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine [9]. Back pain has been termed as “an illness in search of a disease” [10]. Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative [11, 12].

We will elaborate on these degenerative processes and their clinical implications. We will further discuss the diagnostic approaches and the efficacy of existing treatment options.

Tackling the terminology

The terms lumbar osteoarthritis, disk degeneration, degenerative disk disease, and spondylosis are used in the literature to describe anatomical changes to the vertebral bodies and intervertebral disk spaces that may be associated with clinical pain syndromes.

Spinal osteoarthritis (OA) is a degenerative process defined radiologically by joint space narrowing, osteophytosis, subchondral sclerosis, and cyst formation [13, 14]. Osteophytes included within this definition fall into one of the two primary clinical categories [14]. The first, spondylosis deformans describes bony outgrowths arising primarily along the anterior and lateral perimeters of the vertebral end-plate apophyses. These hypertrophic changes are believed to develop at sites of stress to the annular ligament and most commonly occur at thoracic T9–10 and lumbar L3 levels [15]. These osteophytes have minimal effect on intervertebral disk height [16] and are frequently asymptomatic, with only rare complications arising from their close anatomic relationship to organs anterior to the spine [15].

By contrast, intervertebral osteochondrosis describes the formation of more pathological end-plate osteophytes, associated with disk space narrowing, vacuum phenomenon, and vertebral body reactive changes [16]. If protruding within the spinal canal or intervertebral foramina, these bony growths may compress nerves with resulting radiculopathy or spinal stenosis. Moreover, these bony projections may limit joint mobility and invade other organs or tissues [14]. The term “osteoarthritis” suggests pathology limited to bone. Nevertheless, in this context, it has clear implications for the health of neighboring disks and nerve roots.

Comparatively, degenerative disk disease (DDD) refers to back pain symptoms attributable to intervertebral disk degeneration. Such pathologic changes include disk desiccation, fibrosis, and narrowing. The anulus may bulge, fissure, or undergo mucinous degeneration. Also included within the anatomic definition of DDD are defects and sclerosis of the end-plates, and osteophytes at the vertebral apophyses [16]. With these bony changes included in the radiographic description of both OA and DDD, there exists diagnostic overlap between the conditions. As a result, these terms are often used interchangeably in the medical literature to describe similar phenomena.

Spondylosis of the lumbar spine, the subject of this paper, is a term with many definitions. In the literature, it has been utilized in many different contexts, employed synonymously with arthrosis, spondylitis, hypertrophic arthritis, and osteoarthritis. In other instances, spondylosis is considered mechanistically, as the hypertrophic response of adjacent vertebral bone to disk degeneration (although osteophytes may infrequently form in the absence of diseased disks) [17]. Finally, spondylosis may be applied nonspecifically to any and all degenerative conditions affecting the disks, vertebral bodies, and/or associated joints of the lumbar spine [17, 18]. For purposes of this review, we will use this final, broad definition of spondylosis, recognizing the high incidence of coincident degenerative changes, and the dynamic interplay between adjacent disks, vertebra, and nerves that create the clinical pain syndromes within the axial spine and associated nerves.

Epidemiology

Degenerative spine changes are remarkably common in population studies. Symmons’ et al. [19] study of individuals aged 45–64 years identified 85.5% of participants to demonstrate osteophytes within the lumbar spine. O’Neill et al. [20] explored osteophytosis within a UK adult population over age 50 years, finding 84% of men and 74% of women to demonstrate at least one vertebral osteophyte, with increased incidence among individuals with more physical activity, self reported back pain, or higher BMI scores. Despite marked variability within the population, men appear to have more significant degenerative changes than women, both with regard to number and severity of osteophyte formation [20].

Radiographic evidence of degenerative disease of the lumbar spine among asymptomatic individuals is impressive. MRI imaging in asymptomatic patients over age 60 years reveals disk protrusions in 80% [21] and degenerative spinal stenosis in 20% [11]. A study comparing radiographic evidence of spine degeneration among categories of men who were without pain, with moderate pain, or with severe lower back pain found similar frequency of disk space narrowing and bone spurs among all three groups [22].

Furthermore, degenerative changes may appear in young individuals without decades of spine loading. Lawrence [23] found 10% of women aged 20–29 to demonstrate evidence of disk degeneration. Lumbar spondylosis, while affecting 80% of patients older than 40 years, nevertheless was found in 3% of individuals aged 20–29 years in one study [15]. The high incidence of degeneration among young and asymptomatic individuals highlights the challenge involved in establishing causality between imaging findings and pain symptoms in affected patients.

Pathogenesis

The high incidence of simultaneous degenerative changes to the intervertebral disk, vertebral body, and associated joints suggests a progressive and dynamic mechanism, with interdependent changes occurring secondary to disk space narrowing [17].

Intervertebral disks are believed to undergo what Kirkaldy Willis and Bernard [24] first coined a “degenerative cascade” (Fig. ) of three overlapping phases that may occur over the course of decades. Phase I (Dysfunction Phase) describes the initial effects of repetitive microtrauma with the development of circumferential painful tears of the outer, innervated anulus, and associated end-plate separation that may compromise disk nutritional supply and waste removal. Such tears may coalesce to become radial tears, more prone to protrusion, and impact the disk’s capacity to maintain water, resulting in desiccation and reduced disk height. Fissures may become ingrown by vascular tissue and nerve endings, increasing innervation and the disk’s capacity for pain signal transmission [25]. Phase II (Instability Phase) is characterized by the loss of mechanical integrity, with progressive disk changes of resorption, internal disruption, and additional annular tears, combined with further facet degeneration that may induce subluxation and instability. During Phase III (Stabilization Phase), continued disk space narrowing and fibrosis occurs along with the formation of osteophytes and transdiscal bridging [26].

The spectrum of pathological changes in facial joints and the disk and the interaction of these changes. The upper light horizontal bar represents dysfunction, the middle darker bar instability, and the lower dark bar stabilization

Schneck presents a further mechanical progression, building upon this degenerative cascade of the intervertebral disk, to explain other degenerative changes of the axial spine. He proposes several implications of disk space narrowing. Adjacent pedicles approximate with a narrowing of the superior–inferior dimension of the intervertebral canal. Laxity due to modest redundancy of the longitudinal ligaments enables bulging of the ligamentum flavum and potential for spine instability. Increased spine movement permits subluxation of the superior articular process (SAP), causing a narrowed anteroposterior dimension of the intervertebral and upper nerve root canals. Laxity may also translate into altered weight mechanisms and pressure relationships on vertebral bone and joint spaces believed to influence osteophyte formation and facet hypertrophy to both inferior and superior articular processes with risks for projection into the intervertebral canal and central canal, respectively. Oblique orientations of the articular processes may further cause retrospondylolisthesis, with resulting anterior encroachment of the spinal canal, nerve root canal, and intervertebral canal [17].

Biochemical research exploring osteophyte formation supports the above process. Osteophyte lipping is believed to form at periosteum [27] through the proliferation of peripheral articular cartilage which subsequently undergoes endochondral calcification and ossification [28]. Changing weight mechanics and pressure forces as well as alterations in oxygen tension and dynamic fluid pressure appear to be influential factors in osteophyte formation [14]. Mesenchymal stem cells of the synovium or periostium are likely precursors, with synovial macrophages and a milieu of growth factors and extracellular matrix molecules acting as probable mediators in this process [29].

Clinical presentation

Pain within the axial spine at the site of these degenerate changes is not surprising as nociceptive pain generators have been identified within facet joints, intervertebral disks, sacroiliac joints, nerve root dura, and myofascial structures within the axial spine [9].

These degenerative anatomical changes may culminate in a clinical presentation of spinal stenosis, or narrowing within the spinal canal [30] through progressive ingrowth of osteophytes, hypertrophy of the inferior articular process [31], disk herniation, bulging of the ligamentum flavum [17], or spondylolisthesis. The clinical result: a constellation of pain symptoms encompassed in the term neurogenic claudication (NC). NC may include (to varying extents) lower back pain, leg pain, as well as numbness and motor weakness to lower extremities that worsen with upright stance and walking, and improve with sitting and supine positioning [30].

