What is the significance of spondylosis in adults, particularly those with a history of back pain or stiffness?

What is Spondylosis and Is It Significant?

Spondylosis is a degenerative condition of the spine caused by age-related wear and tear of the discs and facet joints, and in most cases it is NOT clinically significant—it represents normal aging changes that are commonly found in asymptomatic individuals and should not be used as sole justification for treatment. 1, 2

Understanding Spondylosis

Spondylosis is a chronic, noninflammatory degenerative disease affecting the spine, most commonly in the lumbar and cervical regions. 3 The condition involves:

• Degenerative disc disease with loss of disc height and hydration 2, 3
• Facet joint arthritis with hypertrophic changes 3
• Osteophyte formation (bone spurs) along vertebral margins 4
• Ligamentous thickening and calcification 5

The etiology is multifactorial, involving genetic predisposition, mechanical stress, aging, and repetitive microtrauma. 3

Clinical Significance: When to Be Concerned

Most Cases Are NOT Significant

Imaging findings of spondylosis are commonly seen in asymptomatic patients and cannot be used as sole justification for treatment. 1 The key principle is that radiographic findings must correlate with clinical symptoms to be considered significant.

Spondylosis Becomes Significant When:

1. It causes symptomatic spinal stenosis with neurogenic claudication (leg pain with walking that improves with rest or forward flexion) 2, 6

2. It progresses to degenerative spondylolisthesis (vertebral slippage) causing:

• Radiculopathy (nerve root compression with radiating leg pain) 2, 6
• Neurological deficits such as weakness or sensory changes 2
• Cauda equina syndrome (rare but emergent—requires immediate evaluation) 7

3. Cervical spondylosis causes myelopathy with:

• Progressive weakness in arms or legs 5
• Gait instability and difficulty with fine motor tasks 5
• Bowel or bladder dysfunction 5

4. It causes refractory pain despite comprehensive conservative management (minimum 3-6 months) 1, 2

Distinguishing Spondylosis from Inflammatory Conditions

A critical pitfall is confusing degenerative spondylosis with inflammatory spondyloarthritis (ankylosing spondylitis). 4, 8 Key differences:

Degenerative Spondylosis:

• Mechanical pain pattern: worse with activity, better with rest 8
• Onset typically after age 40-50 3, 5
• Morning stiffness <30 minutes 8
• Osteophytes and disc degeneration on imaging 4

Inflammatory Spondyloarthritis:

• Inflammatory pain pattern: worse at night, improves with exercise 8
• Onset before age 40-45 years 8
• Morning stiffness >30 minutes 8
• Sacroiliitis, bone marrow edema, and syndesmophytes on MRI 4
• HLA-B27 positive in 74-89% of cases 4, 8

MRI findings should be interpreted with attention to morphologic features—disc degeneration and osteophytes favor degenerative changes rather than inflammatory spondyloarthritis. 4

Management Approach

For Asymptomatic or Mildly Symptomatic Spondylosis:

No treatment is required. 1 Reassure the patient that degenerative changes are part of normal aging and do not predict future disability.

For Symptomatic Spondylosis:

Conservative management should be the initial course of action in most cases, with or without neurologic symptoms. 2 This includes:

• NSAIDs or COX-2 inhibitors for pain control 3
• Structured physical therapy for minimum 3-6 months focusing on core strengthening and flexibility 1
• Activity modification avoiding aggravating positions 2, 5
• Epidural steroid injections for radicular symptoms if conservative measures fail 2, 3

The prognosis is favorable for most patients with conservative treatment. 2

When to Consider Advanced Intervention:

Surgery is reserved for patients who:

• Have completed 3-6 months of comprehensive conservative management without improvement 1
• Have progressive neurological deficits 2, 6
• Have severe or progressive cervical myelopathy 5
• Have cauda equina syndrome (emergency) 7

For degenerative spondylolisthesis, decompression alone or decompression with fusion may be considered, but fusion should be limited to 1-2 levels maximum where specific pathology is documented. 1, 6

Critical Pitfalls to Avoid

1. Ordering imaging without clinical correlation: Spondylosis on imaging does not equal clinically significant disease. 1

2. Proceeding to surgery without adequate conservative management: This violates evidence-based guidelines and exposes patients to unnecessary risks. 1

3. Performing extensive multilevel fusion for degenerative changes: Complication rates increase substantially (31-40% vs 6-12% for limited procedures), and functional outcomes may worsen. 1

4. Missing inflammatory spondyloarthritis: Failure to recognize inflammatory back pain features (onset <40 years, improvement with exercise, night pain, morning stiffness >30 minutes) leads to delayed diagnosis and treatment. 7, 8

5. Using discography as standalone justification: It has limited predictive value and may accelerate degenerative changes. 1

Red Flags Requiring Urgent Evaluation

Seek immediate medical attention if spondylosis is associated with: 7

• Cauda equina symptoms: urinary retention, fecal incontinence, saddle anesthesia 7
• Progressive motor deficits at multiple levels 7
• Myelopathic signs: gait instability, upper motor neuron findings 5
• Constitutional symptoms: fever, weight loss, night sweats (concern for infection or malignancy) 7