Lumbal spondylose

Lumbar spondylosis is a progressive degenerative condition affecting the intervertebral discs, vertebral bodies, and associated joints in the lower back¹². The condition is described as age-related degeneration of the lumbar vertebrae. Although degenerative changes may also be seen in younger individuals, they occur more frequently and are more pronounced with increasing age¹³.

The term lumbar spondylosis encompasses a broad spectrum of conditions, including spinal stenosis, degenerative spondylolisthesis, osteoarthritis, age-related changes, trauma, and ordinary wear of the intervertebral discs and associated structures¹⁴. When degeneration involves the facet joints, this may be referred to as facet joint osteoarthritis. The lumbar spine is particularly vulnerable due to mechanical load.

Radiological findings of degenerative changes are common but do not always correlate with clinical symptoms, especially in younger individuals where the findings are often incidental and painless¹. For example:

• 85.5% of people aged 45–64 years have osteophytes in the lumbar spine¹.

• 10% of women aged 20–29 years show disc degeneration on imaging¹.

• Although lumbar spondylosis is common in individuals over 40, it is seen in 3% of those aged 20–29 years¹.

This underscores the need for thorough clinical assessment to distinguish symptomatic from asymptomatic cases¹.

Clinically Relevant Anatomy

Degenerative changes often begin in the intervertebral discs, where reduced water content and loss of proteoglycans lead to disc dehydration and decreased elasticity¹³. As the disc loses height and elasticity, the load on adjacent vertebral bodies and facet joints increases, contributing to osteophyte formation, particularly along the anterior and lateral vertebral margins¹⁴. Posterior osteophytes are less common and rarely cause neurological symptoms¹.

These processes may also lead to secondary changes such as facet arthropathy, hypertrophy of the ligamentum flavum, and narrowing of the spinal canal or neural foramina, which in turn can cause nerve root involvement and clinical symptoms¹.

Epidemiology and Etiology

Lumbar spondylosis is one of the most common structural causes of low back pain and represents a considerable clinical, public health, and socioeconomic burden globally¹⁵. The condition develops through a combination of anatomical and biomechanical changes that drive progressive degeneration of discs, facet joints, and surrounding structures¹.

Prevalence increases with age. Imaging demonstrates that:

• The prevalence of lumbar spondylosis among asymptomatic individuals is 27–37%. In the United States, it is seen in 3% of those aged 20–29 years and in over 80% of those over 40⁵.

• Approximately 84% of men and 74% of women have vertebral osteophytes, most commonly at T9–10 and L3⁴.

Sex differences in prevalence are small. The condition is considered predominantly age-related, with little or inconsistent association with lifestyle factors such as smoking, physical activity, alcohol use, or BMI⁶.

Pathogenesis

Lumbar spondylosis is often described as a three-phase process based on the Kirkaldy-Willis and Bernard model¹⁷:

Dysfunction phase: Repeated mechanical loading leads to annular tears and endplate changes, reducing nutrient delivery and causing disc dehydration and height loss.

Instability phase: Further degeneration weakens segmental stability. This may result in abnormal motion and possible subluxation.

Stabilization phase: Fibrosis and loss of disc height, osteophyte formation, and reduced mobility as the body attempts to stabilize the segment.

Clinical Presentation

Lumbar spondylosis often produces chronic low back pain, sometimes with radiating leg symptoms depending on the degree and location of involvement¹. Pain is usually centered in the lower back and arises from nociceptive structures such as intervertebral discs, facet joints, the sacroiliac joints, and musculature¹.

With further degeneration, patients may develop:

• Spinal stenosis

• Disc herniation

• Hypertrophy of the ligamentum flavum

• Spondylolisthesis

• Lumbar radiculopathy

Neurological symptoms vary with the level and direction of compression. Patients with neurogenic claudication typically report leg pain, numbness, and weakness that worsen with standing and walking but improve with sitting and forward flexion¹³.

The course is often gradual but may include acute exacerbations. Symptoms can vary with posture and activity and may lead to functional limitations over time.

Differential Diagnoses

Because symptoms overlap, differential diagnoses must be considered carefully.