Clinical presentations of radiculopathy may emanate from many sources, all of which can be explained by the degenerative process. Disk bulging may affect descending rootlets of the cauda equina, nerve roots exiting at the next lower intervertebral canal, or the spinal nerve within its ventral ramus, if protruding centrally, posterolaterally, or laterally, respectively [32]. Osteophyte lipping along the posterior aspect of vertebral bodies, along upper or lower margins, may similarly impinge upon the same neural structures as the bulging disk just described [17, 33]. Hypertrophic changes to the superior articular process may intrude upon nerve roots within the upper nerve root canal, dural sac, or prior to exiting from next lower intervertebral canal, depending on their projection [34]. These theoretical forms of impingement have been substantiated through cadaver studies. A 70% reduction or 30% residual diameter of neuroforminal space is cited as the critical amount of occlusion to induce neural compromise [15]. Moreover, compression of the posterior disk to less than 4 mm height, or foraminal height to less than 15 mm has also been determined as critical dimensions for foraminal stenosis and nerve impingement [35].

Etiology/risk factors

What factors mediate this degenerative progression? What leads a large portion of the population to manifest spondylosis, even early on in their lives? Given the substantial variability in the number and degree of spine changes observed in individuals and the wide range of clinical presentations, answers to these questions hold promise to broaden treatment options.

The influence of age

Large studies of osteoarthritis have long recognized the aging process to be the strongest risk factor for bony degeneration, particularly within the spine [36]. An extensive autopsy study in 1926 reported evidence of spondylitis deformans to increase in a linear fashion from 0% to 72% between the ages of 39 and 70 years [37]. A subsequent autopsy study by Miller et al. [38] similarly noted an increase in disk degeneration from 16% at age 20 to about 98% at age 70 years based on macroscopic disk degeneration grades of 600 specimens. Other studies corroborate this finding [20, 39].

The associations are nevertheless imperfect. Kramer [40] found increasing age to be significantly associated with osteophyte formation but not predictive of the degree of disk space narrowing observed in a retrospective review of radiographs of women. She observed significant variability, noting “although few younger women have high average scores, some older women have no radiographic sign of OA, while others are severely affected.” Multiple studies have also demonstrated the presence of significant lumbar degeneration to be evident even within the first two decades [38, 39]. Such variability within members of the same age category suggests the influence of other contributing factors.

The impact of activity and occupation

Disk generation has long been associated with certain activities. Retrospective studies cite Body Mass Index (BMI), incident back trauma, daily spine loading (twisting, lifting, bending, and sustained nonneutral postures), and whole body vibration (such as vehicular driving) to be factors which increase both the likelihood and severity of spondylosis [20, 41]. While these correlations exist, a study following progressive radiographic changes in lumber DDD did not find significant associations with the extent of physical activity, noting only age, back pain, and associated hip OA to be predictive of DDD and osteophyte changes [42].

The role of heredity

Genetic factors likely influence the formation of osteophytes and disk degeneration. Spector and MacGregor [43] proposed that 50% of the variability found in osteoarthritis can be attributed to heritable factors. Similarly, twin studies evaluating the progression of degenerative changes in lumbar MRI imaging suggest that approximately half (47–66%) of the variance could be explained by genetic and environmental factors, attributing only 2–10% of variance to physical loading and resistance training [44]. Another twin study revealed a high degree of similarity in signal intensity, disk height narrowing, disk bulging, and end-plate changes [45]. A search for these underlying genetic factors has identified polymorphisms in genes regulating inflammatory pathways and a Vitamin D Receptor allele to correspond to radiographic progression of lumbar disk degeneration [46].

A functional adaptation?

Is osteophyte formation inherently pathological? van der Kraan and van den Berg question if osteophyte formation may represent a remodeling process, functionally adapting to the instability or the changes in the demands of the spine [14]. Likewise, Humzah and Soames [47] emphasize the dynamic and reparative qualities of the intervertebral disk, responding to variations in mechanical loading and influencing vertebral kinematics to extend this argument. Osteophytes may form in the absence of other degenerative processes, and cartilaginous damage may exist without corresponding osteophytes [14]. Although there remains a strong association between the presence of osteophytes and other degenerative spine changes, isolated instances of one without the other occur, in the absence of overt symptoms.

A diagnostic approach

The initial evaluation for patients with low back pain begins with an accurate history and thorough physical exam with appropriate provocative testing. These first steps are complicated by the subjectivity of patient experiences of chronic spinal pain and the inherent difficulty isolating the anatomic region of interest during provocative testing without the influence of neighboring structures.

Radiographic studies, whether plain film, CT, CT myelogram, or MRI, may provide useful confirmatory evidence to support an exam finding and localize a degenerative lesion or area of nerve compression. However, imaging is an imperfect science, identifying the underlying cause of LBP in only 15% of patients in the absence of clear disk herniation or neurological deficit [25]. Furthermore, there remains a frequent disconnection between the symptom severity and the degree of anatomical or radiographic changes [18]. While correlations between the number and severity of osteophytes and back pain exist [20, 22], the prevalence of degenerative changes among asymptomatic patients underlies the difficulty assigning clinical relevance to observed radiographic changes in patients with LBP.

Nerve compression symptoms by clinical history may also be confirmed by electromyographic studies demonstrating normal distal motor and sensory nerve conduction studies with abnormal needle exam. Diagnostic injections can facilitate localization by isolating and anesthetizing irritated nerve roots (via epidural), or by blocking suspected pain generators within facet joints, sacroiliac joints, or the disk space itself (via discography) [48].

Intervention and treatment options

Given our limited ability to isolate causative sources of chronic lower back pain, there is a little consensus with regard to a definitive treatment approach. Substantial variation in management by conservative and invasive approaches exists between practitioners throughout the country [8]. We will briefly describe these treatment options for the management of chronic low back pain syndromes within each of the four primary categories: physical therapy (and associated modalities and behavioral techniques), pharmacotherapy, injection therapy, and surgical intervention.

Exercise-based and behavioral interventions

Exercise therapy

Exercise therapy (ET) remains one of the conservative mainstays of treatment for chronic lumbar spine pain, and may be tailored to include aerobic exercise, muscle strengthening, and stretching exercises [49]. Significant variation in regimen, intensity, and frequency of prescribed programs presents challenges to assessing efficacy among patients [50]. One meta-analysis of the current literature exploring the role of ET in patients with varying duration of symptoms found a graded exercise program implemented within the occupational setting demonstrated some effectiveness in subacute LBP. Among those suffering chronic pain symptoms, small, but statistically significant improvements were observed among patients, with regard to pain reduction and functional improvement [49]. The optimal approach to exercise therapy in chronic low back pain sufferers appears to be those regimens involving an individually-designed exercise program emphasizing stretching and muscle strengthening, administered in a supervised fashion, with high frequency and close adherence. Such results are complemented by other conservative approaches, including NSAIDS, manual therapies, and daily physical activity [50].

Transcutaneous electrical nerve stimulation (TENS)

A “TENS” unit is a therapeutic modality involving skin surface electrodes which deliver electrical stimulation to peripheral nerves in an effort to relieve pain noninvasively. Such devices are frequently available in outpatient exercise therapy settings, with up to a third of patients experiencing mild skin irritation following treatment [51]. While one small study identified an immediate reduction in pain symptoms 1 h following TENS application, there remains little evidence of long-term relief. Another larger study did not discover significant improvement with TENS compared with placebo with regard to pain, functional status, or range of motion [52, 53].

Back school

Back School was introduced first in Sweden with the purpose of minimizing lower back pain symptoms and their reoccurrence through review with patients of lumbar anatomy, concepts of posture, ergonomics, and appropriate back exercises [54]. Two meta-analyses concluded that there is moderate evidence for improvement in both pain and functional status for chronic low back pain within short and intermediate time courses, when measured against other modalities such as exercise, joint manipulation, myofascial therapy, and/or other educational therapy [52, 54].

Lumbar supports

Lumbar back supports may provide benefit to patients suffering chronic LBP secondary to degenerative processes through several potential, debated mechanisms. Supports are designed to limit spine motion, stabilize, correct deformity, and reduce mechanical forces. They may further have effects by massaging painful areas and applying beneficial heat; however, they may also function as a placebo. There is moderate available evidence evaluating efficacy of lumbar supports within a mixed population of acute, subacute, and chronic LBP sufferers to suggest that lumbar supports are not more effective than other treatment forms; data is conflicting with regard to patient improvement and functional ability to return to work [52].

Traction

Lumbar traction applies a longitudinal force to the axial spine through use of a harness attached to the iliac crest and lower rib cage to relieve chronic low back pain. The forces, which open intervertebral space and decrease spine lordosis, are adjusted both with regard to level and duration and may closely be measured in motorized and bed rest devices. Temporary spine realignments are theorized to improve symptoms related to degenerative spine disease by relieving mechanical stress, nerve compression, and adhesions of the facet and annulus, as well as through disruption of nociceptive pain signals [52]. Nonetheless, patients with chronic symptoms and radicular pain have not found traction to provide significant improvement in pain nor daily functioning [55–57]. Little is known with regard to the risks associated with the applied forces. Isolated case reports cite nerve impingement with heavy forces, and the potential for respiratory constraints or blood pressure changes due to the harness placement and positioning [52].

