Definition/Description

Lumbar spondylosis can be described as all degenerative conditions affecting the discs, vertebral
bodies, and associated joints of the lumbar vertebrae.[1] Spondylosis is not a clinical diagnosis
but instead a descriptive term utilized to designate spinal problems. Within the literature, lumbar
spondylosis encompasses numerous associated pathologies including spinal stenosis,
degenerative spondylolisthesis, osteoarthritis and many others. It also captures effects of aging,
trauma and just the daily use of the intervertebral discs, the vertebrae, and the associated joints.[2]
Concerning older patients, the disease is said to be progressive and irreversible. Often is the
lumbar region the most affected, because of the exposure to mechanical stress. When a patient
suffers from lumbar spondylosis, it is possible that osteophytes are formed. These osteophytes
are bony overgrowths that occur due to the stripping of the periosteum from the vertebral body.
Pain can be produced when a neural foraminal stenosis is formed, which comes from the
formation of osteophytes. The patient can also experience joint stiffness, which can limit motion.
Patients with lumbar spondylosis also have neurologic claudication, which includes: lower back
pain, leg pain, numbness when standing and walking.[3][4][5]

Clinically Relevant Anatomy

Spondylosis (degeneration of the lumbar spine) generally initiates from the intervertebral disc. At this
level progressive biochemical and structural changes take place leading to a modification in the physical
properties of elasticity and mechanical resistance. Disc lesions cause pathological changes in the
vertebral bodies, where osteophytes appear, Most osteophytes are anterior or lateral in projection.
Posterior vertebral osteophytes are less common and only rarely impinge upon the spinal cord or nerve
roots.[6][1][7]
See Lumbar stenosis and Lumbar strain physiopedia pages for a detailed anatomy of the lumbar region.

Epidemiology /Etiology
Spondylosis is a form of lower back pain and is an important clinical, social, economic and
public health problem affecting the worldwide population. It is a disorder with many possible
etiologies and many definitions. The incidence of lumbar spondylosis is 27-37% of the
asymptomatic lower back pain population. For example, In the United States, more than 80% of
individuals older than 40 years have lumbar spondylosis, increasing from 3% of individuals aged
20-29 years.[8]

Approximately 84% of men and 74% of women have vertebral osteophytes, most frequently at
T9-10 and L3 levels. Approximately 30% of men and 28% of women aged 55-64 years have
lumbar osteophytes. Approximately 20% of men and 22% of women aged 45-64 years have
lumbar osteophytes. Sex ratio reports have been variable but are essentially equal.[9] Muraki et al,
did a cross-sectional study in a large population, which revealed a high prevalence of
radiographic lumbar spondylosis in elderly subjects. Gender seems to be distinctly in the form of
lumbar spondylosis, and disc space narrowing with or without osteophytes in women may be a
risk factor for low back pain.[10]

Lumbar spondylosis can begin in persons as young as 20 years. It increases with, and perhaps is
an inevitable concomitant of, old age. That is why it appears to be a nonspecific aging
phenomenon, also known as spinal arthritis. Most international studies suggest no relation to
lifestyle, height, weight, body mass, physical activity, cigarette and alcohol consumption, or
reproductive history. Adiposity is seen as a risk factor in British populations, but not in Japanese
populations. The effects of heavy physical activity are controversial, as is a purported relation to
disk degeneration.[11] Spondylosis can therefore be seen as a cascade- anatomical changes of the
spine occurs, which leads to more degeneration and changes in other spine structures. These
changes combine to cause spondylosis and its symptoms.[12]

Characteristics/Clinical Presentation
Patients with lumbar spondylosis have pain in the axial spine. The location of these degenerate
changes is not surprising as nociceptive pain generators that were identified within facet joints,
intervertebral disks, sacroiliac joints, nerve root dura and myofascial structures. These changes
may peak in different clinical presentations such asSpinal sstenosis,Disk herniation, Bulging of
the ligamentum flavum and Spondylolisthesis