Inflammatory and autoimmune conditions:

• Ankylosing spondylitis

• Rheumatoid arthritis

• Reactive arthritis

• Sacroiliitis

Infectious and systemic causes:

• Vertebral osteomyelitis

• Discitis

• Spinal tuberculosis

• Systemic infections with spinal involvement

Mechanical and degenerative disorders:

• Mechanical low back pain

• Disc herniation

• Facet joint osteoarthritis

• Spinal stenosis without spondylosis

• Spondylolysis/spondylolisthesis (isthmic or traumatic)

Neoplastic conditions:

• Spinal metastases

• Primary spinal tumours

• Spinal cord compression

Trauma:

• Lumbar compression fracture

• Coccygeal fracture

Other conditions:

• Overuse injuries

• Coccydynia

• Infection

• Cauda equina syndrome

• Chronic pain syndromes (e.g., fibromyalgia)⁸

In the presence of red flags (e.g., weight loss, fever, neurological deficits, bowel/bladder disturbance), prompt further investigation is required.

Diagnostic Procedures

Diagnosis of lumbar spondylosis should be based on a thorough clinical assessment, supported by imaging and other tests when indicated. In the absence of red flags, early imaging is not required for nonspecific low back pain. In the acute phase, a conservative approach with education, exercise, and analgesia is recommended¹.

If symptoms persist beyond 6–12 weeks, or if red flags are present (e.g., neurological deficits, weight loss, night pain, trauma, suspected infection), further diagnostic work-up should be considered to identify underlying structural pathology.

Imaging Modalities

• X-ray: May demonstrate reduced disc height, osteophytes, or facet arthrosis, but such findings are often present in asymptomatic individuals.

• MRI: Preferred for assessing disc degeneration, nerve root involvement, and spinal stenosis. Provides detailed soft-tissue information.

• CT: Useful for evaluating bony structures when MRI is contraindicated or unavailable.

• SPECT or bone scintigraphy: Seldom used, but can help assess metabolic activity in the spine, particularly when fracture or infection is suspected.

Neurological and Neurodynamic Testing

A neurological screen should assess reflexes, sensation, and motor function, especially when radiculopathy or spinal stenosis is suspected. Neurodynamic tests such as Straight Leg Raise or Femoral Nerve Stretch Test can help identify nerve root involvement.

Other tests, including FABER, Ely’s, Mennell’s, and Stork Test, may help differentiate lumbar pain from hip or sacroiliac pathology. These tests have limited diagnostic specificity and should always be interpreted in conjunction with other findings.

Standardised Outcome Measures

Standardised outcome measures provide an objective basis to assess symptoms, function, and treatment effects over time in people with lumbar spondylosis. These measures support clinical decision-making and enable comparison of interventions.

Common outcome measures:

• Numeric Pain Rating Scale (NPRS): Simple 0–10 scale for pain intensity.

• Roland–Morris Disability Questionnaire (RMDQ): Assesses functional limitation related to low back pain.

• Oswestry Disability Index (ODI): Measures disability related to low back pain.

• Pain Self-Efficacy Questionnaire (PSEQ): Assesses confidence in performing activities despite pain.

• Patient-Specific Functional Scale (PSFS): Allows the patient to identify difficult activities and track progress over time.

Choice of measures should match the patient’s primary complaints and goals. For instance, ODI is useful when functional limitation is substantial.

Clinical Examination

A systematic clinical examination is essential to evaluate lumbar spondylosis and exclude other causes of low back pain. The goal is to assess spinal posture, mobility, neurological function, and any red flags that may suggest serious pathology.

General spinal examination

• Observe posture and alignment in all planes.

• Look for scoliosis, loss of lumbar lordosis, kyphosis, hyperlordosis, shoulder asymmetry, or pelvic tilt.

• Assess for swelling, muscle atrophy, scars, or signs of inflammation.

Palpation

• Palpate spinous processes and paraspinal muscles for tenderness or spasm.

• Check for step-off or irregularities (e.g., in spondylolisthesis).

• Abdominal palpation may be necessary to exclude non-musculoskeletal causes.

