Lumbar Spine Spondylosis

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Aetiology

Lumbar spondylosis is defined as a defect in the pars interarticularis of the vertebral arches in the lumbar region of the spine. The defect is often found through radiographic imagining. Lumbar spondylosis can present with or in the absence of low back pain (Standaert & Herring, 2000). Spondylosis is sometimes a precursor to spondylolisthesis which is the “forward displacement of one vertebral body to the one subadjacent to it” (Standaert & Herring, 2000b, p. 415). Factors influencing the onset of lumbar spondylosis include: “genetics, psychosocial stress, exposure to vibration, inadequate physical fitness, strenuous body positioning…age, height…smoking, and other health conditions…as well as…posture” (Gokhale, 2008, p.10).

Prevalence

60-85% of adults experience lower back pain (LBP) in their lifetime, 15-45% of which are said to be chronic cases (Middleton & Fish, 2009). In 10% of these cases lumbar spondylosis is responsible for back pain in patients according to Murtagh (1991). In 75% of lumbar spondylosis patients, degeneration is found between the L4-L5 or L5-S1 vertebrae (Cailliet, 1981). This figure differs depending on the literature however, with earlier studies by Turner and Bianco (1971) quoting 85-95% of defects at L5 and 5-15% at L4, with less frequency of defects at more proximal lumbar levels. Amato, Totty and Gilula (1984) found that males are twice as likely to be affected by the condition compared to females.

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Pathology Description

In lumbar spondylosis a sequence of degeneration occurs over time. Firstly the intervertebral disc degenerates, leading to slackening of the longitudinal ligament, which causes the ligament to pull away from the vertebral body. Disc degeneration and therefore sclerotic changes to their cartilaginous end plates also means decreased height, which causes narrowing of the foramen. Following these changes are the formation of osteophytes and degeneration to the cartilage that makes up the articular surface of the facet joints. Finally, foraminal stenosis is present which can lead to nerve root compression, causing paraesthesia and numbness in the legs and feet (Cailliet, 1981).

Clinical signs and symptoms as a consequence of pathological changes

Most patients present with stiffness in the lower back, in rare cases without pain, but mostly with varying degrees of discomfort brought on by certain movements and postures (Edmonston & Elvey, 1997). The patient may describe having recurring episodes of pain of a number of months or years, leading to chronic discomfort. Degeneration of the intervertebral discs may protrude and compress nerve roots causing sciatica (Mceachran, 1999). Severe pain referred to the leg due to nerve root compression is more likely to be due to osteophyte formation than to disc protrusion in elderly patients (Grieve, 1988).

Medical Investigation and Diagnostic Tools

An accurate history must be taken from the patient as part of a thorough subjective examination, followed by an appropriate objective and physical examination, tailored to the patient’s severity, irritability and nature of symptoms (Petty & Moore, 2001). X-rays taken antero-posteriorly and laterally whilst standing of the lumbar spine and lumbosacral regions can pinpoint the exact location of any defect. CT and MRI are also options with the later used to identify any foraminal stenosis which can lead to nerve root compression. (Sairyo, Sakai & Yasui, 2009).

Medical, Surgical, Pharmaceutical and Multidisciplinary Management

It is recommended that patients with back pain should be as active as possible and once a check for the lack of presence of any “red flags” has been completed, patients are encouraged to resume their normal daily activites. (Moffett & Frost, 2000). Regimes include aerobic fitness e.g. walking, swimming, maintaining regular activites and ensuring correct posture, all of which aim to prevent recurrences of the problem (Moffett & Frost, 2000) by muscle stretching and strengthening, providing more natural support. Some sources advocate the use of transcutaneous electrical nerve stimulation (TENS) to relieve back pain, however studies show mixed results. Other management options include: traction; manual therapy and manipulation and massage. Medication to control pain and swelling, thereby improving quality of life includes NSAIDs, opoid, antidepressants and muscle relaxants (Middleton & Fish, 2009). In the event that conservative management as mentioned above fails, surgical intervention may be considered. (Middleton & Fish, 2009).

References
Amato, M. E., Totty, W. G. & Gilula, L. A. (1984). Spondylolysis of the lumbar spine: demonstration of defects and laminal fragmentation. Radiology, 153(3), 627-629.
Cailliet, R. (1981). Low back pain syndrome. (3rd ed.). Philadelphia: F.A. Davis company.
Edmonston, S. J. & Elvey, R. L. (1997). Physiotherapy management of low back of mechanical origin. In L. G. F. Giles & K. P. Singer (Eds.), Volume I: Clinical anatomy and management of low back pain. (pp. 370-385). Oxford: Butterworth Heinemann.
Gokhale, E. (2008). 8 steps to a pain-free back: natural posture solutions for pain in the back, neck, shoulder, hip, knee and foot. Stanford: Pendo Press.
Grieve, G. P. (1988). Common vertebral joint problems. (2nd ed.). New York: Churchill Livingstone.
Mceachran, C. M. (1999). Spondylosis: Pensions appeal tribunals scotland medical appendices. Retrieved January 4th, 2012, from http://www.patscotland.org.uk/medical_appendices/S/SPONDYLOSIS.pdf.
Middleton, K., & Fish, D. E. (2009). Lumbar spondylosis: clinical presentation and treatment approaches. Curr Rev Musculoskelet Med, 2(2), 94-104.
Moffett, J. K. & Frost, H. (2000). Back to fitness programme: the manual for physiotherapists to set up classes. Physiotherapy, 86(6), 295-305.
Murtagh, J.E. (1991). Low back pain. Australian Family Physician, 20(NA), 320-326.
Petty, N. J. & Moore, A. P. (2001). Neuromusculoskeletal examination and assessment: a handbook for therapists. (2nd ed.). London: Churchill Livingstone.
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