What are the management options for degenerative spondylosis?

Management Options for Degenerative Spondylosis

Lumbar fusion is recommended for patients with chronic low-back pain due to 1-2 level degenerative disc disease that is refractory to conservative treatment. 1

Initial Conservative Management

Conservative management should be the first-line approach for degenerative spondylosis:

1. Physical Therapy

   • Spinal mobility exercises
   • Core strengthening
   • Posture correction
   • Flexion strengthening exercises 2

2. Medication Management

   • NSAIDs at maximum tolerated doses (with consideration of cardiovascular, gastrointestinal, and renal risks)
   • Muscle relaxants for acute pain episodes
   • Analgesics for pain control 2

3. Adjunctive Therapies

   • Epidural steroid injections for radicular symptoms
   • Transforaminal injections for nerve root compression
   • Paravertebral blocks for recalcitrant cases 3
   • Bracing/corsets in selected cases (though not routinely required) 3

4. Activity Modification

   • Correction of poor posture
   • Elimination of stressful occupational requirements
   • Avoidance of certain spine movements 3

Comprehensive Rehabilitation Program

For patients with chronic low-back pain due to degenerative spondylosis, a comprehensive rehabilitation program incorporating cognitive therapy is recommended as an alternative to surgery 1. This should include:

• Intensive physical therapy
• Pain management strategies
• Cognitive behavioral approaches to pain
• Self-management education

Surgical Management

Surgical intervention should be considered when conservative measures fail to provide adequate symptom relief:

1. Indications for Surgery

   • Chronic low-back pain refractory to 6+ weeks of conservative treatment
   • Pain due to 1-2 level degenerative disc disease without stenosis or spondylolisthesis
   • Significant functional limitations 1

2. Surgical Options

   • Lumbar Fusion: Recommended for carefully selected patients with disabling low-back pain due to 1-2 level degenerative disease without stenosis or spondylolisthesis (Grade B recommendation) 1

   • Decompression with Fusion: For patients with degenerative spondylolisthesis with stenosis, decompression with fusion shows better outcomes than decompression alone 1

   • Minimally Invasive Surgery: Promising approach for degenerative spondylolisthesis, promoting early recovery and enhanced quality of life by reducing muscular damage and perioperative pain 4

Special Considerations

1. Degenerative Spondylolisthesis

   • Prognosis is generally favorable with conservative management
   • Patients with neurological symptoms (intermittent claudication, vesicorectal disorder) may experience neurological deterioration without surgery 2
   • The preponderance of evidence favors fusion following decompression in patients with stenosis and spondylolisthesis, particularly in those requiring extensive decompression 1

2. Cervical Spondylosis

   • Usually produces intermittent neck pain that responds to activity modification, neck immobilization, isometric exercises, and medication
   • Surgical intervention should be considered for persistent pain or progressive neurologic deficit 5
   • For cervical spondylotic myelopathy, neck immobilization can result in improvement in 30-50% of patients with minor neurologic findings 5

Monitoring and Follow-up

• Regular assessment of pain levels and functional status
• Radiographic monitoring generally not needed more frequently than once every 2 years 1
• Monitor for complications such as spinal fractures or advanced hip arthritis

Pitfalls and Caveats

1. Surgical Outcomes: While fusion procedures show good initial results, functional outcomes may decline with long-term follow-up, raising questions about how much surgical treatment affects the natural course of the disease 5

2. Pedicle Screw Fixation: Routine use of pedicle screw instrumentation does not necessarily improve functional outcomes in all patients; however, it may benefit those with kyphosis or excessive motion at the site of degenerative spondylolisthesis 1

3. Patient Selection: Careful patient selection is critical for surgical success, as not all patients with degenerative changes on imaging are appropriate surgical candidates

4. Conservative Treatment Duration: A minimum of 6 weeks of conservative management should be attempted before considering surgical interventions