What is spondylosis (degenerative spinal disease)?

From the Guidelines

For patients with spondylosis, the initial approach should focus on conservative therapy, including pharmacologic and nonpharmacologic treatments, with imaging reserved for those who have failed 6 weeks of conservative therapy or have red flags 1. When managing spondylosis, it's essential to consider the patient's overall condition and symptoms.

• Initial treatment typically involves over-the-counter medications like acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) or NSAIDs such as ibuprofen (400-800mg three times daily with food) or naproxen (220-500mg twice daily with food) for pain relief.
• Physical therapy focusing on strengthening core and back muscles is crucial for long-term management, ideally 2-3 sessions weekly for 4-6 weeks, as it helps improve function and reduce pain 1.
• Daily home exercises should include gentle stretching and strengthening movements to maintain flexibility and strength.
• Heat therapy (15-20 minutes several times daily) can relieve muscle tension, while maintaining proper posture and ergonomics helps prevent symptom worsening.
• For severe cases, prescription muscle relaxants like cyclobenzaprine (5-10mg at bedtime) or pain medications may be necessary, and some patients benefit from epidural steroid injections 1.
• Imaging, such as MRI, CT myelography, or CT lumbar spine without IV contrast, may be useful in assessing the patency of the spinal canal/thecal sac and of the subarticular recesses and neural foramen, especially in patients who have failed conservative therapy or have red flags 1.
• Surgery is typically reserved for cases with significant nerve compression or spinal instability, and the decision to operate should be made on a case-by-case basis, considering the patient's overall condition and symptoms 1.

From the Research

Definition and Classification of Spondylosis

• Spondylolisthesis is defined as the forward displacement of one vertebrae upon another, usually at the L5-S1 level, but also occurring at L4-5 2
• The degree of vertebral body anterior displacement is rated from 1-4 depending upon the severity of the slip 2
• Five major categories have been proposed for the classification of spondylolisthesis, with isthmic and degenerative being the most common types 2

Causes and Risk Factors

• Degenerative lumbar spondylolisthesis is a common cause of low back pain, affecting about 11.5% of the United States population 3
• Spondylolisthesis can occur due to an anatomical change in the structures that normally resist the anterior displacement of one vertebrae upon the other, such as the bony block of the posterior facets, the intact neural arch and pedicle, and the intervertebral disc 2

Diagnosis and Treatment

• Plain x-rays of the lumbar spine can reveal structural changes such as disc space narrowing, scoliosis, lumbarization or sacralization, spondylolysis, and spondylolisthesis 2
• Standing, lateral lumbosacral radiographs remain the gold standard for diagnosis 4
• Conservative management strategies include non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy 3
• Surgical management is appropriate for well-selected patients who fail conservative management strategies 3
• Conservative treatment for spondylolisthesis includes instruction in exercise and body mechanics, the use of back supports, and job modifications 2

Prognosis and Outcomes

• The majority of patients will improve with conservative treatments 4
• Surgical options are warranted after 6 months of failed conservative treatments for patients with radiculopathy, neurogenic claudication, progressive neurological deficits, high-grade slips, or bladder and bowel symptoms 4
• The effectiveness of treatment largely hinges on the patient's ability to improve their dysfunction 5