Spine manipulation

Spine manipulation is a manual therapy approach involving low-velocity, long lever manipulation of a joint beyond the accustomed, but not anatomical range of motion. The precise mechanism for improvement in low back pain sufferers remains unclear. Manipulative therapy may function through: “(1) release for the entrapped synovial folds, (2) relaxation of hypertonic muscle, (3) disruption of articular or periarticular adhesion, (4) unbuckling of motion segments that have undergone disproportionate displacement, (5) reduction of disk bulge, (6) repositioning of miniscule structures within the articular surface, (7) mechanical stimulation of nociceptive joint fibers, (8) change in neurophysiological function, and (9) reduction of muscle spasm” [58].

Available research regarding its efficacy in the context of chronic LBP finds spinal manipulation to be “more effective” compared to sham manipulation with regard to both short- and long-term relief of pain, as well as short-term functional improvement [52]. Compared with other conventional, conservative treatment approaches such as exercise therapy, back school, and NSAID prescription, spinal manipulation appears comparable in its effectiveness both in short- and long-term benefits [52, 59]. Research exploring the safety of such therapy among trained therapists found a very low risk of complications, with clinically worsened disk herniation or cauda equina syndrome occurring in fewer than 1/3.7 million [60].

Massage therapy

Massage therapy for chronic LBP appears to provide some beneficial relief. Weighed against other interventions, it proved less efficacious than TENS and manipulation, comparable with corsets and exercise regimens, and superior to acupuncture and other relaxation therapies, when followed over a 1-year course. Such preliminary results need confirmation, and evaluation for cost-effectiveness, but nevertheless suggest a potential role in certain, interested patients [61].

Multidisciplinary back therapy: the bio-psychosocial approach

Psychopathology is well recognized for its association with chronic spinal pain, and, when untreated, its ability to compromise management efforts [25]. For this reason, patients may find relief through learned cognitive strategies, termed “behavioral”, or “bio-psychosocial” therapy. Strategies involving reinforcement, modified expectations, imagery/relaxation techniques, and learned control of physiological responses aim to reduce a patient’s perception of disability and pain symptoms. To date, evidence is limited with regard to the efficacy of operant, cognitive, and respondent treatment approaches [52].

Pharmacotherapy

Treatment efforts to control pain and swelling, minimize disability, and improve the quality of life with lumbar spondylosis often require medication to complement nonpharmacologic interventions. Extensive research efforts have explored the efficacy of different oral medications in the management of low back pain secondary to degenerative processes. Nonetheless, there remains no clear consensus regarding the gold-standard approach to pharmacologic management [62].

NSAIDS

NSAIDS are widely regarded as an appropriate first step in management, providing analgesic and anti-inflammatory effects. There is adequate data demonstrating efficacy in pain reduction in the context of chronic low back pain [63–66], with use most commonly limited by gastrointestinal (GI) complaints. COX2 inhibitors offer modest relief in chronic LBP and improved function in the long-term setting. While they elicit fewer GI complications, their utilization has been curbed due to evidence for increased cardiovascular risk with prolonged use [52].

Opioid medications

Opioid medications may be considered as an alternative or augmentive therapy for patients suffering from gastrointestinal effects or poor pain control on NSAID management. The practice of prescribing narcotics for chronic low back pain sufferers is extremely variable within practitioners, with a range of 3–66% of chronic LBP patients taking some form of opioid in various literature studies [67]. These patients tend to report greater distress/suffering and higher functional disability scores [68, 69]. Two meta-analyses suggest a modest short-term benefit of opioid use for treatment of chronic LBP while issuing a warning regarding the limited quality of available studies and the high rate of tolerance and abuse associated with long-term narcotic use within this patient population [62, 67].

Antidepressants

The use of antidepressants for treatment of LBP symptoms has also been explored considerably given their proposed analgesic value at low doses, and dual role in treatment of commonly comorbid depression that accompanies LBP and may negatively impact both sleep and pain tolerance [52]. Two separate reviews of available literature found evidence for pain relief with antidepressants, but no significant impact on functioning [70, 71].

Muscle relaxants

Muscle relaxants, taking the form of either antispasmodic or antispasticity medications, may provide benefit in chronic low back pain attributed to degenerative conditions. There remains moderate to strong evidence through several trials comparing either a benzodiazepine, or non-benzodiazepine with placebo that muscle relaxants provide benefit with regard to short-term pain relief and overall functioning [52, 62, 72].

Injection therapy

Epidural steroid injections

Epidural steroid injections (ESI) have become a common interventional strategy in the management of chronic axial and radicular pain due to degeneration of the lumbar spine. These injections may be performed through interlaminar, transforaminal, or caudal approaches. Usually by way of needles guided under fluoroscopy, contrast, then local anesthetic and steroid are infused into the epidural space at the target vertebral level and bathe exiting nerve roots. Symptomatic relief is theorized to occur through complementary mechanisms. Local anesthetics provide quick diagnostic confirmation, and therapeutically may short circuit the “pain spasm cycle” and block pain signal transmission [73]. Corticosteroids are well recognized for their capacity to reduce inflammation through blockade of pro-inflammatory mediators.

Within the span of less than one decade (1998–2005), the number of ESI procedures performed has increased by 121% [73]. Despite this widespread utilization, controversy remains regarding the efficacy of these injections, fueled by the expense and the infrequent but potential risks related to needle placement and adverse medication reactions. Available published data cites wide ranges in reported success rates due to variation in study designs, distinct procedural techniques, small cohorts, and imperfect control groups [74]. For example, prior to the year 2000, few efficacy studies of lumbar ESI utilized fluoroscopy to establish appropriate needle position. Research suggests that without fluoroscopic guidance confirmation, needle position may be inappropriate in as frequently as 25% of cases, even with experienced providers [75]. Review articles and practicing clinicians alike must interpret such methodological differences between studies to assemble opinions on efficacy and utility of ESI for LBP treatment.

One such review exploring efficacy of interlaminar lumbar injections concluded strong evidence for short-term pain relief and limited benefit for long-term benefit [73] citing, among many, randomized controlled trials (RCT) by Arden and Carette of unilateral sciatic pain, finding statistically significant improvement in up to 75% of patients with steroid/anesthesia versus saline injections at 3 weeks, with benefit waning by 6 weeks and 3 months, respectively [76, 77].

The same review evaluating the transforaminal injection approach to unilateral sciatica found strong evidence for short-term, and moderate evidence for long-term symptom and functional improvement, based on the findings from several RCT. Vad et al. [78] studied 48 patients with herniated nucleus pulposus or radicular pain, treated with transforaminal ESI versus trigger point injections, citing an 84% improvement in functional scoring compared with 48% in the control group, extending for a follow-up period of 1 year. Lutz et al. [79] treated and followed a different cohort of 69 patients with the same underlying diagnoses, with transforaminal ESI for 80 weeks demonstrating 75% of patients with a successful long-term outcome, defined as >50% reduction in pain scores. In spinal stenosis, transforaminal ESI has achieved >50% pain reduction, improved walking, and improved standing tolerance in symptomatic patients extending through 1 year follow-up [80]. Furthermore, prospective trials by Yang and Riew found patients with severe lumbar radiculopathies and spinal stenosis treated with transforaminal injections experienced such sustained functional and symptomatic benefits so as to avoid intended surgical intervention [81–83].

Facet injections

Facet joints, also termed zygapophysial joints, are paired diarthrodial articulations between adjacent vertebrae. These joints are innervated from the medial branches of the dorsal rami and, through anatomical studies, possess free and encapsulated nerve endings, mechanoreceptors, and nociceptors. Inflammation to the joint creates pain signals which are implicated in 15–45% of patients with low back pain [25].

Diagnostic blocks of the joint inject anesthesia directly into the joint space or associated medial branch (MBB). Systematic reviews of both retrospective and prospective trials reveal single diagnostic facet blocks carry a false-positive rate of 22% to 47% [84] and medial branch blocks of 17–47% in the lumbar spine [85].

