What is Lumbar Spondylosis
Lumbar spondylosis is a chronic, noninflammatory degenerative disease of the lumbar spine caused by age-related deterioration of the intervertebral discs and facet joints, which is a normal aging phenomenon that remains asymptomatic in most individuals. 1, 2
Definition and Pathophysiology
Lumbar spondylosis represents degenerative changes affecting the lumbar spine's structural components, including disc degeneration, facet joint arthritis, and associated bony changes that occur as part of normal aging. 1, 2
The condition is multifactorial in etiology, with degenerative changes identified on MRI frequently occurring in asymptomatic patients, meaning imaging findings alone cannot determine clinical significance. 3, 1
The disease process may progress to include spinal stenosis (narrowing of the spinal canal), spondylolisthesis (vertebral slippage), or nerve root compression, though many patients with these radiographic findings remain symptom-free. 3, 4
Clinical Presentation and Symptoms
Primary Symptoms
Patients typically present with discomfort localized to the lower back, which may be chronic and mechanical in nature (worsening with activity, improving with rest). 2
Radiating leg pain (radiculopathy) occurs when nerve roots become compressed, presenting as pain following a specific lumbar nerve root distribution down the leg. 3, 2
Neurogenic intermittent claudication manifests as bilateral leg pain, cramping, or weakness that worsens with walking or standing and improves with sitting or forward flexion, indicating lumbar spinal stenosis. 3, 2
Associated Findings
Patients may experience pseudoclaudication (leg symptoms mimicking vascular claudication but due to spinal stenosis), which improves with downhill treadmill testing or sitting. 3, 4
Morning stiffness, alternating buttock pain, and awakening due to back pain during the second part of the night may suggest associated ankylosing spondylitis in younger patients. 3
Psychosocial factors and emotional distress are stronger predictors of outcomes than physical examination findings or pain severity, requiring assessment during evaluation. 3
Treatment Approach
Conservative Management (First-Line Treatment)
The majority of patients with lumbar spondylosis respond appropriately to nonsurgical management, which should be attempted for a minimum of 3-6 months before considering surgical options. 5, 1, 6
Pharmacological Treatment
NSAIDs are the first-line drug treatment for controlling pain and muscle spasms, with non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors recommended for patients with gastrointestinal risk factors. 5, 2
Acetaminophen and short-term opioids may be considered when NSAIDs are insufficient, contraindicated, or poorly tolerated. 5
Neuroleptic medications (gabapentin or pregabalin) should be added for radicular symptoms or nerve root compression, particularly when MRI demonstrates nerve root approximation. 7, 5
Prostaglandin medications may provide additional symptomatic relief for leg pain and intermittent claudication. 2
Physical Therapy Requirements
Formal structured physical therapy for a minimum of 6 weeks is mandatory before considering any surgical options, focusing on core strengthening and flexibility rather than patient-directed exercises alone. 5, 8
Group physical therapy shows better patient global assessment outcomes than home exercise alone. 5
Activity modification to avoid positions that exacerbate symptoms is essential. 5
Interventional Options
Epidural steroid injections may provide short-term relief (less than 2 weeks) for radiculopathy, though evidence for chronic low back pain without radiculopathy is limited. 7, 5
Transforaminal injections can target specific nerve roots when radicular symptoms predominate. 2
External bracing may help diminish pain and immobilize the involved segment during concurrent medical therapy. 5
Surgical Treatment Indications
Surgery should only be considered after documented failure of comprehensive conservative management for at least 3-6 months, with pain remaining disabling and refractory to all conservative measures. 5, 8, 6
Specific Surgical Criteria
Lumbar fusion is recommended for carefully selected patients with disabling low-back pain due to 1- or 2-level degenerative disc disease without stenosis or spondylolisthesis (Grade B recommendation). 3
Decompression combined with fusion is superior to decompression alone for patients with stenosis and degenerative spondylolisthesis, with 96% reporting excellent/good results versus 44% with decompression alone. 7, 4
Fusion is specifically indicated when there is documented instability, spondylolisthesis on dynamic flexion-extension films, or when extensive decompression (>50% facet removal) might create iatrogenic instability. 7, 8
Surgical Outcomes
Clinical improvement occurs in 86-97% of appropriately selected surgical candidates, with statistically significant reductions in back pain and leg pain compared to conservative management or decompression alone. 7, 5
Instrumented fusion with pedicle screws provides optimal biomechanical stability with fusion rates up to 95%. 7, 5
Complication rates for instrumented fusion procedures range from 31-40%, substantially higher than decompression alone (6-12%), necessitating careful patient selection. 7, 8
Critical Clinical Pitfalls to Avoid
Never proceed to surgery without documented completion of formal physical therapy for at least 6 weeks, as intensive rehabilitation programs with cognitive components show equivalent outcomes to fusion for chronic low back pain without stenosis or instability. 5, 8
Do not perform fusion for purely radiological findings without correlating clinical symptoms, as degenerative changes on MRI occur frequently in asymptomatic patients. 3, 5
Avoid routine MRI imaging until the patient has failed initial conservative management and is a potential candidate for surgery, as imaging should guide treatment decisions only in surgical candidates. 5
Lumbar fusion should be limited to 1-2 levels for degenerative disc disease, not extensive multilevel constructs, as evidence supports only limited fusion with higher complication rates for extensive procedures. 3, 8
Natural History and Prognosis
The natural history of lumbar spondylosis is generally favorable, with most patients improving within the first 4 weeks of conservative treatment. 5
Reassessment at 4 weeks is appropriate, with continuation of conservative management up to 3-6 months if symptoms are improving. 5
Understanding the natural history is important to tailor an individualized management plan, as many patients with radiographic spondylolisthesis or stenosis remain asymptomatic or improve without intervention. 4