Lumbar Spondylosis

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Practice Essentials

Lumbar spondylosis (spondylosis deformans, lumbar osteoarthritis), as shown in the image below, describes bony overgrowths (osteophytes), predominantly those at the anterior, lateral, and, less commonly, posterior aspects of the superior and inferior margins of vertebral centra (bodies).[1, 2, 3, 4] Lumbar spondylosis occurs as a result of new bone formation in areas where the anular ligament is stressed. The margins of vertebral bodies are normally smooth. Growth of new bone projecting horizontally at these margins identifies osteophytes. 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.[5]   This dynamic process increases with, and is perhaps an inevitable concomitant, of age. Lumbar osteophytes have long been thought to cause back pain because of their frequency and size. This has led to many studies of the distribution of vertebral osteophytes, not all of which are pertinent. The frequency of signs or symptoms among individuals with osteophytes is no greater than among those individuals without osteophytes.[1]  



View Image

Anteroposterior view of lumbar spine. Vertical overgrowths from margins of vertebral bodies represent osteophytes.

Lumbar spondylosis is usually asymptomatic, with no diagnostic or prognostic significance. When back or sciatic pains are symptoms, lumbar spondylosis is usually an unrelated finding.

Lumbar spondylosis appears to be a nonspecific aging phenomenon. Most studies suggest no relationship 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 Japanese populations. The effects of heavy physical activity are controversial, as is a purported relationship to disk degeneration.[6]

Radiographs, CT scans, and MRIs are used only in the event of complications. Bone density scan (eg, dual-energy x-ray absorptiometry scan [DEXA]) is used. Ensure that no osteophytes are in the area used for density assessment for spinal studies. Osteophytes produce the impression of increased bone mass, thus invalidating bone density tests if in the field of interest and masking osteoporosis.[5]

Because back pain is an unrelated finding of lumbar spondylosis, seek the real cause of the patient's back or sciatica-type symptoms.[4] Do not assume that the patient's symptoms are related to osteophytosis. Look for an actual cause of a patient's symptoms. If actual symptomatic nerve root impingement occurs, 2 days of absolute bed rest is indicated. If that does not solve the problem, then surgical excision is indicated. Medication is not indicated in the absence of complications.

Surgery is indicated only for complications (eg, for impingement-documented sciatica that is unresponsive to 2 days of absolute bed rest) of lumbar spondylosis. Surgery is not indicated if no complications (eg, impingement) of lumbar spondylosis are present.

Nerve compression from posterior osteophytes is a possible complication only if a neuroforamen is reduced to less than 30% of normal. If lumbar spondylosis projects into the spinal canal, spinal stenosis is a possible complication. If osteophytes disappear, look for aortic aneurysm. Aortic aneurysms can cause pressure erosions of the adjacent vertebrae.[7] If osteophytes are present, the first sign is often erosion of those osteophytes, so they are no longer visible. An isolated report of a bony L4 mass pressing on the duodenum has been described.

For further reading, please see the Medscape article Lumbar Spondylosis and Spondylolysis.

 

Epidemiology

Spondylolysis occurs in 6-10% of the general population and has been found to be as high as 25-60% in athletes. It is especially common in young athletes younger than 18 years who participate in sports that involve twisting or backward bending motions of the spine. This injury also runs in some families, suggesting that there may be a hereditary component.[8]

Lumbar spondylosis is present in 27-37% of the asymptomatic population. 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. Lumbar osteophytes have been found to be present in about 20% of men and 22% of women aged 45-64 years and in 30% of men and 28% of women aged 55-64 years. Sex ratio reports have been variable but are essentially equal. Spinal osteophytosis in postmenopausal Japanese women correlated with the CC genotype of the transforming growth factor β1 gene.[9, 10]

The prevalence of radiographic spondylosis increases with age. It is present only in a small percentage of the population in the first few decades of life, but is common by the age of 65 years . In those with low back pain, prevalence ranges from 7 to 75%, depending on the diagnostic criteria. Despite its frequency in patients with low back pain, there is no validated correlation between radiographic presence of lumbar spondylosis and the presence of low back pain. Age is the greatest risk factor, but other possibilities include disc desiccation, previous injury, joint overload from malalignment and/or abnormal z-joint orientation, and genetic predisposition. Studies evaluating the role of body mass index (BMI), level of activity, and gender on incidence and severity of lumbar spondylosis do not show a clear correlation.[11]

 

Presentation

Lumbar spondylosis usually produces no symptoms. When back or sciatic pains are symptoms, lumbar spondylosis is usually an unrelated finding. Lumbar spondylosis is usually not found unless a complication ensues.

Other problems to consider include the following:

What is lumbar spondylosis?What are the signs and symptoms of lumbar spondylosis?What are the risk factors for lumbar spondylosis?What is the role of imaging in the workup of lumbar spondylosis?What does a history of back pain suggest in lumbar spondylosis?What is the role of surgery in lumbar spondylosis?What are possible complications of lumbar spondylosis?What is the prevalence of lumbar spondylosis?What is the presentation of lumbar spondylosis?Which conditions should be included in the differential diagnoses of lumbar spondylosis?

