Ministry of Defence

Synopsis of Causation

Spondylosis

Author: Dr Tony Woolfson, Medical Author, Medical Text, Edinburgh

Validator: Professor S P F Hughes, Charing Cross Hospital, London

September 2008

Disclaimer
This synopsis has been completed by medical practitioners. It is based on a literature search at the
standard of a textbook of medicine and generalist review articles. It is not intended to be a metaanalysis of the literature on the condition specified.
Every effort has been taken to ensure that the information contained in the synopsis is accurate and
consistent with current knowledge and practice and to do this the synopsis has been subject to an
external validation process by consultants in a relevant specialty nominated by the Royal Society of
Medicine.
The Ministry of Defence accepts full responsibility for the contents of this synopsis, and for any
claims for loss, damage or injury arising from the use of this synopsis by the Ministry of Defence.

1.

Definition
1.1

Strictly speaking, spondylosis means fusion of vertebrae. In normal usage, however, the
word refers to a variety of conditions involving degenerative changes of the spine.
These are:

1.2

Cervical spondylosis
Lumbar spondylosis
Lumbar degenerative disc disease; and
Lumbar facet arthropathy

Related changes in the longitudinal ligaments and the ligamentum flavum are often also
included.

2.

Clinical Features
2.1

Clinical features.1,2 Degenerative disease of the spine is an inevitable consequence of

ageing. Back pain is a frequent complaint, but in general practice it has been reported
that a definite cause for the pain is established in only about 15% of patients.3
Degenerative changes in the vertebrae, intervertebral discs and ligaments becomes
increasingly common with age. It is reported that 7% of people in their 20s have annular
tears in their lumbar discs. This increases to 20% in the 30s, 41% in the 40s, 53% in the
50s, and 85% in the 60s, whilst 92% of people over 70 have been shown to have these
tears.4 However, a relationship between any of these changes and the patient's
symptoms is very difficult to prove. The most clinically important forms of
degenerative disease of the spine are the four described below. Overall, lumbar
symptoms are more frequent than cervical symptoms, although 60% of patients with
low back pain have cervical spondylosis.
2.1.1

Cervical spondylosis is a common chronic condition of the neck involving the

vertebral bodies (osteophyte formation), intervertebral discs (deformation, disc
herniation), and adjacent ligaments. 80-90% of people over the age of 50 years
have radiological evidence of degenerative changes in the cervical spine, but the
vast majority of these are asymptomatic.5 The nerve root foramina and the
spinal canal may be narrowed, and nerve roots and the spinal cord compressed.
Symptoms include neck pain and frontal headaches, paraesthesiae and pain in
varying distributions according to which nerve roots are involved, progressive
weakness from nerve root compression (radiculopathy), and even paralysis and
bowel or bladder dysfunction if the spinal cord is compressed (myelopathy).6

2.1.2

Lumbar spondylosis describes the presence of osteophytes arising from the

bodies of the lumbar vertebrae. Whereas cervical spondylosis is usually
considered as a single entity, some authors make a distinction between the three
main components of degenerative disease of the lumbar spine, of which
osteophyte formation is one. The other two (disc disease and facet arthropathy)
are described below. Osteophytes are usually seen on the anterior and lateral
aspects of the superior and inferior margins of the vertebral bodies. They are the
result of new bone formation in response to stresses on the ligaments. These
changes occur in more than 80% of people over the age of 50 in the Western
world, although only a small proportion of these have any symptoms that can be
convincingly related to the radiological changes.7 Osteophytes are not
themselves painful. If the nerve root canals are narrowed, this may produce
nerve root compression. These patients may experience pain, or there may be
numbness, paraesthesiae or (lower motor neurone) muscle weakness in the
distribution of the relevant nerves.