Subsequent therapeutic injections are similarly performed through either approach, with systematic reviews concluding moderate evidence available for short-term and long-term pain relief with facet blocks [86]. This evidence stems from studies such as Fuch’s RCT showing significant pain relief, functional improvement, and quality of life enhancement at 3 and 6 month intervals [87]. By contrast, Carette et al. [88] found no meaningful difference in perceived benefit between patients treated with steroid versus saline (control) injection at 3 and 6 month intervals. Available literature of MBB similarly show moderate evidence for short- and long-term relief [86] based on RCT of MBB under fluoroscopy, showing significant relief (by means of pain relief, physical health, psychological benefit, reduced narcotic intake, and employment status), with 1–3 injections in 100% patients at 3 months, 75–88% at 6 months, and 17–25% at 1 year [89].

SI joint injections

The sacroiliac joint space is a diarthrodial synovial joint with debated innervation patterns that involve both myelinated and unmyelinated axons. Injury or inflammation at the joint creates pain signals which are implicated in 10–27% of patients with low back pain [25] and may also refer to the buttocks, groin, thigh, and lower extremities.

There is moderate evidence to support the use of both diagnostic and therapeutic blocks of the SI joint [25]. Pereira treated 10 patients with MRI-guided bilateral SI joint injections of steroid, eight of whom reported “good to excellent” pain relief persisting through 13 months follow-up [90]. Maugers compared corticosteroid versus placebo injections under fluoroscopic guidance in SI joints of 10 symptomatic patients, reporting patient benefit only in the corticosteroid group. That benefit waned slowly over time, from 70% of patients at 1 month, to 62% at 3 months, and 58% at 6 months [91]. At this point, there is limited evidence to support radiofrequency neurotomy (ablation procedure) of the SI joint [92].

A recent meta-analysis provided the following guiding principles with regard to the frequency these procedures should be implemented in clinical practice. In cases of ESI, facet, and sacroiliac injections, diagnostic injections should be considered at intervals of no sooner than 1–2 weeks apart. Therapeutic injections may be performed at most every 2–3 months, provided the patient experiences greater than 50% relief within 6 weeks. Injections should be performed only as they are medically necessary given their associated risks and significant costs [25].

Intradiscal nonoperative therapies for discogenic pain

Discogenic pain has been identified as the source in 39% of patients with chronic low back pain. As described above, a cascade of effects induces the changes in the disk which generate pain. Discography seeks, when noninvasive imaging has failed, to identify damaged disks through injection of fluid into disk levels, in an attempt to reproduce patient symptoms. The technique’s utility remains controversial given significant potential for false positives. Provoked pain may be alternatively represent central hyperalgesia, reflect the patient’s chronic pain or psychological state, or result from technical difficulty due to the procedure itself [93].

If a diseased disk is identified, several treatment options exist. In addition to surgical correction, there are minimally invasive options. Both Intradiscal electrothermal therapy (IDET) and Radiofrequency posterior annuloplasty (RPA) involve electrode placement into the disk. Heat and electrical current coagulate the posterior anulus, and in doing so, strengthen collagen fibers, seal figures, denature inflammatory exudates, and coagulate nociceptors [25]. Current evidence provides moderate support for IDET in discogenic pain sufferers. Preliminary studies of RPA provide limited support for short term relief, with indeterminate long-term value. Both procedures have associated complications, including catheter malfunction, nerve root injuries, post-procedure disk herniation, and infection risk [25].

Surgical options

Surgical interventions are generally reserved for patients who have failed conservative options. Patients must be considered as appropriate “surgical candidates,” taking into consideration medical comorbidities as well as age, socioeconomic status, and projected activity level following a procedure [18]. Many surgical approaches have been developed to achieve one of the two primary goals: spinal fusion or spine decompression (or both).

Spinal fusion is considered in patients with malalignment or excessive motion of the spine, as seen with DDD and spondylolisthesis. Several surgical fusion approaches exist, all involving the addition of a bone graft to grow between vertebral elements to limit associated motion. Decompression surgery is indicated for patients with clear evidence of neural impingement, correcting the intrusion of bone or disk as might be seen in spinal or foraminal stenosis, disk herniation, osteophytosis, or degenerative spondylolisthesis. Despite dramatic increases in the number of procedures performed over the last several decades, there remains controversy as to the efficacy of these procedures in resolving chronic low back unresponsive to conservative management.

Controversy arises, in part, due to the inherent challenges of comparing the available research. Systematic reviews cite the heterogeneity of current trials which evaluate different surgical techniques with differing comparison groups and limited follow-up, frequently without patient-centered or pain outcomes included [18]. Some case series reveal promising results [94]. Nonetheless, a recent meta-analysis of 31 randomized controlled trials, concluded, “[there is] no clear evidence about the most effective technique of decompression for spinal stenosis or the extent of that decompression. There is limited evidence that adjunct fusion to supplement decompression for degenerative spondylolisthesis produces less progressive slip and better clinical outcomes than decompression alone.” Another review, noting no statistically significant improvement in patients undergoing fusion compared with nonsurgical interventions commented, “surgeons should recommend spinal fusion cautiously to patients with chronic low back pain. Further long-term follow-ups of the studies reviewed in this meta-analysis are required to provide more conclusive evidence in favor of either treatment” [95].

Conclusion

Lumbar spondylosis is a complicated diagnosis. We chose to define it broadly as degenerative conditions of the spine, but definitions vary widely within the literature. While it may not present a challenge to identify radiographically, its pervasiveness throughout all patient populations makes the exact diagnosis of symptomatic cases extremely difficult. Moreover, there is no current concrete, gold-standard treatment approach to the diverse range of patient presentations despite substantial research efforts to identify conservative and more invasive methods of managing symptoms and slowing progressive decline. Given the morbidity of low back pain within the population and its social and economic implications, this area will continue to be a critical research focus. Important clues are in place, from genetic studies, risk factor analysis, and explorative treatment approaches. These efforts, and future endeavors will no doubt fine-tune and present means to tackle not only symptoms, but confront progression, and ultimately prevention of disease in years to come.

Open Access

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

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clinical presentation and treatment approaches

Curr Rev Musculoskelet Med. 2009 Jun; 2(2): 94–104.

1 and 2

Kimberley Middleton

1Department of Physical Medicine and Rehabilitation, University of Washington Medical Center, Seattle, WA USA

David E. Fish

2Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250 16th Street, 7th Floor Tower Building Room 745, Santa Monica, CA 90404 USA

1Department of Physical Medicine and Rehabilitation, University of Washington Medical Center, Seattle, WA USA

2Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, 1250 16th Street, 7th Floor Tower Building Room 745, Santa Monica, CA 90404 USA

Corresponding author.

Received 2007 Nov 26; Accepted 2009 Feb 25.

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

This article has been cited by other articles in PMC.

Abstract

Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable. Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine. Back pain has been termed as “an illness in search of a disease.” Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative. We will elaborate on these degenerative processes and their clinical implications. We will further discuss diagnostic approaches and the efficacy of existing treatment options.

Keywords: Low back pain, Spondylosis, Osteophyte, Degenerative disk disease, Intervertebral osteochondrosis

Introduction

Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives [1–3]. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks [4]. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population [5, 6]. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable [7].

Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country [8]. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine [9]. Back pain has been termed as “an illness in search of a disease” [10]. Indeed, once “red flag” diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative [11, 12].

We will elaborate on these degenerative processes and their clinical implications. We will further discuss the diagnostic approaches and the efficacy of existing treatment options.

Tackling the terminology

The terms lumbar osteoarthritis, disk degeneration, degenerative disk disease, and spondylosis are used in the literature to describe anatomical changes to the vertebral bodies and intervertebral disk spaces that may be associated with clinical pain syndromes.

Spinal osteoarthritis (OA) is a degenerative process defined radiologically by joint space narrowing, osteophytosis, subchondral sclerosis, and cyst formation [13, 14]. Osteophytes included within this definition fall into one of the two primary clinical categories [14]. The first, spondylosis deformans describes bony outgrowths arising primarily along the anterior and lateral perimeters of the vertebral end-plate apophyses. These hypertrophic changes are believed to develop at sites of stress to the annular ligament and most commonly occur at thoracic T9–10 and lumbar L3 levels [15]. These osteophytes have minimal effect on intervertebral disk height [16] and are frequently asymptomatic, with only rare complications arising from their close anatomic relationship to organs anterior to the spine [15].

By contrast, intervertebral osteochondrosis describes the formation of more pathological end-plate osteophytes, associated with disk space narrowing, vacuum phenomenon, and vertebral body reactive changes [16]. If protruding within the spinal canal or intervertebral foramina, these bony growths may compress nerves with resulting radiculopathy or spinal stenosis. Moreover, these bony projections may limit joint mobility and invade other organs or tissues [14]. The term “osteoarthritis” suggests pathology limited to bone. Nevertheless, in this context, it has clear implications for the health of neighboring disks and nerve roots.