Patients suffering lumbar spondylosis also have neurologic claudication, which includes lower
back pain, leg pain, numbness when standing and walking. These symptoms improve in sitting
and supine positioning.[1]

Other characteristics:
• Pedicle anteroposterior dimension, obliquity and the relative interarticular process-interpedicle
dimensions are important osteological determinants of the presence and size of lateral recesses at
different vertebral lumbar levels.
• The osteo-ligamentous nerve root canals and their terminal intervertebral canals show
significant normal narrowing at the level of the opposed intervertebral discs and facet joint
capsules. This narrowing causes a “grain” appearance in the normal nerve root canals and of the
appearance of long-necked gourds in the osteo-ligamentous intervertebral canals. The narrowing
of the disc intervertebral is an important cause of many of the degenerative changes in the
lumbar spine. [13]

Differential Diagnosis

When a patient is suffering from low back pain, there are a lot of possible pathologies that could
be the cause of this pain. Along with lumbar spondylosis(and its sub-divisions), there are other
causes as well.

• Rheumatoid arthritis- We can understand why some clinicians would include rheumatoid
arthritis, because there are sub-divisions of lumbar spondylosis that have a lot of similarities with
arthritis.
• Minor back trauma- As said in the article of Middleton et al., minor back trauma can be the
cause of degenerative pathologies such as spondylosis. It is the job of the physiotherapist to take
lumbar spondylosis, and other degenerative diseases for that matter, when a patiënt is diagnosed
with a minor back trauma
• Excessive exercise
• Back strain
• Bekhterev’s disease (Ankylosing Spondylitis)
• Coccyx Pain
• Spinal Masses (If the physiotherapist performs a bad investigation, this could be an option, but
normally this would be noticed with palpation.)
• Infection
• Disk Herniation
• Discitis
• Lumbar Compression Fracture
• Lumbar Degenerative Disk Disease
• Lumbar Facet Arthropathy (see Lumbar Facet Syndrome and/or Facet Joint Syndrome)
• Mechanical Low Back Pain
• Overuse Injury[14]

Diagnostic Procedures
For the clinical diagnosis of lumbar spondylosis, a thorough investigation is necessary to ensure
that other pathologies are excluded. In clinical practice we use:

 MRI: expensive, but shows the greatest details in the spine and is used to visualize the
intervertebral discs, including the degree of disc herniation, if present. An MRI is also used to
visualize the vertebrae, the facet joints, the nerves, and the ligaments in the spine and can
reliably diagnose a pinched nerve
 X-rays: show bone spurs on vertebral bodies in the spine, thickening of facet joints (the joints
that connect the vertebrae to each other), and narrowing of the intervertebral disc spaces.
 CT scan: able to visualize the spine in greater detail and can diagnose narrowing of the spinal
canal (spinal stenosis) when present
 SPECT: Single-photon emission computed tomography bone scintigraphy is used to further
evaluate patients with suspected spondylolysis. Controversy surrounds the designation of one of
these tests as most useful in the evaluation of spondylolysis.[15]

These procedures were validated in several studies, which concluded that MRI was effective
(92% sensitivity) in identifying pars lesions. CT scan was also used as a diagnostic procedure,
but the result weren’t equally positive. That’s the reason why MRI is advised as the best method
of diagnosis.[16][17]

As a physiotherapist, it could be helpful that we can search for the probability of lumbar
spondylosis with some clinical tests. In the article of Alqarni et al.[18] they wanted to see if those
clinical tests are accurate to detect this pathology. They found that only one test could be useful
to detect spondylolysthesis is the palpation of the lumbar spinous process, there’s no evidence
that a test could be used for spondylolysis.

