What Are Causes and Risk Factors of Spondylosis?
Spondylosis is an aging phenomenon. With age, the bones and ligaments in the spine wear, leading to bone spurs (osteoarthritis). Also, the intervertebral discs degenerate and weaken, which can lead to disc herniation and bulging discs. Spondylosis is common. Symptoms are often first reported between the ages of 20 and 50. Over 80% of people over the age of 40 have evidence of spondylosis on X-ray studies. The rate at which spondylosis occurs is partly related to genetic predisposition as well as injury history.
Genetics is another risk factor for spondylosis. If many people in a family have spondylosis, there is likely to be a stronger genetic predisposition to spondylosis.
Spinal injury is also a risk factor for spondylosis. Injuries can cause intervertebral discs to herniate. Also, osteoarthritis is more likely to develop in injured joints, including joints in the spine. This can take years to develop.
What Types of Doctors Treat Spondylosis?
Many different specialties of physicians treat spondylosis, including internists, family medicine doctors, general practitioners, rheumatologists, neurologists, neurosurgeons, orthopedists, and pain-management specialists. Non-physician health-care practitioners who often treat spondylosis include physician assistants and nurse practitioners, as well as physical therapists, massage therapists, and chiropractors.
What Are Spondylosis Symptoms and Signs?
Many people with spondylosis on X-ray do not have any symptoms. In fact, lumbar spondylosis (spondylosis in the low back) is present in 27%-37% of people without symptoms. In some people, spondylosis causes back pain and neck pain due to nerve compression (pinched nerves). Pinched nerves in the neck can cause pain in the neck or shoulders and headache. Nerve compression is caused by bulging discs and bone spurs on the facet joints, causing narrowing of the holes where the nerve roots exit the spinal canal (foraminal stenosis). Even if they are not large enough to directly pinch a nerve, bulging discs can cause local inflammation and cause the nerves in the spine to become more sensitive, increasing pain. Also, disc herniations can push on the ligaments in the spine and cause pain. If new nerves or blood vessels are stimulated to grow from the pressure, chronic pain can result. Because of the pain, the local area of the spine may attempt to splint itself, resulting in regional tenderness, muscle spasm, and trigger points.
Characteristic findings of spondylosis can be visualized with X-ray tests. These findings include decrease in the disc space, bony spur formation at the upper or lower portions of the vertebrae, and calcium deposition where the vertebrae have been affected by degenerative inflammation.
Symptoms of spondylosis include localized pain in the area of spondylosis, usually in the back or neck. Spondylosis in the cervical spine (neck) can cause headache. However, it is controversial whether more mild spondylosis, such as small bone spurs and bulging discs that do not compress nerves, causes back pain. This is because most middle-aged and elderly people have abnormal findings on X-ray tests of spondylosis, even when they are completely pain free. Therefore, other factors are likely major contributors to back pain.
If a herniated disc from spondylosis causes a pinched nerve, pain may shoot into a limb. For example, a large disc herniation in the lumbar spine can cause nerve compression and cause pain that originates in the low back and then radiates into the legs. This is called radiculopathy. When the sciatic nerve, which runs from the low back down the leg to the foot, is affected, it is called sciatica. Radiculopathy and sciatica often cause numbness and tingling (sensation of pins and needles) in an extremity. Back pain due to a bulging disc is typically worse with prolonged standing, sitting, and forward bending and is often better with changing positions frequently and walking. Back pain due to osteoarthritis of the facet joints is typically worse with walking and standing and relieved with forward bending. Symptoms of numbness and tingling may be felt if a nerve is pinched. If a nerve is severely pinched, weakness of an affected extremity may occur. If a herniated disc pushes on the spinal cord, this can cause injury to the spinal cord (myelopathy). Spondylosis with myelopathy refers to spondylosis that is injuring the spinal cord. Spondylosis without myelopathy refers to spondylosis without any injury to the spinal cord. Symptoms of myelopathy include numbness, tingling, and weakness. For example, a large herniated disc in the cervical spine could cause cervical myelopathy if it is large enough to push on the spinal cord with resulting symptoms of numbness, tingling, and weakness in the arms and possibly the legs.
What Is Rheumatoid Arthritis (RA)? Symptoms, Treatment, Diagnosis
When Should Someone Seek Medical Care for Spondylosis?
Because the diagnosis of spondylosis is made with images by plain film X-ray, CT scan, or MRI scan, most people with this diagnosis have already seen their doctor. Reasons for re-evaluation by a health-care professional include the following:
- If your pain is not manageable with the prescribed treatment
- For the development of acute nerve dysfunction, such weakness in one or more limbs (For example, see your doctor if your leg is weak and you are unable to flex your foot at the ankle or walk on your toes or heels.)
- Loss of bladder or bowel control, in the setting of acute back or neck pain, such as inability to start or stop urinating, can indicate a serious nerve dysfunction and should be evaluated at the emergency department immediately.