Comparatively, degenerative disk disease (DDD) refers to back pain symptoms attributable to intervertebral disk degeneration. Such pathologic changes include disk desiccation, fibrosis, and narrowing. The anulus may bulge, fissure, or undergo mucinous degeneration. Also included within the anatomic definition of DDD are defects and sclerosis of the end-plates, and osteophytes at the vertebral apophyses [16]. With these bony changes included in the radiographic description of both OA and DDD, there exists diagnostic overlap between the conditions. As a result, these terms are often used interchangeably in the medical literature to describe similar phenomena.

Spondylosis of the lumbar spine, the subject of this paper, is a term with many definitions. In the literature, it has been utilized in many different contexts, employed synonymously with arthrosis, spondylitis, hypertrophic arthritis, and osteoarthritis. In other instances, spondylosis is considered mechanistically, as the hypertrophic response of adjacent vertebral bone to disk degeneration (although osteophytes may infrequently form in the absence of diseased disks) [17]. Finally, spondylosis may be applied nonspecifically to any and all degenerative conditions affecting the disks, vertebral bodies, and/or associated joints of the lumbar spine [17, 18]. For purposes of this review, we will use this final, broad definition of spondylosis, recognizing the high incidence of coincident degenerative changes, and the dynamic interplay between adjacent disks, vertebra, and nerves that create the clinical pain syndromes within the axial spine and associated nerves.

Epidemiology

Degenerative spine changes are remarkably common in population studies. Symmons’ et al. [19] study of individuals aged 45–64 years identified 85.5% of participants to demonstrate osteophytes within the lumbar spine. O’Neill et al. [20] explored osteophytosis within a UK adult population over age 50 years, finding 84% of men and 74% of women to demonstrate at least one vertebral osteophyte, with increased incidence among individuals with more physical activity, self reported back pain, or higher BMI scores. Despite marked variability within the population, men appear to have more significant degenerative changes than women, both with regard to number and severity of osteophyte formation [20].

Radiographic evidence of degenerative disease of the lumbar spine among asymptomatic individuals is impressive. MRI imaging in asymptomatic patients over age 60 years reveals disk protrusions in 80% [21] and degenerative spinal stenosis in 20% [11]. A study comparing radiographic evidence of spine degeneration among categories of men who were without pain, with moderate pain, or with severe lower back pain found similar frequency of disk space narrowing and bone spurs among all three groups [22].

Furthermore, degenerative changes may appear in young individuals without decades of spine loading. Lawrence [23] found 10% of women aged 20–29 to demonstrate evidence of disk degeneration. Lumbar spondylosis, while affecting 80% of patients older than 40 years, nevertheless was found in 3% of individuals aged 20–29 years in one study [15]. The high incidence of degeneration among young and asymptomatic individuals highlights the challenge involved in establishing causality between imaging findings and pain symptoms in affected patients.

Pathogenesis

The high incidence of simultaneous degenerative changes to the intervertebral disk, vertebral body, and associated joints suggests a progressive and dynamic mechanism, with interdependent changes occurring secondary to disk space narrowing [17].

Intervertebral disks are believed to undergo what Kirkaldy Willis and Bernard [24] first coined a “degenerative cascade” (Fig. ) of three overlapping phases that may occur over the course of decades. Phase I (Dysfunction Phase) describes the initial effects of repetitive microtrauma with the development of circumferential painful tears of the outer, innervated anulus, and associated end-plate separation that may compromise disk nutritional supply and waste removal. Such tears may coalesce to become radial tears, more prone to protrusion, and impact the disk’s capacity to maintain water, resulting in desiccation and reduced disk height. Fissures may become ingrown by vascular tissue and nerve endings, increasing innervation and the disk’s capacity for pain signal transmission [25]. Phase II (Instability Phase) is characterized by the loss of mechanical integrity, with progressive disk changes of resorption, internal disruption, and additional annular tears, combined with further facet degeneration that may induce subluxation and instability. During Phase III (Stabilization Phase), continued disk space narrowing and fibrosis occurs along with the formation of osteophytes and transdiscal bridging [26].

The spectrum of pathological changes in facial joints and the disk and the interaction of these changes. The upper light horizontal bar represents dysfunction, the middle darker bar instability, and the lower dark bar stabilization

Schneck presents a further mechanical progression, building upon this degenerative cascade of the intervertebral disk, to explain other degenerative changes of the axial spine. He proposes several implications of disk space narrowing. Adjacent pedicles approximate with a narrowing of the superior–inferior dimension of the intervertebral canal. Laxity due to modest redundancy of the longitudinal ligaments enables bulging of the ligamentum flavum and potential for spine instability. Increased spine movement permits subluxation of the superior articular process (SAP), causing a narrowed anteroposterior dimension of the intervertebral and upper nerve root canals. Laxity may also translate into altered weight mechanisms and pressure relationships on vertebral bone and joint spaces believed to influence osteophyte formation and facet hypertrophy to both inferior and superior articular processes with risks for projection into the intervertebral canal and central canal, respectively. Oblique orientations of the articular processes may further cause retrospondylolisthesis, with resulting anterior encroachment of the spinal canal, nerve root canal, and intervertebral canal [17].

Biochemical research exploring osteophyte formation supports the above process. Osteophyte lipping is believed to form at periosteum [27] through the proliferation of peripheral articular cartilage which subsequently undergoes endochondral calcification and ossification [28]. Changing weight mechanics and pressure forces as well as alterations in oxygen tension and dynamic fluid pressure appear to be influential factors in osteophyte formation [14]. Mesenchymal stem cells of the synovium or periostium are likely precursors, with synovial macrophages and a milieu of growth factors and extracellular matrix molecules acting as probable mediators in this process [29].

Clinical presentation

Pain within the axial spine at the site of these degenerate changes is not surprising as nociceptive pain generators have been identified within facet joints, intervertebral disks, sacroiliac joints, nerve root dura, and myofascial structures within the axial spine [9].

These degenerative anatomical changes may culminate in a clinical presentation of spinal stenosis, or narrowing within the spinal canal [30] through progressive ingrowth of osteophytes, hypertrophy of the inferior articular process [31], disk herniation, bulging of the ligamentum flavum [17], or spondylolisthesis. The clinical result: a constellation of pain symptoms encompassed in the term neurogenic claudication (NC). NC may include (to varying extents) lower back pain, leg pain, as well as numbness and motor weakness to lower extremities that worsen with upright stance and walking, and improve with sitting and supine positioning [30].

Clinical presentations of radiculopathy may emanate from many sources, all of which can be explained by the degenerative process. Disk bulging may affect descending rootlets of the cauda equina, nerve roots exiting at the next lower intervertebral canal, or the spinal nerve within its ventral ramus, if protruding centrally, posterolaterally, or laterally, respectively [32]. Osteophyte lipping along the posterior aspect of vertebral bodies, along upper or lower margins, may similarly impinge upon the same neural structures as the bulging disk just described [17, 33]. Hypertrophic changes to the superior articular process may intrude upon nerve roots within the upper nerve root canal, dural sac, or prior to exiting from next lower intervertebral canal, depending on their projection [34]. These theoretical forms of impingement have been substantiated through cadaver studies. A 70% reduction or 30% residual diameter of neuroforminal space is cited as the critical amount of occlusion to induce neural compromise [15]. Moreover, compression of the posterior disk to less than 4 mm height, or foraminal height to less than 15 mm has also been determined as critical dimensions for foraminal stenosis and nerve impingement [35].

Etiology/risk factors

What factors mediate this degenerative progression? What leads a large portion of the population to manifest spondylosis, even early on in their lives? Given the substantial variability in the number and degree of spine changes observed in individuals and the wide range of clinical presentations, answers to these questions hold promise to broaden treatment options.

The influence of age

Large studies of osteoarthritis have long recognized the aging process to be the strongest risk factor for bony degeneration, particularly within the spine [36]. An extensive autopsy study in 1926 reported evidence of spondylitis deformans to increase in a linear fashion from 0% to 72% between the ages of 39 and 70 years [37]. A subsequent autopsy study by Miller et al. [38] similarly noted an increase in disk degeneration from 16% at age 20 to about 98% at age 70 years based on macroscopic disk degeneration grades of 600 specimens. Other studies corroborate this finding [20, 39].