• Rectal examination should be considered if cauda equina syndrome or malignancy is suspected.

Range of motion (ROM)

• Assess lumbar flexion, extension, lateral flexion, and rotation.

• Note how movement affects symptoms—pain with extension may indicate facet arthrosis, while pain with flexion may suggest disc pathology.

• Examine hip and shoulder mobility to exclude referred pain.

Neurovascular examination

• Test reflexes, myotomal strength, and dermatomal sensation.

• Pay particular attention to L4, L5, and S1 function.

• Assess gait, balance, and coordination when neurological symptoms are present.

• Vascular assessment (palpation of peripheral pulses) can help exclude vascular claudication.

Functional tests

• Observe sit-to-stand transfers, single-leg balance, and walking tolerance.

• Functional limitations help guide treatment goals and outcome measure selection.

Medical Management

There is no universal treatment for lumbar spondylosis. Management is individualized based on symptom severity, presence of neurological deficits, and functional limitation¹. Most patients respond well to conservative therapy, while surgery is reserved for persistent, debilitating symptoms or progressive neurological deficits.

An important component of care is correcting common patient misconceptions—particularly overreliance on imaging or the belief that surgery is inherently superior to conservative treatment. Such beliefs can affect expectations, decision-making, and satisfaction with outcomes. Effective patient education is therefore central to establishing realistic expectations and a strong therapeutic alliance¹²⁹.

Conservative Treatment

Conservative care is the cornerstone of managing lumbar spondylosis, especially when red flags and severe neurological deficits are absent. The aim is to reduce pain, improve mobility, and facilitate return to normal activity through education, activity advice, and exercise-based rehabilitation. Patients are encouraged to stay active, avoid bed rest, and participate in structured training under the guidance of a physiotherapist or other health professional. Key elements include:

• Patient education and reassurance

• Advice to remain active and avoid unnecessary rest

• Self-management strategies and ergonomics

• Referral to physiotherapy for targeted exercises and functional rehabilitation (see dedicated section on physical treatment)

Pharmacological Treatment

Pharmacotherapy can provide symptom relief and improved function, particularly in the short term. It should be tailored to the individual’s pain profile and used cautiously to avoid unnecessary prolonged use. Medications typically supplement other treatments and should rarely be the sole intervention:

• Analgesics: Paracetamol or NSAIDs for mechanical pain

• Muscle relaxants: May be used for muscle spasm

• Neuropathic agents: Gabapentinoids or tricyclic antidepressants when radicular symptoms are suspected

• Corticosteroid injections: May be considered in suspected facet inflammation or nerve root irritation for short-term relief

Interventional Treatment

Interventional procedures may be considered in patients with persistent pain despite conservative therapy. These measures can provide temporary relief, facilitate rehabilitation, and help clarify pain generators. They should be used judiciously and always as part of a comprehensive plan:

• Facet joint injections or medial branch blocks for suspected facet arthropathy

• Epidural steroid injection for nerve root irritation or spinal stenosis

The effects are often transient and should support—not replace—active rehabilitation.

Surgical Treatment

Surgery is usually reserved for patients with substantial neurological deficits, structural instability, or failure of conservative care. Thorough imaging and multidisciplinary evaluation are required prior to surgery. Preoperative education about risks, expectations, and rehabilitation is essential.

Indications for surgery:

• Progressive neurological symptoms (e.g., motor weakness or cauda equina syndrome)

• Severe spinal stenosis with neurogenic claudication unresponsive to conservative therapy

• Documented structural instability (e.g., spondylolisthesis)

Common procedures:

• Laminectomy: Decompression by removing portions of the vertebral arch to relieve pressure on nerve roots.

• Spinal fusion: Fusion of vertebrae to reduce motion and stabilize the segment.

• Foraminotomy or discectomy: Removal of compressive disc material or bone.

• Prostheses or interlaminar devices: Considered in selected cases to preserve motion.

Surgical decisions should be based on detailed imaging, symptom profile, and multidisciplinary input. Robust preoperative education and structured postoperative rehabilitation are critical for optimal outcomes¹⁹.

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