Outcome Measures
 Numeric pain rating scale (NPRS): The patient is asked to score 3 pain rating, worse/current/
best over the last 24h. The score for this scale is the average of these 3 values. This scale is a
variant of the VAS but also assess pain intensity.[19][20]
 Roland Morris disability questionnaire (RMDQ): This questionnaire contains sentences that
people have used to describe themselves when they have back pain on that specific day. As
people read the list they might recognize themselves and then they must tick that box. A score is
appointed according to the number of boxes the patient fills in. This questionnaire makes it
possible to follow changes in time.[21][20]

 Oswestry disability index (ODI): This index is made to evaluate how back pain invalidates people
in their daily activities (sleeping, self-care, sex life, social life and travelling). Each question
contains 6 categories (0: no limitation – 6: most limitation). The score is calculated by the sum of
the 10 questions, multiplied by 2. This value represents the percentage of invalidation.[22][23]

 Pain self-efficacy questionnaire (PSEQ): This questionnaire rates how confident patients feel
performing activities despite the pain. This is indicated on a scale from 0 (no confidence) to 6
(completely confident). Al the scores are then added up to a score from 0 to 60. Where the
closer to 60 means that the patients have a stronger self-efficacy belief. There are also short
versions of this questionnaire available who shows also a great responsiveness.[24][25][22][20]

 The patient-specific functional scale (PSFS): Questionnaire where patients are asked to identify
up to three activities that they had difficulty with or are unable to perform as a result of their
back pain. Each item is given a score of 0-10 (unable- able). The total score is assessed by the
sum of the activity scores/number of activities (Minimum detectable change (90%CI) for average
score = 2 points, Minimum detectable change (90%CI) for single activity score = 3
points)[26][27][28][29]
Of all those questionnaires the NRPS is recommended for assessing pain because of his ease of
administration and responsiveness. The ODI and RMDQ are recommended for assessing
functioning.[20]

Examination
When a physical therapist performs an examination for lumbar spondylosis, it is advised to
follow the principles of the general spine examination and apply them to this specific
pathology.[30]The examination should begin as soon as you first see the patient and continues
with careful observation during the whole consultation. It is essential to observe the patient's gait
and posture.

1.) General examination of the spine

  Inspection of the entire spine
 Look for any obvious swellings or surgical scars.
 Assess for deformity: scoliosis, kyphosis, loss of lumbar lordosis or hyperlordosis of the lumbar
spine. Look for shoulder asymmetry and pelvic tilt.

2.) Palpation

 Palpate for tenderness over bone and soft tissues.

 Perform an abdominal examination to identify any masses and consider a rectal examination to
exclude other pathologies in this region

3.) Movement

 Flexion, extension, lateral flexion and rotation. Examination of the spine must also include
examination of the shoulders and examination of the hips to exclude these joints as a cause of
the symptoms.

4.) Neurovascular examination

 Sensation, tone, power and reflexes should be assessed. All peripheral pulses should also be
checked, as vascular claudication in the upper and lower limbs can mimic symptoms of
radiculopathy or canal stenosis.

Medical Management
There is little consensus about the definitive treatment approach due to a lack of information
about the sources of chronic lower back pain, There are different approaches to the management-
conservative or surgical. Franz EW. et al (2015) says that there is a surprisingly high percentage
of the patients that have misconceptions regarding the diagnosis and the treatment of lumbar
spondylosis and that these misconceptions persist in patients with a history of spine surgery.
Specifically, patients overemphasize the value of radiological studies and have mixed
perceptions of the relative risk and effectiveness of surgical intervention compared with more
conservative management. These misconceptions have the potential to alter patient expectations
and decrease satisfaction, which could negatively impact patient outcomes and subjective
valuations of physician performance. While these results are preliminary, they highlight a need
for improved communication and patient education during surgical consultation for lumbar
spondylosis.

Non-surgical management

Pharmacologic management
A lot of research has been done to explore the efficacy of different oral medications in the
management of lumbar spondylosis, to complement non-pharmacological interventions. Yet,
there is no agreement about the golden-standard approach.
  NSAIDS (non-steroidal anti-inflammatory drugs) are analgesics and anti-inflammatory. It covers
wide range selectivity. From the nonselective cyclooxygenase (COX) inhibitors to the
preferential COX-2. It is generally accepted to be the first step in the management of lumbar
spondylosis.[31]

 Opioid medication is an alternative therapy for patients suffering from gastrointestinal side-
effects due to a poor control of NSAIDS management. Patients who use this type of medication
report greater distress/ suffering and higher functional disability scores.

