Author(s): Ameet Nagpal, MD, MS, MEd, Adedeji Olusanya, DO, MPH, Austin Bevil, DO
Originally published: September 20, 2013 Last updated: May 31, 2023
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Disease/ Disorder

Definition

Lumbar spondylosis is a radiographic diagnosis that refers to degenerative changes of the discs, vertebral bodies and paired zygapophysial joints (z-joints) of the lumbar spine.  Degenerative lumbar spondylosis is a term used to describe a “mixed group of spinal bone diseases related to degeneration of the lumbar motion segment and associated pathologies.”30 The term spondylosis is not used as a clinical diagnosis but rather as a term to illustrate spinal pathology. Spondylosis may be associated with low back pain (LBP) and is associated with numerous spinal pathologies including spinal stenosis (narrowing of the spinal canal), vertebral instability, degenerative spondylolisthesis, osteoarthritis and malalignment.29

Etiology

Though the etiology of lumbar spondylosis remains unclear, many have characterized it as osteoarthritis of the spine.  It is thought to result from cumulative stresses combined with repetitive microtrauma, leading to an imbalance between the synthesis and degeneration of cartilage. When combined with increased stresses placed on the vertebrae and ligaments, osteophytes and calcifications occur, respectively.1,3

Bone spurs, also known as osteophytes, most commonly occur along the anterolateral aspect of the lumbar vertebral body. Posterior vertebral osteophytes are rare but can cause impingement on the nerve roots or spinal cord. Lumbar spondylosis can also occur due to new bone formation in areas where the annular ligament is stressed over time.29

Epidemiology including risk factors and primary prevention

The prevalence of radiographic spondylosis increases with age.4,5 It is present only in a small percentage of the population in the first few decades of life but is relatively common by the age of 65. In those with LBP, the prevalence ranges from 7% to 75%, depending on the diagnostic criteria.6 Despite its frequency in patients with LBP, there is no validated correlation between the radiographic findings of lumbar spondylosis and presence of LBP. In the United States, approximately 80% of individuals older than 40 years old were found to have lumbar spondylosis, contrasted to3% of individuals aged 20-29 years.5 Recent studies have shown a positive correlation with the CC genotype of the transforming factor B1 gene and postmenopausal women.31

Risk factors

Age is the greatest risk factor for lumbar spondylosis, but other risk factors including disc desiccation, previous injury, joint overload from malalignment and/or abnormal z-joint orientation, as well as genetic predisposition have been identified.2 Studies evaluating the role of body mass index, level of activity and gender on the incidence and severity of lumbar spondylosis do not show a clear correlation.5,7

Patho-anatomy/physiology

Some investigators believe that lumbar spondylosis is due to a “degenerative cascade” that is initiated by intervertebral disc desiccation.8 The degenerative changes which characterize lumbar spondylosis are thought to be due to cumulative stresses on the annular ligaments which then form (i.e., marginal osteophytes).29 Failure of annulus and nucleus collagen cross-linking and the discs’ inability to retain water results in stiffening of the cartilaginous and capsular structures, further restricting z-joint mobility causing earlier and more advanced degenerative changes. This is particularly true at the L4/L5 and L5/S1 levels likely because of their proximity to the fused sacral segments.1,3

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Although variable, most patients experience a benign clinical course. Studies have shown the following:

  • radiologic spondylosis directly increases with age, irrespective of pain.9
  • spondylosis was shown to be equally present in those with and without LBP.2
  • no correlation between the magnitude of z-joint arthropathy and the severity of pain.6

Thus, progression is variable and unpredictable, and therefore difficult to study, but seems to be most closely linked to aging.

Specific secondary or associated conditions and complications

Z-joint hypertrophy in combination with ligamentous redundancy from disc desiccation may contribute to central canal, lateral recess and neuroforaminal stenosis. The increase in translational forces from disc desiccation, combined with the z-joints’ decreased ability to resist these factors, may also result in spondylolisthesis. Clinically, these changes can cause lumbosacral radiculopathy and neurogenic claudication.  Disuse atrophy of the erector spinae and multifidi muscles secondary to pain-limited spine motion can also occur.

Essentials of Assessment

History

As mentioned previously, lumbar spondylosis refers to certain radiographic findings that do not rely on clinical symptoms for diagnosis.  However, in some patients with acute, subacute or chronic LBP, the radiological changes which make up lumbar spondylosis can be potential pain generators.  Patients with lumbar spondylosis often complain of axial lumbosacral back pain with potential nociceptive input from the sacroiliac joints, overlying myofascial structures, intervertebral discs, nerve roots, and facet joints.30 Pain may refer unilaterally, bilaterally, or to the contralateral buttock, hip, groin and thigh regions; although, typically, it does not extend past the knee.6,10 The pain tends to worsen with extension, rotation and standing and is better with lying down and lumbar flexion.10 By definition, the term lumbar spondylosis is not associated with a neurologic deficit. However, spinal stenosis, spondylolisthesis, lumbar disc herniation and radiculopathy are known to be associated with neurological deficits. This is why it is imperative for the clinician to ask about weakness, gait and balance and bowel/bladder function when assessing patients with lumbar spondylosis.

