Dissecting Low Back Pain: Degenerative causes including lumbar spondylosis, degenerative disc disease, spinal stenosis and facet joint syndrome.
Most of chronic lower back pain is due to degenerative causes. Before we go over these lets first define degenerative disease. The definition of degenerative disease is one in which the function or structure of the affected tissues or organs changes for the worse over time. In this post we are talking about the spine and the affected tissues are the vertebrae, intervertebral discs, facet joints, ligaments and tendons. As we live our lives and age, our bodies including the spine will go through wear and tear and this aging related wear and tear is what accounts for the majority of spine degenerative disease. Any injuries and trauma (falls, car accidents, lifting injuries, etc.) can add and contribute to the degeneration. The point is that its a slow gradual process resulting in gradual loss of the normal structure and function, eventually resulting in pain, stiffness, and limited mobility. How much pain there is and at what age one starts to have pain can vary from person to person.
What are the most common degenerative causes of lower back pain?
Those who are having lower back pain due to degenerative causes will likely have either lumbar spondylosis, degenerative disc disease, spinal stenosis, facet joint pain, or even some combination of the these. Now lets discuss each of these diagnoses, what they are, and what kind of pain to expect.
Lumbar spondylosis: More a descriptive term rather then a diagnosis defined as pain and loss of function from any spine degeneration. It can be due to arthritis of the spine, intervertebral disc degeneration, facet joint arthritis, to name the most common. Here the back pain is due to the painful degeneration and arthritis and will be mostly localized to the axial lower back. The pain may be right in the middle of the lower back (midline) or can effect one side or both sides (bilateral). There is usually no pain, numbness or tingling in the lower extremities unless one has developed spinal stenosis or nerve root compression. Pain will typically be worse with standing, walking, and better with sitting or laying down.
Degenerative disc disease: Not really an actual disease but more of a condition that results form natural wear and tear of the intervertebral discs. The discs are located between vertebrae bones and absorb forces of movement, twisting, bending, and walking and therefore are prone to wear and tear from all the motion and stress. The term degeneration does not necessarily mean that the symptoms get worse with age, rather it describes the process of the discs degenerating over time. Disc degeneration is a natural part of aging and is seen in everyone to some degree. Degeneration of disc however does not always result in pain and some people may never develop much back pain from it. Those that do can develop a constant chronic mild to moderate amount of back pain localized to the degenerated discs involved. The pain can occasionally flare up to a more severe level. Pain is usually worse with prolonged positions such as sitting too long or standing too long and flare ups can be due to increased activity and abnormal stress on the back.
Spinal stenosis: The word stenosis defines as an abnormal narrowing of a passage. In the case of spinal stenosis the abnormal narrowing is of the spinal canal. The spinal canal is the bony channel located in the vertebral column that protects the spinal cord and nerve roots. The most common reason for stenosis of the spinal canal is due to degenerative wear and tear. As our spine goes through the age related degenerative process with disc degeneration, facet joint arthritis, and spondylosis the spinal canal diameter may start to narrow leading to stenosis. At some point the spinal canal may get too narrow and the spinal cord and nerve roots inside will have much less space resulting in pain. The pain will usually be worse with standing and walking and feel better with sitting or with leaning forward while walking (such as leaning over a shopping cart while walking to alleviate the pain). Sometimes pain will also be in the legs and can be associated with numbness or tingling , also worse when walking and better when sitting.
Facet joint pain: The facet joints are spinal joints that connect the vertebrae bone to each other and allow movement of the spine (bend, twist, and extend in different directions). Natural wear and tear will eventually lead to degenerative joint disease and arthritis of the spinal joints. Eventually this may result in lower back pain. The pain is typically worse with standing too long or walking too long and usually better with sitting down. The pain can also be triggered when bending backwards or twisting/rotating (like in golf, tennis).
How are these diagnosed?
A good thorough history and physical exam can help a specialist diagnose and narrow down possible causes of lower back pain as these degenerative causes will have their own telltale signs and unique physical exam findings. Eventually advanced imaging like CT scan or MRI can be helpful to confirm the diagnosis.
What are the treatment options?
As mentioned above, degenerative causes of lower back pain is the result of natural wear and tear and the level of pain and loss of function can vary. Some may have little to no pain and may be fortunate to never really need formal treatment, others may have occasional episodes of pain and so called flare ups, and some unfortunately can develop constant daily chronic pain. Just as presentation and severity of pain can very so does treatment which sometimes will need to be individualized to the person as what is successful in one may not be in someone else. Usually treatment will start with physical therapy and home exercise program. Medications can be utilized responsibly to help alleviate pain while the patient goes through the physical therapy program. If trial of therapy is not successful or the pain is too severe to be able to do the therapy program then interventional care options can be explored. This can include steroid injections, nerve blocks, radiofrequency ablation and maybe even surgical options depending on diagnosis (degenerative disc vs facet joint, spinal stenosis or spondylosis). For most, surgery is typically the last result unless there are neurological deficits (weakness, loss of feeling, loss of bodily function), or refractory pain.
