Lumbar spondylosis treatment: Do injections work?

Ross Hauser, MD

Most of the patients that we see for problems of lumbar spondylosis are patients with a long history of conservative care for their back pain problem and they have now been advised to consider spinal surgery. These patients have a pretty common thread in their medical histories. It sounds something like this:

The patient had been suffering from low back pain, on and off, sometimes acute, mostly chronic. At some point, they could no longer manage this pain on their own with over-the-counter medications and stretching or yoga exercises that they found on YouTube.  (Please see our article Why physical therapy and yoga did not help your low back pain for some possible answers to why they did not help you.) So they made an appointment with their general practitioner who prescribed stronger medications and a referral to a low back pain specialist.  The specialist, following x-rays, MRIs, and examination diagnosed them with lumbar spondylosis (age-related wear and tear of the spine) and suggested a conservative care treatment of therapy, rest, varying medications, perhaps chiropractic in order to see if you respond well enough that surgery would not be needed.

For some people, this conservative care regimen works very well, their back pain alleviates or becomes more manageable. However, for some, typically the patients we see, for whom the conservative care provided little or no relief, or, the conservative care treatments worked well at first but the back pain has returned, they may be facing a recommendation to surgery. A patient will often tell us this type of story.

As the pain developed and became less manageable I learned that I had now progressed to Grade II spondylolisthesis

The specialist told me I had Grade I spondylolisthesis and I was told that the exercises, therapy, and medications would help with the pain I was having.

I thought these treatments would fix me.

As the pain developed and became less manageable I learned that I had now progressed to Grade II spondylolisthesis during the last few months. This is why my pain was becoming more acute. While I got a prescription for stronger medications, I was also given a recommendation that I should consider spinal fusion to stop the progression. I am looking for a second opinion because I need to work, spinal fusion is going to put me out of work for a long time.

What are we seeing in this image?

This is an MRI showing lumbar spondylosis. In this MRI this patient suffers from:

• Endplate sclerosis, (If you have been diagnosed with endplate sclerosis it was probably explained to you that this shock-absorbing structure of cartilage and porous bone has now hardened or degenerated and is no longer protecting the disc and vertebrae. Endplate sclerosis can often be a leading indicator to the recommendation to spinal fusion surgery.) The reason the bone is porous is to allow blood and nutrients into the disc area.
• Disc narrowing or loss of disc height.
• Osteophytes or more commonly bone spurs.

In our experience, this degenerative condition of the spine and spondylosis is caused by facet joint instability in the spine. The vertebrae are hypermobile because their posterior connections to each other have broken down and vertebrae are “floating around” causing disc herniation, slipped discs, and vertebrae sliding away from each other. This is the cause of severe pain in some.

What are we seeing in this image? A further understanding of facet joint instability

In this image, we see an illustration of the side or lateral view of two adjacent vertebral segments. What are we seeing? Facet joint hypermobility in the spine causes excessive motion between the vertebrae. This excessive movement as described above leads to a disc injury, disc herniations, and disc degeneration. In this image, we also discuss the use of Prolotherapy injections to strengthen the lumbar ligaments to normalize or reduce the hypermobility of the vertebrae and create stability in the spine. This can help patients reduce pain associated with degenerative disc disease.

Lumbar spondylosis has many diagnostic terms

The problem with a diagnosis of lumbar spondylosis is that lumbar spondylosis is really not a diagnosis, it is a description of problems of the lumbar spine.

In their heavily cited 2009 paper, “Lumbar spondylosis: clinical presentation and treatment approaches.” (1), Dr. Kimberley Middleton of the University of Washington and Dr. David Fish of the David Geffen School of Medicine at UCLA give this description of the many diagnostic terms surrounding lumbar spondylosis. Here are some learning points of their research:

Inconsistent treatment results:

• Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country.

Inconsistent diagnosis: What is causing the back pain? “It is Anybody’s guess”

• There is difficulty establishing a clear cause of low back pain in most patients, with known nociceptive (nerve) pain generators identified throughout the axial spine. (This is pain that is confined to the low back, it does not travel into the hip/groin complex).
• Once cancer and fracture have been ruled out the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative. (The diagnosis remains unclear, what is causing the low back in some instances can be best described as “anybody’s guess.)

The confusion of diagnostic terms

• Diagnostic terms:
  • The terms lumbar osteoarthritis, disc degeneration, degenerative disc disease, and spondylosis are used to describe anatomical changes to the vertebral bodies and intervertebral disc spaces that may be associated with clinical pain syndromes.
    • Spinal osteoarthritis is a degenerative process defined radiologically by joint space narrowing, osteophytes (bone spurs), subchondral sclerosis (thickening bone formation under the cartilage), and cyst formation.
    • Intervertebral osteochondrosis describes the formation of more advanced end-plate osteophytes, associated with disc space narrowing, vacuum phenomenon (accumulation of gas in the disc that causes pressure), and vertebral body reactive changes  (that can include bone marrow lesions). If protruding within the spinal canal or intervertebral foramina, these bony growths may compress nerves with resulting lumbar radiculopathy or lumbar spinal stenosis.
    • Spondylosis of the lumbar spine is a term with many definitions employed synonymously with arthrosis (the breakdown at the joint endplates of soft tissue) spondylitis, hypertrophic (enlarged bone or joints) arthritis, and osteoarthritis.

The bottom line

The bottom line is lumbar spondylosis is a degenerative condition that prevents the lumbar spine from doing its job of bearing tremendous loads and carry the weight of the body from the lower back to the head. The lumbar spine, in conjunction with the hips, is also responsible for the mobility of the trunk. It is not surprising, then, that the most common diagnosis given to people who have low back pain other than lumbar spondylosis is degenerative disc disease (DDD).