The associations are nevertheless imperfect. Kramer [40] found increasing age to be significantly associated with osteophyte formation but not predictive of the degree of disk space narrowing observed in a retrospective review of radiographs of women. She observed significant variability, noting “although few younger women have high average scores, some older women have no radiographic sign of OA, while others are severely affected.” Multiple studies have also demonstrated the presence of significant lumbar degeneration to be evident even within the first two decades [38, 39]. Such variability within members of the same age category suggests the influence of other contributing factors.

The impact of activity and occupation

Disk generation has long been associated with certain activities. Retrospective studies cite Body Mass Index (BMI), incident back trauma, daily spine loading (twisting, lifting, bending, and sustained nonneutral postures), and whole body vibration (such as vehicular driving) to be factors which increase both the likelihood and severity of spondylosis [20, 41]. While these correlations exist, a study following progressive radiographic changes in lumber DDD did not find significant associations with the extent of physical activity, noting only age, back pain, and associated hip OA to be predictive of DDD and osteophyte changes [42].

The role of heredity

Genetic factors likely influence the formation of osteophytes and disk degeneration. Spector and MacGregor [43] proposed that 50% of the variability found in osteoarthritis can be attributed to heritable factors. Similarly, twin studies evaluating the progression of degenerative changes in lumbar MRI imaging suggest that approximately half (47–66%) of the variance could be explained by genetic and environmental factors, attributing only 2–10% of variance to physical loading and resistance training [44]. Another twin study revealed a high degree of similarity in signal intensity, disk height narrowing, disk bulging, and end-plate changes [45]. A search for these underlying genetic factors has identified polymorphisms in genes regulating inflammatory pathways and a Vitamin D Receptor allele to correspond to radiographic progression of lumbar disk degeneration [46].

A functional adaptation?

Is osteophyte formation inherently pathological? van der Kraan and van den Berg question if osteophyte formation may represent a remodeling process, functionally adapting to the instability or the changes in the demands of the spine [14]. Likewise, Humzah and Soames [47] emphasize the dynamic and reparative qualities of the intervertebral disk, responding to variations in mechanical loading and influencing vertebral kinematics to extend this argument. Osteophytes may form in the absence of other degenerative processes, and cartilaginous damage may exist without corresponding osteophytes [14]. Although there remains a strong association between the presence of osteophytes and other degenerative spine changes, isolated instances of one without the other occur, in the absence of overt symptoms.

A diagnostic approach

The initial evaluation for patients with low back pain begins with an accurate history and thorough physical exam with appropriate provocative testing. These first steps are complicated by the subjectivity of patient experiences of chronic spinal pain and the inherent difficulty isolating the anatomic region of interest during provocative testing without the influence of neighboring structures.

Radiographic studies, whether plain film, CT, CT myelogram, or MRI, may provide useful confirmatory evidence to support an exam finding and localize a degenerative lesion or area of nerve compression. However, imaging is an imperfect science, identifying the underlying cause of LBP in only 15% of patients in the absence of clear disk herniation or neurological deficit [25]. Furthermore, there remains a frequent disconnection between the symptom severity and the degree of anatomical or radiographic changes [18]. While correlations between the number and severity of osteophytes and back pain exist [20, 22], the prevalence of degenerative changes among asymptomatic patients underlies the difficulty assigning clinical relevance to observed radiographic changes in patients with LBP.

Nerve compression symptoms by clinical history may also be confirmed by electromyographic studies demonstrating normal distal motor and sensory nerve conduction studies with abnormal needle exam. Diagnostic injections can facilitate localization by isolating and anesthetizing irritated nerve roots (via epidural), or by blocking suspected pain generators within facet joints, sacroiliac joints, or the disk space itself (via discography) [48].

Intervention and treatment options

Given our limited ability to isolate causative sources of chronic lower back pain, there is a little consensus with regard to a definitive treatment approach. Substantial variation in management by conservative and invasive approaches exists between practitioners throughout the country [8]. We will briefly describe these treatment options for the management of chronic low back pain syndromes within each of the four primary categories: physical therapy (and associated modalities and behavioral techniques), pharmacotherapy, injection therapy, and surgical intervention.

Exercise-based and behavioral interventions

Exercise therapy

Exercise therapy (ET) remains one of the conservative mainstays of treatment for chronic lumbar spine pain, and may be tailored to include aerobic exercise, muscle strengthening, and stretching exercises [49]. Significant variation in regimen, intensity, and frequency of prescribed programs presents challenges to assessing efficacy among patients [50]. One meta-analysis of the current literature exploring the role of ET in patients with varying duration of symptoms found a graded exercise program implemented within the occupational setting demonstrated some effectiveness in subacute LBP. Among those suffering chronic pain symptoms, small, but statistically significant improvements were observed among patients, with regard to pain reduction and functional improvement [49]. The optimal approach to exercise therapy in chronic low back pain sufferers appears to be those regimens involving an individually-designed exercise program emphasizing stretching and muscle strengthening, administered in a supervised fashion, with high frequency and close adherence. Such results are complemented by other conservative approaches, including NSAIDS, manual therapies, and daily physical activity [50].

Transcutaneous electrical nerve stimulation (TENS)

A “TENS” unit is a therapeutic modality involving skin surface electrodes which deliver electrical stimulation to peripheral nerves in an effort to relieve pain noninvasively. Such devices are frequently available in outpatient exercise therapy settings, with up to a third of patients experiencing mild skin irritation following treatment [51]. While one small study identified an immediate reduction in pain symptoms 1 h following TENS application, there remains little evidence of long-term relief. Another larger study did not discover significant improvement with TENS compared with placebo with regard to pain, functional status, or range of motion [52, 53].

Back school

Back School was introduced first in Sweden with the purpose of minimizing lower back pain symptoms and their reoccurrence through review with patients of lumbar anatomy, concepts of posture, ergonomics, and appropriate back exercises [54]. Two meta-analyses concluded that there is moderate evidence for improvement in both pain and functional status for chronic low back pain within short and intermediate time courses, when measured against other modalities such as exercise, joint manipulation, myofascial therapy, and/or other educational therapy [52, 54].

Lumbar supports

Lumbar back supports may provide benefit to patients suffering chronic LBP secondary to degenerative processes through several potential, debated mechanisms. Supports are designed to limit spine motion, stabilize, correct deformity, and reduce mechanical forces. They may further have effects by massaging painful areas and applying beneficial heat; however, they may also function as a placebo. There is moderate available evidence evaluating efficacy of lumbar supports within a mixed population of acute, subacute, and chronic LBP sufferers to suggest that lumbar supports are not more effective than other treatment forms; data is conflicting with regard to patient improvement and functional ability to return to work [52].

Traction

Lumbar traction applies a longitudinal force to the axial spine through use of a harness attached to the iliac crest and lower rib cage to relieve chronic low back pain. The forces, which open intervertebral space and decrease spine lordosis, are adjusted both with regard to level and duration and may closely be measured in motorized and bed rest devices. Temporary spine realignments are theorized to improve symptoms related to degenerative spine disease by relieving mechanical stress, nerve compression, and adhesions of the facet and annulus, as well as through disruption of nociceptive pain signals [52]. Nonetheless, patients with chronic symptoms and radicular pain have not found traction to provide significant improvement in pain nor daily functioning [55–57]. Little is known with regard to the risks associated with the applied forces. Isolated case reports cite nerve impingement with heavy forces, and the potential for respiratory constraints or blood pressure changes due to the harness placement and positioning [52].

Spine manipulation

Spine manipulation is a manual therapy approach involving low-velocity, long lever manipulation of a joint beyond the accustomed, but not anatomical range of motion. The precise mechanism for improvement in low back pain sufferers remains unclear. Manipulative therapy may function through: “(1) release for the entrapped synovial folds, (2) relaxation of hypertonic muscle, (3) disruption of articular or periarticular adhesion, (4) unbuckling of motion segments that have undergone disproportionate displacement, (5) reduction of disk bulge, (6) repositioning of miniscule structures within the articular surface, (7) mechanical stimulation of nociceptive joint fibers, (8) change in neurophysiological function, and (9) reduction of muscle spasm” [58].

Available research regarding its efficacy in the context of chronic LBP finds spinal manipulation to be “more effective” compared to sham manipulation with regard to both short- and long-term relief of pain, as well as short-term functional improvement [52]. Compared with other conventional, conservative treatment approaches such as exercise therapy, back school, and NSAID prescription, spinal manipulation appears comparable in its effectiveness both in short- and long-term benefits [52, 59]. Research exploring the safety of such therapy among trained therapists found a very low risk of complications, with clinically worsened disk herniation or cauda equina syndrome occurring in fewer than 1/3.7 million [60].