There are several validated outcome measures for grading functional limitations including the McGill Low Back Pain Scale, Oswestry Disability Index and the Medical Outcomes Study 36-Item Short-Form Health Survey.11 These should typically be administered at every office visit for following the patient’s progression.

Physical examination

A systematic review revealed that most physical exam maneuvers have limited or no diagnostic validity for spondylosis.6 Paraspinal tenderness is the only physical exam maneuver that seems to correlate with z-joint arthropathy, but not with high diagnostic confidence. Although classically felt to diagnose z-joint pain, joint loading with pain on extension and ipsilateral rotation has not been shown to consistently correlate with spondylosis.12,13 The pain distribution of lumbar spondylosis may overlap with other clinical entities. A comprehensive physical exam that includes evaluation for radiculopathy, including dural tension signs, as well as hip and sacroiliac joint provocative maneuvers can help guide clinical decision making. Neurologic deficits seen with lumbar nerve root compression should be evaluated through muscle, sensation, reflexes, gait, and balance testing. Discogenic pain is exacerbated when the patient is asked to repeatedly bend forward or when the patient is sitting up and one leg is placed in a flexed position by the examiner.

Laboratory studies

Although laboratory studies are not routinely indicated, C-reactive protein, sedimentation rate, and a complete blood count, may be ordered if there is clinical suspicion for conditions such as malignancy, infection or rheumatologic disease.

Imaging

Lumbar spondylosis is visible on multiple imaging modalities, including plain radiographs, magnetic resonance imaging (MRI) and computed tomography (CT) studies. However, as spondylosis on imaging does not constitute a cause for LBP, imaging is typically ordered to rule out other disorders.13,14,15

Plain radiographs are not sensitive for detecting early z-joint arthropathy or spondylosis but are often obtained. Lateral views are important for sagittal alignment and to assess for spondylolisthesis. If present, patients should undergo flexion and extension radiographs to rule out segmental instability which may necessitate earlier surgical consultation.

MRI is generally not needed but is useful for evaluating the soft tissues and neural elements within the spine, especially to rule out neuroforaminal stenosis in patients with concomitant leg pain. The presence of small amounts of fluid or synovial cysts within the z-joints may be physiologic or may represent instability and/or infection within the lumbar spine, and therefore would warrant further work up and/or treatment. However, this is beyond the scope of this article.

CT is typically utilized when an MRI is unobtainable, if fracture is suspected or for the assessment of pseudoarthrosis.  It can also be helpful in identifying synovial cyst borders with implications for surgical vs percutaneous treatment.34

Supplemental assessment tools

Diagnostic Injections

Given the low correlation of radiographic spondylosis with axial low back pain, the only means for an accurate diagnosis of symptomatic lumbar spondylosis secondary to facet arthropathy are controlled diagnostic blocks of the medial branch nerves that innervate the z-joints.16 This assumes that the patient’s pain generator(s) are the z-joints and not the intervertebral discs. Each z-joint has dual innervation from the medial branch of the dorsal ramus of the spinal nerve at the corresponding level and the level above. To treat the pain associated with a specific z-joint, both nerves must be targeted.

Several key principles exist for diagnostic medial branch blocks:

  • Because of the inaccuracy of landmark guidance, all blocks should be performed utilizing image guidance. Both fluoroscopic and ultrasound guidance have been described in literature.34
  • False positive blocks occur at a high rate of 17% to 41% in the lumbar spine, thus necessitating a second control block for confirmation of the diagnosis. Ideally, the two injections should be performed with anesthetics of differing duration. Concordant pain relief (>1h with lidocaine and >3h with bupivacaine hydrochloride), greatly enhances the sensitivity and specificity of the injections.13
  • The greater the percentage of pain relief a patient obtains with a given injection, the more likely that injection correctly targeted the pain generator. An 80% pain relief threshold with comparative medial branch blocks results in more successful outcomes with radiofrequency ablation, a denervation procedure which uses radiofrequency to thermally ablate the medial branch nerves.13,16 For more details, please see the Lumbar Zygapophyseal Joint Arthropathy section of PM&R KnowledgeNOW.

