What is degenerative spondylosis of the lumbar spine?

Degenerative Spondylosis of the Lumbar Spine

Degenerative spondylosis of the lumbar spine is a chronic, non-inflammatory condition characterized by progressive deterioration of the intervertebral discs, facet joints, and associated structures in the lower back, resulting in pain, stiffness, and potential neurological symptoms.

Definition and Pathophysiology

Degenerative spondylosis refers to age-related changes in the spine that include:

• Intervertebral disc degeneration (loss of disc height, hydration, and elasticity)
• Facet joint arthritis (cartilage breakdown and osteophyte formation)
• Ligamentum flavum hypertrophy
• Osteophyte formation at vertebral endplates
• Potential narrowing of the spinal canal and neural foramina

These degenerative changes are part of the normal aging process but can become symptomatic when they result in nerve compression or mechanical instability 1.

Clinical Presentation

Patients with lumbar spondylosis may present with:

• Low back pain (typically worse with activity and improved with rest)
• Morning stiffness
• Radicular symptoms (leg pain, numbness, tingling) if nerve roots are compressed
• Neurogenic claudication (leg pain with walking) in cases of spinal stenosis
• Decreased range of motion
• In severe cases, neurological deficits including motor weakness

It's important to note that degenerative changes on imaging often correlate poorly with symptoms, as many individuals with significant radiographic changes remain asymptomatic 1.

Diagnosis

Diagnosis of lumbar spondylosis involves:

Clinical Evaluation

• Detailed history focusing on pain characteristics, neurological symptoms, and functional limitations
• Physical examination including neurological assessment

Imaging

MRI is the preferred imaging modality for evaluating lumbar spondylosis when symptoms persist beyond 6 weeks of conservative management 1. MRI provides excellent soft-tissue contrast and can accurately depict:

• Disc degeneration
• Neural compression
• Facet arthropathy
• Ligamentum flavum hypertrophy
• Spinal stenosis

CT without contrast may be useful for:

• Preoperative planning
• Evaluating osseous structures
• Patients who cannot undergo MRI
• Assessment of facets and neural foramina 1

Plain radiographs can provide complementary information about:

• Alignment
• Stability (with flexion/extension views)
• Gross degenerative changes
• Spondylolisthesis

Classification

Lumbar spondylosis can be categorized based on:

1. Anatomical involvement:

   • Disc degeneration
   • Facet arthropathy
   • Combined disc and facet disease

2. Clinical presentation:

   • Nonspecific low back pain
   • Radiculopathy (nerve root compression)
   • Neurogenic claudication (spinal stenosis)

3. Severity of symptoms:

   • Mild (minimal functional limitation)
   • Moderate (significant functional limitation but able to perform daily activities)
   • Severe (unable to perform daily activities)

Management

Treatment of lumbar spondylosis should follow a stepwise approach:

Conservative Management (First-line)

• Activity modification
• Physical therapy focusing on core strengthening and flexibility
• NSAIDs and COX-2 inhibitors for pain control 2
• Prostaglandin therapy
• Epidural or transforaminal injections for radicular symptoms 2

Interventional Procedures

For patients who fail conservative management:

• Facet joint injections
• Medial branch blocks
• Epidural steroid injections
• Radiofrequency ablation

Surgical Management

Surgery is reserved for patients with:

• Severe, disabling symptoms unresponsive to conservative treatment
• Progressive neurological deficits
• Cauda equina syndrome

Surgical options include:

• Decompression (laminectomy, foraminotomy)
• Fusion procedures (PLIF, TLIF, ALIF, LLIF) 3
• Disc replacement in selected cases

Complications and Special Considerations

Potential Complications

• Progression to spinal stenosis
• Development of spondylolisthesis
• Cauda equina syndrome (rare but requires urgent intervention)

Important Distinctions

It's crucial to differentiate lumbar spondylosis from other conditions that may present similarly:

• Inflammatory spondyloarthropathies
• Infection (spondylodiscitis)
• Malignancy
• Vertebral compression fractures

Red Flags Requiring Urgent Evaluation

• Severe or progressive neurological deficits
• Bowel or bladder dysfunction (cauda equina syndrome)
• Fever or other signs of infection
• History of cancer
• Unexplained weight loss
• Severe trauma

Prognosis

The natural history of lumbar spondylosis is variable:

• Many patients improve with conservative management
• Some experience chronic, fluctuating symptoms
• Progressive deterioration can occur in a subset of patients

The presence of significant spinal stenosis, instability, or neurological deficits may predict a poorer outcome with conservative management alone.

Prevention

Preventive measures include:

• Regular physical activity and core strengthening
• Proper body mechanics and ergonomics
• Weight management
• Smoking cessation
• Avoiding prolonged sitting or standing

Lumbar spondylosis is a common degenerative condition that typically responds to conservative management, with surgical intervention reserved for cases that fail non-operative treatment or present with significant neurological compromise.