Author

Bruce M Rothschild, MD, Professor of Medicine, IU Health; Research Associate, Carnegie Museum

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Brian H Kopell, MD, Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from Abbott Neuromodulation for consulting.

Additional Contributors

Michael G Nosko, MD, PhD, Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, Rutgers Robert Wood Johnson Medical School

Disclosure: Nothing to disclose.

References

  1. O'Neill TW, McCloskey EV, Kanis JA, et al. The distribution, determinants, and clinical correlates of vertebral osteophytosis: a population based survey. J Rheumatol. 1999 Apr. 26(4):842-8. [View Abstract]
  2. Kasai Y, Kawakita E, Sakakibara T, Akeda K, Uchida A. Direction of the formation of anterior lumbar vertebral osteophytes. BMC Musculoskelet Disord. 2009 Jan 13. 10:4. [View Abstract]
  3. Pye SR, Reid DM, Lunt M, Adams JE, Silman AJ, O'Neill TW. Lumbar disc degeneration: association between osteophytes, end-plate sclerosis and disc space narrowing. Ann Rheum Dis. 2007 Mar. 66 (3):330-3. [View Abstract]
  4. Goode AP, Carey TS, Jordan JM. Low back pain and lumbar spine osteoarthritis: how are they related?. Curr Rheumatol Rep. 2013 Feb. 15 (2):305. [View Abstract]
  5. Brooks BK, Southam SL, Mlady GW, Logan J, Rosett M. Lumbar spine spondylolysis in the adult population: using computed tomography to evaluate the possibility of adult onset lumbar spondylosis as a cause of back pain. Skeletal Radiol. 2010 Jul. 39 (7):669-73. [View Abstract]
  6. Yoshimura N, Dennison E, Wilman C, et al. Epidemiology of chronic disc degeneration and osteoarthritis of the lumbar spine in Britain and Japan: a comparative study. J Rheumatol. 2000 Feb. 27(2):429-33. [View Abstract]
  7. Chanapa P, Yoshiyuki T, Mahakkanukrauh P. Distribution and length of osteophytes in the lumbar vertebrae and risk of rupture of abdominal aortic aneurysms: a study of dry bones from Chiang Mai, Thailand. Anat Cell Biol. 2014 Sep. 47 (3):157-61. [View Abstract]
  8. Julie Sherry, DPT, MS, Marc Sherry, DPT, LAT, et al. Rehabilitation Guidelines for Lumbar Spondylolysis/Spondylolisthesis. UW Health. Available at https://www.uwhealth.org/files/uwhealth/docs/sportsmed/Spondy_Rehab_Guide.pdf. Accessed: September 25, 2018.
  9. Yamada Y, Okuizumi H, Miyauchi A, et al. Association of transforming growth factor beta1 genotype with spinal osteophytosis in Japanese women. Arthritis Rheum. 2000 Feb. 43(2):452-60. [View Abstract]
  10. Zukowski LA, Falsetti AB, Tillman MD. The influence of sex, age and BMI on the degeneration of the lumbar spine. J Anat. 2012 Jan. 220 (1):57-66. [View Abstract]
  11. Ameet Nagpal, MD and Alan Swearingen, MD. Lumbar Spondylosis Without Myelopathy. American Academy of Physical Medicine and Rehabilitation. Available at https://now.aapmr.org/lumbar-spondylosis-without-myelopathy/. 02/14/2018; Accessed: September 25, 2018.
  12. Miyakoshi N, Itoi E, Murai H. Inverse relation between osteoporosis and spondylosis in postmenopausal women as evaluated by bone mineral density and semiquantitative scoring of spinal degeneration. Spine. 2003 Mar 1. 28(5):492-5. [View Abstract]
  13. Bridges PS. Vertebral arthritis and physical activities in the prehistoric southeastern United States. Am J Phys Anthropol. 1994 Jan. 93(1):83-93. [View Abstract]
  14. Pahl MA, Brislin B, Boden S, et al. The impact of four common lumbar spine diagnoses upon overall health status. Spine J. 2006 Mar-Apr. 6(2):125-30. [View Abstract]
  15. Booka E, Kawakubo H, Ishii K, Hikata T, Fukuda K, Nakamura R, et al. Superior Mesenteric Artery Syndrome Caused by Massive Lumbar Osteophytes: A Case Report. Spine (Phila Pa 1976). 2015 Aug 1. 40 (15):E909-12. [View Abstract]

Anteroposterior view of lumbar spine. Vertical overgrowths from margins of vertebral bodies represent osteophytes.

Anteroposterior view of lumbar spine. Vertical overgrowths from margins of vertebral bodies represent osteophytes.