- Numbness in the groin area, or "saddle anesthesia," meaning numbness in the distribution where the bottom would contact a saddle: This can indicate a serious nerve dysfunction and should be evaluated at the emergency department immediately.
- If back or neck pain is associated with weight loss or fever greater than 100 F
What Tests Do Doctors Use to Diagnose Spondylosis?
The diagnosis of spondylosis is made using radiology tests such as plain film X-rays, MRI, or CT scans. X-rays can 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 scans of the spine are able to visualize the spine in greater detail and can diagnose narrowing of the spinal canal (spinal stenosis) when present. MRI scans are expensive but show the greatest detail in the spine and are 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.
What Is the Treatment for Spondylosis?
There is no treatment to reverse the process of spondylosis, because it is a degenerative process. The treatments for spondylosis target the back pain and neck pain that spondylosis can cause. Therefore, the treatment of spondylosis is similar to the treatment of back pain and neck pain. Available treatments fall into several categories: medications, self-care, exercise and physical therapy, adjunctive therapies (chiropractics and acupuncture), minimally invasive procedures such as injections, and surgery.
What Medications Treat Spondylosis?
No medication has been proven to reverse the degenerative process of spondylosis. Treatment of pain from spondylosis commonly includes anti-inflammatory medications, analgesics (pain medications), and muscle relaxants. Nonsteroidal anti-inflammatory medications, or NSAIDs, can be very effective in relieving back and neck pain from spondylosis. Some of these medications, such as ibuprofen (Advil, Motrin) and naproxen (Aleve), are available without a prescription. Other NSAIDs are prescription strength and may be prescribed by a health-care professional. Muscle relaxants such as cyclobenzaprine (Flexeril) and tizanidine (Zanaflex) are examples of prescription medications that can relieve the muscle spasm associated with spondylosis. Analgesics (pain medications), such as acetaminophen (Tylenol) and tramadol (Ultram), are used to treat pain. If the pain is extremely severe, sometimes a narcotic medication (Norco, Vicodin or others) is prescribed for the first several days. Fish oil is known to be anti-inflammatory and has been proven to improve several conditions such as heart disease and rheumatoid arthritis. There are some studies suggesting it may improve back and neck pain symptoms, as well.
Certain antidepressants are helpful in treating chronic back pain. Medications termed tricyclic antidepressants, including amitriptyline (Elavil) and doxepin (Sinequan), have been used for many years, in low doses, to treat chronic back pain, neck pain, and other pain. Recently, another antidepressant, duloxetine (Cymbalta), has been shown to improve chronic back pain. Cymbalta is approved by the Food and Drug Administration (FDA approved) to treat chronic low back pain, as well as other chronic pain conditions.
Some people find topical medications, which are massaged directly onto the location of the pain, helpful in relieving pain from spondylosis. These medications work in different ways, and many are available without a prescription. Some examples of topical medications include Aspercreme, which contains aspirin and is anti-inflammatory. Capsaicin cream is another topical medication which many find helpful. Capsaicin is the active ingredient in chili pepper and should not be used on areas where the skin is cut or irritated. After application, thorough hand washing is important, especially prior to touching the face, to avoid irritation from the capsaicin.
Are There Home Remedies for Spondylosis?
Home treatment is important in pain caused by spondylosis because pain may frequently improve or resolve after several days. Experts have found that bed rest prolongs the time to recovery. Therefore, it is recommended to continue normal or near normal activities. However, do not do anything that could exacerbate the problem, such as heavy lifting.
Home remedies, including warm compresses and/or ice, may be helpful for back and neck pain caused by spondylosis.
Sleeping with a pillow between the legs may be helpful for low back pain. Special pillows to offer additional cervical spine support have been developed for neck pain.
Are Physical Therapy, Exercise, and Adjunctive Therapies Effective for Spondylosis?
A doctor may prescribe physical therapy for back or neck pain that does not resolve on its own after a few weeks. Physical therapy is often prescribed for chronic back or neck pain for muscle strengthening and stretching. Physical therapists can demonstrate specific exercises which, when performed daily, may help strengthen the back and abdominal muscles and prevent recurrent pain. Physical exercise on a regular basis, specifically walking and yoga, have been shown in studies to be beneficial for chronic back pain.
Chiropractic spinal manipulation may be helpful to some people, especially within the first month of pain. However, certain patients should not undergo spinal manipulation for safety reasons. Specifically, patients with inflammatory arthritis involving the spine, such as ankylosing spondylitis and in some cases, rheumatoid arthritis, should not undergo spinal manipulation due to a small but serious risk of damage to the spinal cord.
Acupuncture for back pain involves inserting very thin needles at various depths into specified areas in the body. The needle placement is designed to balance the chi (or qi), which is thought to flow on meridians throughout the body. Studies of acupuncture for back and neck pain have had mixed results. Other alternative therapies such as homeopathic treatments have not been shown in studies to improve the symptoms of spondylosis.