 Antidepressants: have been used for the treatment of LBP because of their analgesic value at
low doses. The use of antidepressants has also been explored for their dual role in the
treatment of depression that accompanies lumbar spondylosis syndrome.[32][33]

 Muscle relaxants may provide benefit with regard to short-term pain relief and overall
functioning.[34][35]
 Epidural steroid injections are the most common injections and target the epidural space (space
surrounding the membrane that covers the spine and nerve roots). These are strong anti-
inflammatory (combination of a corticosteroid with a local anesthetic pain relief medicine) and
give an immediate pain relief. However, there is poor evidence for the effectiveness
(improvement in short-term and long-term benefits) and safety of epidural steroid injections for
spinal stenosis.[36][37]
 Lumbar Facet joint injections are minimally invasive injections of medication (intra-articular
injection of local anesthetics with or without steroid) into the inflamed facet joints. This
medication can temporarily relieve back pain. It can be used as a diagnostic test or as a
treatment to relieve inflammation and pain.[38][39]
 SI joint injections are used for the treatment of sacroiliac joint pain. It consists of injections of
local anesthetics and steroids, radiofrequency ablation of the joint capsule, or radiofrequency
neurotomy of the lumbosacral lateral branch nerves L5 and S1–S3. No serious complications
have been reported after SI joint injection.[40]

Taping

Another non-surgical management could be taping. A lot of studies have shown that taping helps
to relieve pain in the lower back. This tape could be standard tape or kinesiotape as it is shown
that there is no difference between both tapes. It is also important to note that taping alone is not
enough, it should be used during the therapy to improve ROM etc.[41][42]

Lumbar support

Lumbar support with the help of braces are used for stabilization and reducing mechanical
forces, they are also produced to limit spine motion and correct deformity of the spine. There is
limited evidence-based research available about the efficacy of lumbar supports regarding patient
improvement and functional ability to go back to work. An example of a brace for Lumbal
support is The Lyon Antikyphosis Brace. This brace has the best results for patients with
scoliosis but could also help patients suffering from lumbar spondylosis.[43] Braces may have
effects by massaging and heating the painful areas, there is also a probability that the lumbar
supports work as a placebo.

Surgical management

Lumbar fusion
Lumbar fusion is generally used when conservative management has failed and the patient still
suffers from pain after 6 months. Two vertebrae are fused together and will subsequently act like
one solid vertebra. After two years the bony fusion can be considered high.[44]
There are different types of lumbar fusions: anterior lumbar interbody fusion (ALIF), posterior
lumbar interbody fusion (PLIF) and posterolateral fusion. The study of Lammli et al. 2014 about
ALIF, where they access the spine via the abdominal cavity, has shown a significant decrease in
blood loss, hospital stay and operative time.
5-10% of patients treated with surgery still endure serious pain after for example a lumbar
fusion. Electrical stimulation of the dorsal columns of the spinal cord , therefore, became a
popular “second-line” technique like they call it.[45][46]
Besides ALIF there also exists TLIF but it seems to have the same clinical outcomes as ALIF.
[74, Level of evidence 1A] It has been demonstrated that early psychomotor therapy results in a
better outcome after cognitive-behavioral training and motor relearning than early exercise
therapy does after a lumbar fusion.[47][48]

Artificial Disc Replacement (ADR)

Artificial disc replacement is the replacement of the degenerated intervertebral disc with an
artificial disc in people with degenerative disc disease (DDD) of the lumbar or cervical spine that
has been unresponsive to nonsurgical treatments for at least 6 months. Unlike spinal fusion, ADR
preserves movement of the spine, which is thought to reduce or prevent the development of
adjacent segment degeneration. Additionally, a bone graft is not required for ADR, and this
alleviates complications, including bone graft donor site pain and pseudoarthrosis. On the other
hand, not all patients who suffer from DDD are eligible ADR; it is estimated that about 5% of
patients who require surgery for DDD will be candidates for ADR.[49]