2.1.3

Lumbar degenerative disc disease occurs as a normal part of the ageing

process, although there are other contributing factors (see aetiology). As with all
the other components of degenerative disease of the spine, changes can be
demonstrated with increasing frequency related to age, but degenerative discs
are not necessarily painful and the degree of change cannot generally be related
to the presence or severity of symptoms. When symptoms occur, they are often
associated with a precipitating event such as sudden flexion or rotation, but
some episodes begin without such an event. Pain due to disc damage is usually
dull in nature, but can be very severe, and is felt in the low lumbar or buttock

areas. Movements that put a load on the disc precipitate the pain. If there is a
prolapse of the disc resulting in impingement on the nerve roots, there will be
symptoms and signs according to the site and degree of root compression.
Lumbar disc prolapse is usually preceded by previous episodes of pain, but may
occur without warning.
2.1.4

Lumbar facet arthropathy.8 The ligaments supporting the facet joints between
the vertebrae are subjected to a great deal of stress during all spinal movements,
particularly rotation and extension. These joints are well supplied by nerves and
pain can be provoked by various manoeuvres. Symptoms include local pain and
tenderness, pain on extension or rotation (usually toward the affected side),
groin or thigh pain and relief from the pain by walking. It has been claimed that
patients who do not have damage to these joints demonstrable on magnetic
resonance scanning do not have back pain.9 Injection of local anaesthesia in and
around affected joints has been shown to reduce symptoms in certain patients.
This condition on its own does not appear to produce any serious consequences,
although the pain can limit activities. It is probable that facet joint changes are
linked to the whole process of disc degeneration.

2.2

The symptom of low back pain is probably caused initially by disc injuries, initially
circumferential tears in the annulus fibrosus. The outer part of this structure has a nerve
supply, and the pain results from local damage. If there are a number of these tears, they
may join to produce one or more radial tears. Herniation of the disc may occur and will
produce symptoms depending on the pressure effects of the herniated portion. The
nucleus pulposus undergoes biochemical changes resulting in loss of water, reduction in
intrinsic resilience and change in shape. In turn, this can cause stresses on the ligaments
and facet joints. Eventually, the discs become dehydrated, smaller and irregular. By this
time, they may not themselves produce pain, but disruption of the normal anatomy
results in osteophyte formation, and stress, damage and inflammation in the facet joints
and ligaments.

2.3

Back pain and spinal cord injury may occur with decompression sickness in divers. This
is not directly related to spondylosis but may be relevant in individuals presenting with
back pain who have been divers. The damage sustained is thought to be due to the
formation of gas bubbles or fat in the arteries and veins supplying the spinal cord or in
the spinal cord itself. Recovery is usually good, but in some patients there may be longterm consequences.10

3.

Aetiology
3.1

There is no general agreement as to the cause of spondylosis. There are several

contributing factors.

3.2

Environment and genetics

3.3

3.2.1

Degenerative disease of the spine was thought for some time to be entirely due
to loading stresses and repeated minor trauma to the discs, joints and ligaments.
However, the aetiology of degenerative spine disease is now known to be more
complex and multifactorial, with family history and childhood environment
being of considerable importance.11

3.2.2

Family and twin studies have demonstrated the significant role of genetic
factors, and various specific genetic features have been shown to be associated
with sciatica, lumbar disc degeneration and herniation.12

3.2.3

There is also good evidence to link cigarette smoking and other cardiovascular
risk factors to degenerative spine disease and to back pain. This is probably due
to a reduction in blood supply resulting in anoxia in the intervertebral disc, and
leading to cell death. The response to this cell death is inflammation, with
ingrowth of blood vessels and nerves into the disc.

Heavy, repeated or abnormal loading

3.3.1

Physical loading of the spine almost certainly plays a part in the causation of
back disorders.13

3.3.2

The effects on the spine of compression, torsion and shearing have been
investigated directly in various studies, both in the workplace and in the
laboratory.14 In general, there appears to be a cause and effect relationship
between the magnitude of the forces exerted and the resulting damage, but the
relationships are complicated and depend on posture when the forces are
applied. In addition, tolerance to the damage and the degree of disability
produced varies greatly between individuals.