What Are Surgical Treatment Options for Spondylosis?
Spondylosis is a chronic condition. Surgery for patients with chronic low back pain is controversial, because while some studies do show improvements in pain and disability, most studies do not show improvement as compared to nonsurgical treatment such as physical therapy and pain management. Also, many patients continue to have chronic back pain after the surgery.
However, surgery is sometimes necessary when spondylosis or spinal stenosis causes a nerve problem that is severe or worsening, progressive nerve damage, or difficulty walking. Surgery is rarely necessary in patients with acute back pain, unless progressive neurologic problems develop. This is because most patients improve dramatically after treatment with medications and physical therapy, and most patients improve within days to weeks after back pain starts. Surgery is sometimes performed for acute sciatica (if nerve problems such as weakness and numbness are severe and worsen rather than improve) and cauda equina syndrome, a syndrome where the nerves at the bottom of the spinal cord are compressed by an intervertebral disc or a mass, causing neurologic problems.
Spinal decompression surgery involves various surgical procedures that can relieve pressure on the nerves in the back due to spinal stenosis, herniated intervertebral discs, or foraminal stenosis (narrowing of the openings between the facet joints due to bone spurs). Common techniques for decompression include the following:
- Laminectomy is a procedure to remove the bony arches of the spinal canal (lamina) subsequently increasing the size of the spinal canal and decreasing pressure on the spinal cord.
- Discectomy is a procedure to remove a portion of an intervertebral disc that is putting pressure on a nerve root or the spinal canal.
- Foraminotomy or foraminectomy is a procedure to expand the openings for the nerve roots to exit the spinal canal. During a foraminectomy, generally more tissue is removed than during a foraminotomy.
- Osteophyte removal is a procedure to remove bone spurs from an area where they are causing pinched nerves.
- Corpectomy is a procedure to remove a vertebral body and discs.
Fusion of the vertebrae is sometimes combined with one or more of these procedures in order to stabilize the spine.
The term arthritis refers to stiffness in the joints.
Are Minimally Invasive Procedures and Injections Effective Treatments for Spondylosis?
Steroids (cortisone) can be injected into the epidural space (the space surrounding the spinal cord). This is commonly known as an epidural injection. Steroids can also be injected into the facet joints that connect the vertebrae, trigger points in the soft tissue, or directly into the intervertebral disc spaces. These procedures may have a role in managing acute pain, especially radicular pain, which radiates into a limb.
Other procedures for back and neck pain include intradiscal injections (cortisone injection directly into an intervertebral disc), trigger point injections of steroid, anesthetic, or both, facet joint steroid injection, steroid injection into the sacroiliac joints, steroid injection into the piriformis muscle for piriformis syndrome, and radiofrequency denervation (destruction of painful nerves using a radiofrequency current) among others.
Your doctor may want you to schedule a follow-up appointment to monitor your response to treatment. Routine follow-up imaging, such as X-ray, CT, or MRI, is usually unnecessary. The exception is a change in symptoms that may change therapy, such as new onset sciatica or new onset pain radiating down one arm.
What Are Spondylosis Complications?
The main complication of spondylosis is low back, mid back, or neck pain. Usually the back and neck pain caused by spondylosis is not serious, but some people develop chronic pain due to their condition. It is unusual for spondylosis to cause serious neurologic dysfunction due to nerve compression. Over time, the degenerative changes of spondylosis can cause spinal stenosis, where the spinal canal becomes narrow, and the spinal cord can become pinched. Therefore, spinal stenosis in the neck or low back can be a complication of spondylosis. Cauda equina syndrome, a syndrome where the nerves at the bottom of the spinal cord are compressed by an intervertebral disc or a mass, is a rare complication of spondylosis that can cause severe nerve problems.
Is It Possible to Prevent Spondylosis?
Spondylosis is a degenerative process, and there is no known method to prevent the degenerative pathologic process. However, some measures may be helpful to prevent the neck and back pain that spondylosis may cause.
What Is the Prognosis of Spondylosis?
Generally, the prognosis of spondylosis is favorable. Many people with spondylosis do not have any symptoms. Of those who develop back or neck pain due to spondylosis, most improve within a few weeks of the onset of their symptoms. Few people go on to develop chronic pain due to spondylosis.
Reviewed on 8/13/2019
Carragee, E.J. "Persistent Low Back Pain." The New England Journal
of Medicine 352 (2005): 1891-1898.
Deyo, R.A. et al. "Herniated Lumbar Intervertebral Disk." The New England Journal of Medicine 374 (2016): 1763-1772.
Hochberg, M.C., et al. Rheumatology, 4th ed. London: Elsevier, 2008.
Ropper, A.H., and R.D. Zafonte. "Sciatica." NEJM 372 (2015): 1240-1248.
Rothschild, B.M. "Lumbar Spondylosis." Medscape. Apr. 19, 2011. <http://emedicine.medscape.com/article/249036-overview>.