Massage therapy

Massage therapy for chronic LBP appears to provide some beneficial relief. Weighed against other interventions, it proved less efficacious than TENS and manipulation, comparable with corsets and exercise regimens, and superior to acupuncture and other relaxation therapies, when followed over a 1-year course. Such preliminary results need confirmation, and evaluation for cost-effectiveness, but nevertheless suggest a potential role in certain, interested patients [61].

Multidisciplinary back therapy: the bio-psychosocial approach

Psychopathology is well recognized for its association with chronic spinal pain, and, when untreated, its ability to compromise management efforts [25]. For this reason, patients may find relief through learned cognitive strategies, termed “behavioral”, or “bio-psychosocial” therapy. Strategies involving reinforcement, modified expectations, imagery/relaxation techniques, and learned control of physiological responses aim to reduce a patient’s perception of disability and pain symptoms. To date, evidence is limited with regard to the efficacy of operant, cognitive, and respondent treatment approaches [52].

Pharmacotherapy

Treatment efforts to control pain and swelling, minimize disability, and improve the quality of life with lumbar spondylosis often require medication to complement nonpharmacologic interventions. Extensive research efforts have explored the efficacy of different oral medications in the management of low back pain secondary to degenerative processes. Nonetheless, there remains no clear consensus regarding the gold-standard approach to pharmacologic management [62].

NSAIDS

NSAIDS are widely regarded as an appropriate first step in management, providing analgesic and anti-inflammatory effects. There is adequate data demonstrating efficacy in pain reduction in the context of chronic low back pain [63–66], with use most commonly limited by gastrointestinal (GI) complaints. COX2 inhibitors offer modest relief in chronic LBP and improved function in the long-term setting. While they elicit fewer GI complications, their utilization has been curbed due to evidence for increased cardiovascular risk with prolonged use [52].

Opioid medications

Opioid medications may be considered as an alternative or augmentive therapy for patients suffering from gastrointestinal effects or poor pain control on NSAID management. The practice of prescribing narcotics for chronic low back pain sufferers is extremely variable within practitioners, with a range of 3–66% of chronic LBP patients taking some form of opioid in various literature studies [67]. These patients tend to report greater distress/suffering and higher functional disability scores [68, 69]. Two meta-analyses suggest a modest short-term benefit of opioid use for treatment of chronic LBP while issuing a warning regarding the limited quality of available studies and the high rate of tolerance and abuse associated with long-term narcotic use within this patient population [62, 67].

Antidepressants

The use of antidepressants for treatment of LBP symptoms has also been explored considerably given their proposed analgesic value at low doses, and dual role in treatment of commonly comorbid depression that accompanies LBP and may negatively impact both sleep and pain tolerance [52]. Two separate reviews of available literature found evidence for pain relief with antidepressants, but no significant impact on functioning [70, 71].

Muscle relaxants

Muscle relaxants, taking the form of either antispasmodic or antispasticity medications, may provide benefit in chronic low back pain attributed to degenerative conditions. There remains moderate to strong evidence through several trials comparing either a benzodiazepine, or non-benzodiazepine with placebo that muscle relaxants provide benefit with regard to short-term pain relief and overall functioning [52, 62, 72].

Injection therapy

Epidural steroid injections

Epidural steroid injections (ESI) have become a common interventional strategy in the management of chronic axial and radicular pain due to degeneration of the lumbar spine. These injections may be performed through interlaminar, transforaminal, or caudal approaches. Usually by way of needles guided under fluoroscopy, contrast, then local anesthetic and steroid are infused into the epidural space at the target vertebral level and bathe exiting nerve roots. Symptomatic relief is theorized to occur through complementary mechanisms. Local anesthetics provide quick diagnostic confirmation, and therapeutically may short circuit the “pain spasm cycle” and block pain signal transmission [73]. Corticosteroids are well recognized for their capacity to reduce inflammation through blockade of pro-inflammatory mediators.

Within the span of less than one decade (1998–2005), the number of ESI procedures performed has increased by 121% [73]. Despite this widespread utilization, controversy remains regarding the efficacy of these injections, fueled by the expense and the infrequent but potential risks related to needle placement and adverse medication reactions. Available published data cites wide ranges in reported success rates due to variation in study designs, distinct procedural techniques, small cohorts, and imperfect control groups [74]. For example, prior to the year 2000, few efficacy studies of lumbar ESI utilized fluoroscopy to establish appropriate needle position. Research suggests that without fluoroscopic guidance confirmation, needle position may be inappropriate in as frequently as 25% of cases, even with experienced providers [75]. Review articles and practicing clinicians alike must interpret such methodological differences between studies to assemble opinions on efficacy and utility of ESI for LBP treatment.

One such review exploring efficacy of interlaminar lumbar injections concluded strong evidence for short-term pain relief and limited benefit for long-term benefit [73] citing, among many, randomized controlled trials (RCT) by Arden and Carette of unilateral sciatic pain, finding statistically significant improvement in up to 75% of patients with steroid/anesthesia versus saline injections at 3 weeks, with benefit waning by 6 weeks and 3 months, respectively [76, 77].

The same review evaluating the transforaminal injection approach to unilateral sciatica found strong evidence for short-term, and moderate evidence for long-term symptom and functional improvement, based on the findings from several RCT. Vad et al. [78] studied 48 patients with herniated nucleus pulposus or radicular pain, treated with transforaminal ESI versus trigger point injections, citing an 84% improvement in functional scoring compared with 48% in the control group, extending for a follow-up period of 1 year. Lutz et al. [79] treated and followed a different cohort of 69 patients with the same underlying diagnoses, with transforaminal ESI for 80 weeks demonstrating 75% of patients with a successful long-term outcome, defined as >50% reduction in pain scores. In spinal stenosis, transforaminal ESI has achieved >50% pain reduction, improved walking, and improved standing tolerance in symptomatic patients extending through 1 year follow-up [80]. Furthermore, prospective trials by Yang and Riew found patients with severe lumbar radiculopathies and spinal stenosis treated with transforaminal injections experienced such sustained functional and symptomatic benefits so as to avoid intended surgical intervention [81–83].

Facet injections

Facet joints, also termed zygapophysial joints, are paired diarthrodial articulations between adjacent vertebrae. These joints are innervated from the medial branches of the dorsal rami and, through anatomical studies, possess free and encapsulated nerve endings, mechanoreceptors, and nociceptors. Inflammation to the joint creates pain signals which are implicated in 15–45% of patients with low back pain [25].

Diagnostic blocks of the joint inject anesthesia directly into the joint space or associated medial branch (MBB). Systematic reviews of both retrospective and prospective trials reveal single diagnostic facet blocks carry a false-positive rate of 22% to 47% [84] and medial branch blocks of 17–47% in the lumbar spine [85].

Subsequent therapeutic injections are similarly performed through either approach, with systematic reviews concluding moderate evidence available for short-term and long-term pain relief with facet blocks [86]. This evidence stems from studies such as Fuch’s RCT showing significant pain relief, functional improvement, and quality of life enhancement at 3 and 6 month intervals [87]. By contrast, Carette et al. [88] found no meaningful difference in perceived benefit between patients treated with steroid versus saline (control) injection at 3 and 6 month intervals. Available literature of MBB similarly show moderate evidence for short- and long-term relief [86] based on RCT of MBB under fluoroscopy, showing significant relief (by means of pain relief, physical health, psychological benefit, reduced narcotic intake, and employment status), with 1–3 injections in 100% patients at 3 months, 75–88% at 6 months, and 17–25% at 1 year [89].

SI joint injections

The sacroiliac joint space is a diarthrodial synovial joint with debated innervation patterns that involve both myelinated and unmyelinated axons. Injury or inflammation at the joint creates pain signals which are implicated in 10–27% of patients with low back pain [25] and may also refer to the buttocks, groin, thigh, and lower extremities.

There is moderate evidence to support the use of both diagnostic and therapeutic blocks of the SI joint [25]. Pereira treated 10 patients with MRI-guided bilateral SI joint injections of steroid, eight of whom reported “good to excellent” pain relief persisting through 13 months follow-up [90]. Maugers compared corticosteroid versus placebo injections under fluoroscopic guidance in SI joints of 10 symptomatic patients, reporting patient benefit only in the corticosteroid group. That benefit waned slowly over time, from 70% of patients at 1 month, to 62% at 3 months, and 58% at 6 months [91]. At this point, there is limited evidence to support radiofrequency neurotomy (ablation procedure) of the SI joint [92].