Rehabilitation Management and Treatments

Available or current treatment guidelines

There is no best treatment   for the pathological changes of lumbar spondylosis; therefore, prescribed treatments should focus on decreasing patients’ pain and increasing function. Conservative treatment measures include weight loss, physical therapy, NSAIDs, acetaminophen, and topical pain medications.18

Interventional pain specialists may consider performing a medial branch radiofrequency ablation for certain patients. Ablated nerves may regenerate and result in recurrence of pain.19,20,21,22,23

Physical therapy should focus on increasing flexibility of the spine with strengthening of core muscles, including the lumbar paraspinals and abdominal musculature. There is minimal evidence to support a single proven exercise program for the treatment of lumbar spondylosis.24

Surgical intervention is not recommended for axial back pain secondary to lumbar spondylosis without segmental instability or neurologic compromise.35

Coordination of care

As with all spine conditions, treatment should ideally be guided by the coordinated approach of a multidisciplinary team, including, but not limited to, a physician and physical therapist. Inclusion of a pain psychologist may be beneficial for patients having difficulty coping with chronic pain secondary to lumbar spondylosis.

Patient & family education

Patients should be educated that lumbar spondylosis related symptoms typically respond well to treatment; however, they should be made aware of warning signs consistent with neurologic involvement.  Patients should seek immediate medical attention if they develop myelopathy and/or changes in bowel and bladder.  Patients should be informed that spondylosis on imaging does not necessarily correspond with pain and that a diagnostic block may be used to rule in/out lumbar spondylosis= related LBP.

Providers should work with their patients to develop a tailored treatment plan that may include oral pain medications, interventional procedures and increased physical activity.

Practical Application

Physicians should have a low threshold for ruling out other serious conditions that also commonly present as LBP. The incidence of lumbar facet pain increases with age resulting in a higher positive predictive value of a diagnostic medial branch block and improvement of pain after ablation.  After successful treatment of pain with an RFA, patients should be encouraged to engage in daily therapeutic spine exercises to maximize function and hopefully prevent relapse of pain.

Emerging/unique interventions

Nerve growth factor (NGF) has been linked to chronic low back pain and patients treated with anti-NGF have shown a slight improvement in pain and functional outcomes vs placebo.25 Lieite et al specifically used Tanezumab, an anti-NGF agent, that showed low evidence of small to moderate pain relief of low back pain & small functional improvement when used in patients with chronic low back pain.25

New techniques and methods are being developed to enhance RFA lesion size while preserving safety. Limited literature exists on their efficacy, but two such technologies are water-cooled RFA and multi-tined needles.26, 27, 28 These will hopefully enhance success rates and minimize technical failures. Studies are also currently underway regarding the use of orthobiologics, which are organic and synthetic materials are used to help cure musculoskeletal diseases.37

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Physicians should have a low threshold for ruling out other serious conditions that commonly present as LBP in this age group. For patients that have failed non-interventional treatment options, injections may be required to achieve pain relief. Interventional management should be used in combination with daily therapeutic spine exercises to maximize function and hopefully prevent relapse of pain.

Cutting Edge/ Emerging and Unique Concepts and Practice

New techniques and methods, such as the use of water-cooled RFA and Nimbus needles, aim to enhance RFA lesion size while preserving safety. RFA generates a lesion to a targeted nerve through heat created by passing an electric current through an RFA needle. Water-cooled RFA allows more energy to be delivered to the surrounding tissues without damage by internally cooling the needle with water32. The Nimbus needle, developed by Dr. Robert Wright in 2009, is a tined RF cannulae that produces a cloud-shaped lesion33. The advantage of such a lesion allows for a perpendicular approach to targeting the lumbar medial branches, as opposed to the more technically challenging parallel approach33. These advances will hopefully enhance success rates and minimize technical failures. For more details, please see the Facet Mediated Pain section of PM&R KnowledgeNOW. The use of biologics to alter disease progression and improve pain are being investigated.36

Gaps in the Evidence-Based Knowledge

Current literature shows the limitations in the diagnostic value of patient history, physical examination and imaging findings for diagnosing LBP secondary to lumbar spondylosis.  Subsequent research should focus upon identifying patient-related characteristics of history taking, physical examination, laboratory findings, and/or imaging that may be used to better diagnose LBP related to lumbar spondylosis, especially in patients with diagnostic block-proven and symptomatic lumbar spondylosis.

References

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Original Version of the Topic

D.J. Kennedy, MD, Renata Jarosz, MD, Ryan Demirjian, MD. Lumbar spondylosis without myelopathy. 9/20/2013.

Previous Revision(s) of the Topic

Ameet Nagpal, MD and Alan Swearingen, MD. Lumbar spondylosis without myelopathy. 2/14/2018.

Author Disclosure

Ameet Nagpal, MD, MS, MEd
Nothing to Disclose

Adedeji Olusanya, DO, MPH
Nothing to Disclose

Austin Bevil, DO
Nothing to Disclose