Download Spondylosis, Degeneration of Intervertebral Disc

Spondylosis, Degeneration of
Intervertebral Disc
Diagnosis/Condition:
Discipline:
ICD-9 Codes:
ICD-10 Codes:
Origination Date:
Review/Revised Date:
Next Review Date:
Spondylosis and allied disorders,
Degeneration of cervical
intervertebral disc, Degeneration of
thoracic or lumbar intervertebral disc
DC
721.0; 721.2; 721.3; 722.4; 722.5
M47.812; M47.814; M47.817; M50.30
11/1996
07/2013
07/2015
The focus of this clinical pathway is spondylosis, also described as intervertebral disc degeneration
with or without myelopathy or radiculopathy. These diagnoses refer to conditions of the
intervertebral discs caused by degenerative changes associated most commonly with the natural
consequences of aging (primary) but also occasionally with post traumatic degeneration
(secondary). Most studies suggest no causative relationship between the development of
spondylosis and factors such as lifestyle, height, weight, body mass, physical activity, cigarette and
alcohol consumption, or reproductive history. The effects of heavy physical activity are
controversial in a purported relationship to disc degeneration. It is extremely common in the
population. In the US, more than 80% of individuals older than 40 years have lumbar spondylosis,
increasing from 3% of individuals aged 20-29 years.
As the intervertebral disc ages, its hydrophyllic properties decline with resultant loss of disc height
and increased mechanical instability. This results in greater tensile forces at the junction between
the vertebral body margin and the outer margins of the disc and intervertebral ligaments. This in
turn causes the formation of new bone excrescences seen at x-ray examination and described
radiographically as osteophytes.
Often referred to as degenerative disc disease and spinal osteoarthritis, it is neither uniquely
pathological nor inflammatory. By itself, spondylosis (or disc degeneration) is most likely not a
cause for clinical concern. For example, lumbar spondylosis is present in 27-37% of the
asymptomatic population and there is no greater frequency of signs or symptoms among
individuals with osteophytes than among those without them. However, spondylosis is often seen
with more morbid conditions such as acute and chronic pain, myelopathy and radiculopathy.
It has been long observed that a diagnosis of “spondylosis, disc degeneration opr arthritis” is not
without consequence for patients. “The patient hears that there is a long-term structural difficulty
with their spine or, even worse, is given a diagnosis of arthritis. Consequently, the patient takes care
of his or her back and limits physical activity, which is a natural response to damage to an organ.
This response runs directly contrary to current advice on the management of back pain, which
emphasises active rehabilitation to prevent chronic disability, even in the face of continuing pain.”i
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Spondylosis Clinical Pathway
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Surgery is often recommended for patients with spondylosis in association with symptoms of
disabling back or neck pain, radiculopathy, lateral or central stenosis. The evidence supporting
surgery for degenerative lumbar stenosis is of variable quality and shows conflicting results with
regard to a preferred surgical technique and patient centered outcomes. ii iii Given the uncertainty of
invasive procedures, consideration of non-surgical alternatives seems warranted.
Subjective Findings and History
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Past medical history with documentation of diagnosis
Age, family history
Acute, subacute, or chronic spine pain. Often local, uni- or bilateral
Referred limb pain and paresthesia
Objective Findings
• Loss of intervertebral disc integrity that is due to degenerative change associated with
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normal aging, immobilization or post-traumatic conditions
Screen for “red flags”
Radiographic examination: Evidence of degenerative changes on X-ray
Loss of normal spinal ROM
Palpation for tenderness
Segmental joint dysfunction/subluxation
Spasm of paravertebral muscle
Orthopedic and neurological examination directed at differentiating scleratogenous from
neurogenic pain
Discogenic stress maneuvers often reproduce the patient's low lumbar and referred
symptoms.
Provocative orthopedic tests MAY reproduce the pain (e.g. Straight leg raise and other
tests that cause spinal motion may increase back pain)
Assessment
Disc degeneration should be considered a secondary diagnosis and may accompany an acute injury.
The clinical impression should indicate the specific anatomical structures (spinal level) involved
and clinically correlate them with the mechanism of injury, history, subjective complaints, and
objective findings. Be alert to possible psychosocial and economic issues or personality disorders
Kirkaldy-Willis described a pathophysiologic model that occurs in 3 phases of a continuum with
gradual transition from one to the next. However, great variation of phases can be expected in
different discs in any given individual and individuals of similar ages vary greatly.
• Phase I, the dysfunctional phase, is characterized histologically by circumferential tears or
fissures in the outer annulus. Changes to the zygapophyseal joints during the dysfunctional
phase may include synovitis and hypomobility. The facet joint may serve as a pain generator.