A recent meta-analysis provided the following guiding principles with regard to the frequency these procedures should be implemented in clinical practice. In cases of ESI, facet, and sacroiliac injections, diagnostic injections should be considered at intervals of no sooner than 1–2 weeks apart. Therapeutic injections may be performed at most every 2–3 months, provided the patient experiences greater than 50% relief within 6 weeks. Injections should be performed only as they are medically necessary given their associated risks and significant costs [25].

Intradiscal nonoperative therapies for discogenic pain

Discogenic pain has been identified as the source in 39% of patients with chronic low back pain. As described above, a cascade of effects induces the changes in the disk which generate pain. Discography seeks, when noninvasive imaging has failed, to identify damaged disks through injection of fluid into disk levels, in an attempt to reproduce patient symptoms. The technique’s utility remains controversial given significant potential for false positives. Provoked pain may be alternatively represent central hyperalgesia, reflect the patient’s chronic pain or psychological state, or result from technical difficulty due to the procedure itself [93].

If a diseased disk is identified, several treatment options exist. In addition to surgical correction, there are minimally invasive options. Both Intradiscal electrothermal therapy (IDET) and Radiofrequency posterior annuloplasty (RPA) involve electrode placement into the disk. Heat and electrical current coagulate the posterior anulus, and in doing so, strengthen collagen fibers, seal figures, denature inflammatory exudates, and coagulate nociceptors [25]. Current evidence provides moderate support for IDET in discogenic pain sufferers. Preliminary studies of RPA provide limited support for short term relief, with indeterminate long-term value. Both procedures have associated complications, including catheter malfunction, nerve root injuries, post-procedure disk herniation, and infection risk [25].

Surgical options

Surgical interventions are generally reserved for patients who have failed conservative options. Patients must be considered as appropriate “surgical candidates,” taking into consideration medical comorbidities as well as age, socioeconomic status, and projected activity level following a procedure [18]. Many surgical approaches have been developed to achieve one of the two primary goals: spinal fusion or spine decompression (or both).

Spinal fusion is considered in patients with malalignment or excessive motion of the spine, as seen with DDD and spondylolisthesis. Several surgical fusion approaches exist, all involving the addition of a bone graft to grow between vertebral elements to limit associated motion. Decompression surgery is indicated for patients with clear evidence of neural impingement, correcting the intrusion of bone or disk as might be seen in spinal or foraminal stenosis, disk herniation, osteophytosis, or degenerative spondylolisthesis. Despite dramatic increases in the number of procedures performed over the last several decades, there remains controversy as to the efficacy of these procedures in resolving chronic low back unresponsive to conservative management.

Controversy arises, in part, due to the inherent challenges of comparing the available research. Systematic reviews cite the heterogeneity of current trials which evaluate different surgical techniques with differing comparison groups and limited follow-up, frequently without patient-centered or pain outcomes included [18]. Some case series reveal promising results [94]. Nonetheless, a recent meta-analysis of 31 randomized controlled trials, concluded, “[there is] no clear evidence about the most effective technique of decompression for spinal stenosis or the extent of that decompression. There is limited evidence that adjunct fusion to supplement decompression for degenerative spondylolisthesis produces less progressive slip and better clinical outcomes than decompression alone.” Another review, noting no statistically significant improvement in patients undergoing fusion compared with nonsurgical interventions commented, “surgeons should recommend spinal fusion cautiously to patients with chronic low back pain. Further long-term follow-ups of the studies reviewed in this meta-analysis are required to provide more conclusive evidence in favor of either treatment” [95].

Conclusion

Lumbar spondylosis is a complicated diagnosis. We chose to define it broadly as degenerative conditions of the spine, but definitions vary widely within the literature. While it may not present a challenge to identify radiographically, its pervasiveness throughout all patient populations makes the exact diagnosis of symptomatic cases extremely difficult. Moreover, there is no current concrete, gold-standard treatment approach to the diverse range of patient presentations despite substantial research efforts to identify conservative and more invasive methods of managing symptoms and slowing progressive decline. Given the morbidity of low back pain within the population and its social and economic implications, this area will continue to be a critical research focus. Important clues are in place, from genetic studies, risk factor analysis, and explorative treatment approaches. These efforts, and future endeavors will no doubt fine-tune and present means to tackle not only symptoms, but confront progression, and ultimately prevention of disease in years to come.

Open Access

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

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Lumbar Spondylosis (Degeneration) | McGovern Medical School

What is Lumbar Spondylosis?

Lumbar spondylosis is an age-related degeneration of the vertebrae and disks of the lower back. These changes are often called degenerative disk disease and osteoarthritis. The common condition is marked by the breakdown of one or more of the disks that separate the bones of the spine. The disks provide cushioning between the vertebrae and absorb pressure put on the spine. Although most people experience some degeneration of the spine as they age, not everyone experiences back pain.

What You Can Expect at UTHealth Neurosciences

The UTHealth Neurosciences Spine Center brings together a multidisciplinary team of board-certified, fellowship-trained neurosurgeons, neurologists, researchers, and pain management specialists who work together to help provide relief for even the most complex problems. Your team will share insights, leading to better treatment decisions and outcomes.

We first investigate nonsurgical treatment options, including medical management, pain management, physical therapy, rehabilitation, and watchful waiting. When surgery is needed, our neurosurgeons routinely employ innovative minimally invasive techniques. Throughout the treatment process, we will work closely with the doctor who referred you to ensure a smooth transition back to your regular care. While you are with us, you will receive expert care, excellent communication, and genuine compassion.

Causes of Lumbar Spondylolisthesis

Spondylosis most often affects disks in the lumbar region. When disks herniate, the protruding disk can press against any of the spinal nerves that run from the spinal cord to the rest of the body. Herniated disks can cause nerve pain known as sciatica, which travels along the sciatic nerve running from the lower back down the length of each leg.

As a disk degenerates, bone spurs may form at the edges of the vertebrae. Bone spurs may also compress the spinal nerves, leading to weakness or numbness in the arms or legs. If bone spurs compress the spinal cord, you may develop problems with walking and bladder and bowel control. Over time, a degenerating disc may break down completely, leaving no space between two vertebrae, which can result in impaired movement, pain, and nerve damage. The pressure can cause pain, weakness, and numbness in the back and the legs.

Early Signs of Lumbar Spondylosis and Diagnosis

Symptoms of spondylosis may vary from none to mild to severe. The most common symptom is low back pain. Our spine specialists diagnose spondylosis based on your history of symptoms, a physical exam, and imaging tests that may include X-rays, CT scan, or MRI.

Treatments for Lumbar Spondylolisthesis

Our spine specialists diagnose spondylosis based on your history of symptoms, a physical exam, and imaging tests that may include X-rays, CT scan, or MRI. Most people with lumbar spondylosis can be treated with nonsteroidal anti-inflammatory drugs or pain relievers, heat or ice applications, and physical therapy.

People who still experience pain or are significantly restricted in their daily movements after trying more conservative treatments may consider surgery to remove the deteriorated disk and fuse the two vertebrae. Surgery may be recommended for patients who have severe or high-grade slippage of the vertebra, such as when more than 50% of the fractured vertebra slips forward on the vertebra below it. The procedure most often recommended for people with lumbar spondylolisthesis is spinal fusion.

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Anatomy of the neck and spine

The spine is divided into the following regions:

  • The cervical region (vertebrae C1-C7) encompasses the first seven vertebrae under the skull. Their main function is to support the weight of the head, which averages 10 pounds. The cervical vertebrae are more mobile than other areas, with the atlas and axis vertebra facilitating a wide range of motion in the neck. Openings in these vertebrae allow arteries to carry blood to the brain and permit the spinal cord to pass through. They are the thinnest and most delicate vertebrae.
  • The thoracic region (vertebrae T1-T12) is composed of 12 small bones in the upper chest. Thoracic vertebrae are the only ones that support the ribs. Muscle tension from poor posture, arthritis, and osteoporosis are common sources of pain in this region.
  • The lumbar region (vertebrae L1-L5) features vertebrae that are much larger to absorb the stress of lifting and carrying heavy objects. Injuries to the lumbar region can result in some loss of function in the hips, legs, and bladder control.
  • The sacral region (vertebrae S1-S5) includes a large bone at the bottom of the spine. The sacrum is triangular-shaped and consists of five fused bones that protect the pelvic organs.

Spine Disease and Back Pain


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At UTHealth Neurosciences, we offer patients access to specialized neurological care at clinics across the greater Houston area. To ask us a question, schedule an appointment, or learn more about us, please call (713) 486-8100, or click below to send us a message. In the event of an emergency, call 911 or go to the nearest Emergency Room.

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90,000 Spondylosis. Spinal spondylosis treatment