3.3.3

It may be that heavy loading of certain types can cause more symptoms in some
patients who already have age-related degenerative changes in the spine.15

3.3.4

The relationships between load and disc degeneration, are however not well
established in epidemiological studies, and reviews suggest that other issues,
such as psychosocial factors,16 are important in defining the level of resultant
illness and disability (see section 3.4 below).

3.3.5

Associations have been described between back disorders and various work
activities. A meta-analysis of 31 studies considered to be of sufficient quality
for inclusion found the strongest evidence for heavy repetitive lifting of
materials, bending and twisting.17 Similar results have been found in other
studies.18,19 There is some evidence for degenerative changes and back pain
being related to heavy general work and patient lifting (in healthcare workers),

but none for any relationship with any particular static posture such as sitting
for extended periods, standing or walking.
3.3.6

Military pilots have an incidence of back pain of 13%, reported to be related to

the flying role. This is said to be more common in helicopter pilots due to a
combination of a forward leaning posture during flight and whole body
vibration (see below). There is no good evidence that spondylosis causes the
pain nor that flying causes spondylosis.20

3.3.7

It has been suggested that symptoms occurring in the neck may be exacerbated
by the weight of helmets with their attached instrumentation. There is however
no good evidence that the pain is due to degenerative cervical spine disease.

3.3.8

There is some evidence that whole body vibration (particularly at low

frequencies) is associated with degenerative disc disease. This occurs with the
use of machine tools and driving motor vehicles, particularly tractors and
trucks, which vibrate at 3-6 Hz, the resonant frequency of the spine and whole
body. Damage is more likely in those patients who have spent long periods
driving.21 The frequency of vibration in a helicopter is rather higher, and if back
pain does occur more often in helicopter pilots, this could be related more to the
posture when flying than to the vibration.22

3.3.9

Obesity may be a contributory cause of degenerative disease of the spine, but

the evidence is not convincing.

3.3.10 A recent literature review from Canada summarises the change in emphasis in
recent years regarding occupational exposure and lumbar degeneration. In
exploring the genetic influences on the changes in the disc, Batti and
colleagues evaluated the role of occupational exposure and lumbar
degeneration. Their summary states that physical loading specific to
occupation and sport has a relatively minor role in lumbar degeneration.
Instead genetic factors are felt to have a dominant role. They consider genetic
influences explain 74% of variance in adult populations and note the
identification of several gene forms associated with degeneration.23
3.4

Psychosocial factors
3.4.1

There is no evidence linking psychosocial factors directly with degenerative

disease of the spine.

3.4.2

Psychosocial factors have, however, been shown to be of importance in defining

the frequency and severity of pain and the degree of disability.24 The most
important of these are age, history of back pain, level of education, employment
status and income, and marital status. Patients with severe pain are more likely
to have a history of pre-existing anxiety and depression, possibly related to
being in more stressful occupations. Associations have been found with worry
and with monotonous work.25

3.4.3

Stress, gender and personality traits have been shown to have significant effects
on susceptibility to low back pain following spine loading.26

3.4.4

There is increasing recognition of the strong interactions between the

biomechanical, physiological, psychosocial, and biochemical components of the
human system. Modern research is beginning to consider risk for disability from
low back pain at the systems level to include the different dimensions of the
physical and mental components of the worker.27 The US National Research
Council has also proposed an explanatory model of this type.28

4.

Prognosis
4.1

The prognosis of any of the forms of degenerative spinal disease is difficult to estimate
with any certainty.
4.1.1

Radiological changes become increasingly prevalent with advancing years, and

establishment of a causal relationship with any symptoms is problematic.

4.1.2

While the incidence of back pain seems to have changed little in the last 15
years, the rate of disability from this cause has increased greatly. In the western
world, the only more frequent cause of absence from work is upper respiratory
infection. This may reflect alterations in societal attitudes.

4.2

Cervical spondylosis is a slowly progressive condition, but only a small minority of

patients reach the point where they develop significant nerve root or spinal cord
compression requiring surgical treatment. