Spondylotıc Low Back Pain (Idiopathic)
The majority of patients who present complaining of low back pain with or without leg pain, have associated spondylotic spinal disease. These spondylotic changes may be defined as the primary loss of hydration of lumbar discs with subsequent change in signal characteristics and associated ligament thickening, chronic inflammatory changes in ligaments and adjacent endplates, loss of disc height, facet arthropathy and hypertophy with or without associated canal and foraminal stenosis, or evidence of instability. The presence of spondylosis and the complaints are at least correlated, but the correlation is far from certain ( Boden et al 1990a , Weber 1994 ). Even if the relationship is causative, the mechanisms by which the pain is produced are largely unknown. The diagnostic problem is that a substantial number of patients have spondylotic changes without any apparent related symptoms. Most of the studies that document this observation are limited in scope and only indicate that the patient is not having problems at that time or that back problems are not the predominant issue at the time. Careful population studies with detailed histories outlining past and present history for these patients have not been done. Nevertheless, virtually every physician has had the experience of seeing a patient with profound spondylotic changes who has no complaints currently and has never had complaints. These observations make the correlation of back pain with spondylotic changes difficult and more evidence is needed than the simple occurrence of spondylosis to prove causation. Nevertheless, in a sizeable majority of patients with chronic back pain complaints, spondylotic changes are present and are the only abnormalities which seem to explain the pain. The history of the problem is the most important diagnostic tool. Patients with pain of apparent spondylitic origin characteristically have more pain when standing or load bearing. The symptoms are improved by rest in most. A minority are worsened by reclining, although this is usually limited to reclining in extension. Non-steroidal analgesics are of limited use and pain is temporarily relieved by simple local modalities such as heat and massage. The pain is local in the lumbar region and the patient often can precisely identify an origin with a fingertip. Severe back pain is often associated with non-radicular leg pain, usually diffuse and aching in the anterior or posterior thighs. Associated true radicular pain is common, as is neurogenic claudication. Nearly all patients have pain worsened by activity and improved by rest. The pain is usually best in the morning and worsens with activity in contradistinction to osteoarthritis and the other spondylitic problems.
Diagnosis is made with plain X-ray ( Fig. 23.3 ), CT or MRI, all of which demonstrate different characteristics of the disease ( Hakelius & Hindmarsh 1972a ). The earliest changes are dissication of the disc. The nucleus loses its definitive character and the disc narrows, becomes irregular and loses water. First acute and then chronic inflammatory changes occur in the surrounding bone of the endplate and beyond. Discs erode the endplates and interosseous herniation occurs. There is associated ligamentous thickening, anterior and posterior disc bulges occur, and traction spurs appear anteriorly or posteriorly. The canal may narrow and degenerative changes in facets are typical. Canal narrowing is a combination of facet overgrowth, synovial hypertrophy, ligamentous thickening and bony enlargement ( Annertz et al 1990 ).
Surgical procedures are of value only for the relief of demonstrated nerve root compression, the correction of a specific pain syndromes is difficult.
Fixed deformity or stabilizing an unstable segment ( Spangfort 1972 , Weber 1983 , Hurme & Alaranta 1987 ). Patients who do not demonstrate any of these abnormalities are not likely to be benefited by surgical procedures. Pain-associated spondylosis alone does not constitute a reason for surgery. The selection of patients for surgery will be discussed in greater detail under the specific headings for which surgery is a reasonable choice. For the majority of patients, no direct intervention is likely to be of value. Therapy is symptomatic ( Bell & Rothman 1984 ). For patients whose symptoms have been present for 6 months or longer, there is strong new evidence that spontaneous improvement will not occur. The evidence is equally good that the usual conservative measures, as they are applied in a typical practice, are not useful and cannot be differentiated from no treatment. Our studies have examined many forms of standard physical therapy, manipulation therapy and a wide variety of other treatments, including acupuncture, back schools, nutritional therapies, pain treatment centres and cognitive therapies. We were unable to determine any effect of any of these treatments as currently applied in practice. Therefore, it will not suffice to simply refer patients for any of these treatments. A programme based on the best available data should be individualized for each patient ( Waddell 1987a ).
Adequate analgesia is a first choice. Non-steroidal anti-inflammatory analgesics are standard ( Basmajian 1989 ). Some investigators are examining the use of long-acting narcotics for the relief of pain of benign origin. It has been our experience that very few patients with spondylotic disease will tolerate the side effects of narcotics and refuse to use them. Some patients will be benefitted by short-term bracing, especially when active; so, a trial lumbosacral support is worthwhile. There is reasonable evidence that an individualized exercise programme to strengthen the paravertebral and abdominal muscles, combined with local measures to restore painless range of motion, will benefit many patients. These programmes are typically not available from the usual physical medicine sources, but if such a programme can be obtained, many patients will benefit. Elderly patients are particularly helped by a general physical conditioning programme as well, but any deconditioned patient can be helped. Weight loss has not been proven to be beneficial, but reduction in weight makes intuitive sense and is included in most vigorous rehabilitation efforts. Patients must be convinced that the exercise programme is worth doing and told that it will require 1–2 years to see maximum improvement. These vigorous physical therapy programmes require real commitment from patient and physician if they are to be successful. Serious osteoporosis should be treated as well ( Koes et al 1992b ).