Physical Therapy Management

The conservative therapy can be divided into various exercise-based and behavioral
interventions:

 Exercise therapy

It is the main conservative treatment approach for lumbar spondylosis. The therapy must include
aerobic exercise, muscle strengthening, and stretching exercises. The exercises and programs
have to be of various intensity, duration, and frequency.[50][51] Kumar et al. have concluded that
core muscle strengthening exercises together with the strengthening of the gluteus maximus end
flexibility training of the lumbar spine is an effective rehabilitation approach for all patients with
chronic low back pain.[52]
It is demonstrated that older adults with lumbar spondylosis have a more elevated quality of life
when they have a better abdominal strength. [53]

 Traction

Lumbar traction helps to relieve chronic low back pain. The traction forces open the
intervertebral space and decrease spine lordosis. This temporary spine realignment relieves
(theoretical) mechanical stress, nerve compression, adhesions of the facet and annulus and
disrupts nociceptive pain signals. Nonetheless, little is known about the risks associated with
lumbar traction.[54][55]

 Manual therapy

Its conservative treatment commonly involves manual therapy, more specifically spine
manipulation. Even though the precise mechanism for improvement in low back pain remains
unclear, spine manipulation proves to be useful.[56] On the other hand, there might be a risk using
spine manipulation, there is a risk of calcifications in the spine should be taken into
consideration. Depending on the patient condition the risk may be high or low. But if
manipulation is possible it certainly should be used in treatment as it is shown by Ruddock et al.
(2016) that spine manipulation has a positive effect.[57]

 Massage

Even though massage therapy needs more researche for the effectiveness, it appears to have a
potential role in beneficial pain relief.[58]

 TENS

Is a frequently used therapeutic modality. It appears to give an immediate reduction in pain

symptoms following the therapy. Nevertheless, there remains little evidence of the long-term
relief.[59]

 Patient education

Educating the patient must include reviews of lumbar anatomy, explanations of the concept of
posture, ergonomics and giving appropriate back exercises.[60][61]

 Lumbar back support

Can be beneficial for patients suffering from chronic LBP. It occurs to limit spine motion,
stabilize, correct deformity and reduce mechanical forces. There is no consensus if it may
function as a placebo or really improve pain and functional ability. (level of evidence 1A) Sitting
decreases lumbar lordosis and increase disc pressure, squeeze on the ischium and muscle activity
in the lower back. These are all associated with low back pain. The study of Makhsous et al.
resulted in a diminished lumbar spine load and lumbar muscular activity with lumbar back
support. This may possibly lessen low back pain while sitting.[62]
  McKenzie exercises

McKenzie method focuses on extension, and has promising results concerning the prevention of
further degeneration of the lumbar spine. A review by Busanich B., et al provides evidence that
McKenzie therapy results in a decrease in short-term (<3 months) pain and disability for low
back pain patients compared with other standard treatments, such as nonsteroidal anti-
inflammatory drugs, educational booklet, back massage with back care advice, strength training
with therapist supervision, and spinal mobilization.[63]

For more information on McKenzie method, see Mckenzie Method

It is well-known that chronic spinal pain is often associated with bio-psychosocial problems.
Therefore, multidisciplinary back therapy is needed. A bio-psychosocial approach involved
reinforcement, modified expectations, imagery/relaxation techniques, and learned control of
physiological responses aim to reduce a patient’s perception of disability and pain symptoms.
(level of evidence 1A)

It has also been showed in several studies that Yoga could be helpful in reducing pain in patients
with chronic low back pain. The stretching of muscles is an important part of this technique. The
stretching and relaxing of muscles help the patients to cope with the pain and relieving them. It
should also be noted that Yoga alone is not a therapy for chronic low back pain, it can be an
additional technique in the therapy.[64][65]