Have you been diagnosed with wear and tear lumbar spondylosis?

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 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 though 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 a lot time.”

Lumbar Spondylosis MRI

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.”, 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? “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 which 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.)
  • 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, osteophytosis (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 disk 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 end plates of soft tissue) spondylitis, hypertrophic (enlarged bone or joints) arthritis, and osteoarthritis.1

The bottom line is lumbar spondylosis is a degenerative condition that prevents the lumbar spine from doing its job of bearing the 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 may only be a loose hinge in the facet joint

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. That is 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. At the beginning is the treatment idea is the spinal ligaments.

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

In other words, when the hinges of the spine become loose or wears out with normal use over time, symptoms develop. You may get a diagnosis of lumbar spondylosis

Using our “hinge model”, we can understand that when the ligaments fail, the joint cannot handle the management of weight load or stress bearing load. You put a lot of weight on a floor that is not reinforced to handle that weight, the floor bends and stress is put on the supporting structures, stretching them beyond capacity.

The weakened bridge shows “stretching,” the injection shows where Prolotherapy is given, at the ligament attachments to the bone. The end result, a strengthened and supported bridge.

When symptoms do develop, they are most often complaints of low back pain and stiffness, or feelings of numbness and weakness in the legs, which worsen with standing or walking and improve with sitting or lying down.

Clinical symptoms may also arise after activities involving extremes of motion such as:

  • Bending and twisting, after maintaining stationary postures such as standing for long periods of time, or after sitting with the head bent forward for stretches of time (eg, continuous texting or computer work).
  • On physical exam, limited range of motion and poorly localized tenderness are common findings in patients.

Prolotherapy for back pain

Spinal ligament laxity fails into the realm of Prolotherapy treatments. Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. There is plenty of research to support the use of Prolotherapy for back pain (especially lumbar pain), here are some of the research summaries.

  • University of Manitoba, Winnipeg, Manitoba, Canada. The journal of alternative and complementary medicine
    • One hundred and ninety (190) patients were treated between, June 1999-May 2006.
    • Both pain and Quality of Life scores were significantly improved at least 1 year after the last treatment.
    • This study suggests that prolotherapy using a variety of proliferants can be an effective treatment for low back pain from presumed ligamentous dysfunction for some patients when performed by a skilled practitioner.(2)
  • Harold Wilkinson MD, in the journal The Pain Physician
    • Prolotherapy can provide significant relief of axial pain (soft tissue damage) and tenderness combined with functional improvement, even in “failed back syndrome” patients.(3)

Citing our own Caring Medical and Rehabilitation Services published research on Prolotherapy results for low back pain. We followed 145 patients who had suffered from back pain on average of nearly five years, we examined not only the physical aspect of Prolotherapy, but the mental aspect of treatment as well.

  • In our study, 55 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of 26 patients who were told by their doctor(s) that surgery was their only option.
  • In these 145 low backs,
    • pain levels decreased from 5.6 to 2.7 after Prolotherapy;
    • 89% experienced more than 50% pain relief with Prolotherapy;
    • more than 80% showed improvements in walking and exercise ability, anxiety, depression and overall disability
    • 75% percent were able to completely stop taking pain medications.4

If our study, mentioned above, was solely based on getting 75% of patients off their pain medications, that would be wildly successful in itself. But the fact that Prolotherapy was able to strengthen the patient’s spines and decrease overall disability and return these people to a normal lifestyle. That is not pain management, that is a pain cure.

The first step in determining whether Prolotherapy will be an effective treatment for you

The first step in determining whether Prolotherapy will be an effective treatment for the patient is to determine the extent of ligament laxity or instability in the lower back by physical examination. The examination involves maneuvering the patient into various stretched positions. If weak ligaments exist, the stressor maneuver will cause pain. Pain here is an indicator that Prolotherapy can be very effective for the patient.

Do you have a question about lumbar spondylosis? You can get help and information from our Caring Medical staff.

1 Middleton K, Fish DE. Lumbar spondylosis: clinical presentation and treatment approaches. Current reviews in musculoskeletal medicine. 2009 Jun 1;2(2):94-104.

2 Watson JD, Shay BL. Treatment of chronic low-back pain: a 1-year or greater follow-up. J Altern Complement Med. 2010 Sep;16(9):951-8. doi: 10.1089/acm.2009.0719.

3 Wilkinson HA. Injection therapy for enthesopathies causing axial spine pain and the “failed back syndrome”: a single blinded, randomized and cross-over study. Pain Physician. 2005 Apr;8(2):167-73.

4 Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155. [JOP/CMRS]



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