Back pain can be traced to the idea of damaged spinal ligaments at the facet joint

In the illustrations above we set out to explain how spinal instability would lead to an eventual cascade of degenerative disc disease leading to ultimate spinal fusion. We briefly focused on the ligaments of the lumbar spine. In this section, we will look at the ability of certain injections in helping the patient alleviate his/her pain and possibly regaining function and avoidance of surgery. Some of these injections target the spinal ligaments. With any medical explanation or technique there must also come the understanding that in medicine, there has to be a realistic expectation that these treatments can help.

Targeting the facet joint capsule

The term degeneration denotes deterioration, the whole vertebral joint goes from a healthy state to an unhealthy or weakened one. Generally, when this occurs, the degenerated or deterioration is comprehensive, meaning it encompasses all the structures within the spine: the discs, the ligaments, the vertebral structure, etc.

It is logical then that treatment for a comprehensively degenerated joint or for degenerative disc disease should be geared towards comprehensive regeneration of the deteriorated tissues, beginning with the spinal ligaments.

When the spinal ligaments are injured and weak, abnormal loading across the vertebral joint occurs, abnormal loading causes accelerated degeneration.

People do benefit from conservative care treatments for their back pain

Some people do very well and can manage their lumbar spondylosis-related pain with certain medications. A November 2020 review in the medical journal Pain and Therapy (2) lead by doctors at  Mount Sinai Medical Center, Miami Beach, Beth Israel Deaconess Medical Center, Harvard Medical School, University of Arizona College of Medicine-Phoenix, Louisiana State University Health Sciences Center, among others, made the simple suggestion that “(The) Current literature (research) suggests that NSAIDs and acetaminophen as well as antidepressants, muscle relaxants, and opioids are effective treatments for chronic low back pain.”

However, the warnings were also given. Among them:

• Acetaminophen: “new evidence suggests that acetaminophen may not be as effective in treating acute low back pain (episodes) as other drugs such as NSAIDs or antidepressants such as duloxetine and amitriptyline. Most current international clinical practice guidelines continue to recommend acetaminophen as the first-line treatment for chronic low back pain. However, many international guidelines also advise against its use because of increasing evidence showing questionable benefit.”
• NSAIDs: “The use of NSAIDs, especially over a prolonged time, is also not without risk. While short-term use is considered relatively safe, long-term use predisposes patients to considerable side effects.”

Stepping up the medications

As your pain continued and worsened, you then went ahead and saw the specialist. Here the arsenal of weapons to help your back pain increased in types and potencies. You may have received:

• Upgrade to prescription-strength Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Upgrade to oral prednisone. The decision to go to injectable steroids may wait to see how you responded to the oral dose.
• Upgrade to prescription-strength muscle relaxants.
• Possible use of anti-seizure medications to help with neurologic pain.

Injections

If these upgraded medications did not help your back pain and you have tried physical therapy and chiropractic techniques without more long-term success, your doctor may be or already has recommended and given you injections.

Epidural Steroid Injections

We have a very extensive article: Alternatives to Epidural Steroid Injections. Which discusses the benefits, risks, and realistic outcomes of epidural steroid injections. Here we will briefly outline some points from that article.

If you have had a discussion with your doctor about the use of Epidural steroid injections, remember what they likely said about the realities of this treatment:

• Epidural steroid injections ease the pain temporarily by reducing the size of stressed nerve roots.
• There are however concerns over short-term gain versus long-term costs in the use of epidural steroid injection because of the well-documented side effects.
• Epidurals are part of the common treatments for light (not severe) cases of lumbar radiculopathy which usually include NSAIDs (non-steroidal anti-inflammatory drugs), physical therapy, or chiropractic treatment.
• Although many patients respond very well to these treatments, they are only temporary fixes that can help ease the pain and only relieve some symptoms of the condition.

Understanding Epidurals

A very brief description of the goal of this injection is pain relief through a reduction of inflammation and swelling in the epidural space. The epidural space is an area of the spine that surrounds the spinal nerves and the spinal cord. So injecting into this space allows for access to the spinal nerves and the ability to send a small amount of anesthetic (painkiller) to numb the nerves and block pain signals between spine and brain.

The injection can be given as:

• interlaminar epidural injections (which delivers the injection over a wider area of the back),
• transforaminal epidural injections, (more targeted to a specific nerve – some call this an epidural nerve block or epidural block injection),
• and caudal techniques (delivery into the extreme lumbar spine).

Epidural steroid injections CANNOT be repeated without concern regarding the duration of time between injections.

In May 2020, the journal Pain Medicine,(3) published a section of the journal titled: “Fact Finders for Patient Safety.” In this section came the findings of the Spine Intervention Society’s Patient Safety Committee. What were these findings? The identification of “Two Myths.”

• Myth #1: Epidural steroid injections can be repeated without concern regarding the duration of time between injections.
• Myth #2: A “series” of epidural steroid injections are sometimes required regardless of the clinical response to a single epidural steroid injection.

Myths are busted you should not offer Epidural steroid injections in this way:

What was published as “fact,” was:

• Fact:
  • After an epidural steroid injection, a period of up to 14 days may be needed to assess the clinical response.
  • Systemic effects on the hypothalamic-pituitary-adrenal (HPA) axis may last three weeks or longer. (These are the well-known side effects of epidurals, they include Cushing’s syndrome where a fatty hump may develop between the shoulders, a rounded face (moon face), and pink or purple stretch marks.)
  • These factors must be considered when determining if or when another Epidural steroid injection is indicated.
  • There is no evidence to support the routine performance of a “series” of repeat injections without regard to the clinical response.”

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.