• Phase II may result from progressive loss of mechanical integrity of the trijoint complex. Discrelated changes include multiple annular tears (eg, radial, circumferential), internal disc
disruption and resorption, or loss of disc-space height. Changes in the zygapophyseal joints
include cartilage degeneration, capsular laxity, and subluxation. The biomechanical result of
these alterations leads to segmental instability. Clinical syndromes of segmental instability,
IDD syndrome, and herniated discs.
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Spondylosis Clinical Pathway
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•
Phase III, stabilization, is characterized by further disc resorption, disc-space narrowing,
endplate destruction, disc fibrosis, and osteophyte formation. Discogenic pain from such discs
may have a higher incidence than that of the pain from the discs in phases I and II;
Plan
Spondylosis by itself may not require treatment. Spondylosis however is often associated with
symptomatic conditions, for example, axial spine pain, referred pain, intersegmental dysfunction or
radicular syndromes, all of which may require therapeutic intervention. There is a growing body of
evidence based treatment recommendations for conditions associated with spondylosis. iv An
appropriate treatment plan should address the pathomechanics and clinical sequelae that attend
each phase of disc degeneration as well as any associated disorder (e.g. pain, dysfunction, radicular
syndrome).
Passive Care:
• Spinal manipulation and/or mobilization with exercises
• Physical therapy modalities low level laser therapy v
• Medications: OTC NSAIDS, mild analgesics, herbal medicines
• Supplementation.
Active Care:
• Education is one of the most important components of any back-care program and should
include an explanation of the natural history of acute, subacute, and chronic disc
problems
• Weight loss when indicated
• Active exercise for mobility and strength
• Posture training
• Activity/work restriction, if appropriate
• Smoking cessation.
Length of Treatment
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Conservative therapy: 3-6 months.
Referral Criteria
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Referral to an appropriate non-surgical spine specialist if no improvement noted after 6-8
weeks
Consultation with a spine surgeon may be appropriate for patients with intractable severe
function-limiting symptoms, for those with symptoms lasting longer than 6 months who
have had no relief from nonsurgical approaches, and for persons with abnormal
neurologic findings.
Resources for Clinicians
eMedicine from WebMD. Lumbar spondylosis. Bruce M Rothschild, MD
http://www.emedicine.com/med/topic2901.htm
eMedicine from WebMD. Lumbar degenerative disc disease. Rajeev K Patel, MD.
http://www.emedicine.com/PMR/topic67.htm
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Spondylosis Clinical Pathway
Copyright 2014 The CHP Group. All rights reserved.
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The Evidence
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Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2nd ed. London: Churchill
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Nerlich, A.G.; Schleicher, E.D.; Boos, N.; 1997 Volvo Award Winner in Basic Science Studies:
Immunohistologic Markers for Age-Related Changes of Human Lumbar Intervertebral Discs.
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Freemont AJ, Peacock TE, Goupille P, et al. Nerve ingrowth into diseased intervertebral disc in
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Mayer TG, Gatchel RJ, Kishino N, et al. Objective assessment of spine function following industrial
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Gross, A.R.; Hoving, J.L.; Haines, T.A.; Goldsmith, C.H.; Kay, T.; Aker, P.; Bronfort, G.; A Cochrane
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Borenstein D. Does osteoarthritis of the lumbar spine cause chronic low back pain?. Curr
Rheumatol Rep. Feb 2004;6(1):14-9.
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Harroud A, Labelle H, Joncas J, Mac-Thiong JM, Global sagittal alignment and health-related quality
of life in lumbosacral spondylolisthesis. EUR SPINE J 2013APR; 22(4) pp. 849 - 56.
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Chuck Simpson, DC, CHP Vice President, Clinical Affairs: [email protected]
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Spondylosis Clinical Pathway
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i
Roland M, van Tulder M.Should radiologists change the way they report plain radiography of the spine? The Lancet,
Volume 352, Issue 9123, Pages 229 - 230, 18 July 1998
ii
Gibson JA, Waddell G. Surgery for degenerative lumbar spondylosis. Cochrane Database of Systematic Reviews 2005,
Issue 4. Art. No.: CD001352. DOI: 10.1002/14651858.CD001352.pub3
iii
Nikolaidis I, Fouyas IP, Sandercock PAG, Statham PF. Surgery for cervical radiculopathy or myelopathy. Cochrane
Database of Systematic Reviews 2010, Issue 1. Art. No.: CD001466. DOI: 10.1002/14651858.CD001466.pub3
iv
Hurwitz E, et al. Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade 2000–2010
Task Force on Neck Pain and Its Associated Disorders JMPT Volume 32, Issue 2, Supplement, Pages S141-S175 (February
2009)
v
Chow R, et al. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and metaanalysis of randomised placebo or active-treatment controlled trials
The Lancet, Volume 374, Issue 9705, Pages 1897 - 1908, 5 December 2009
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Spondylosis Clinical Pathway
Copyright 2014 The CHP Group. All rights reserved.
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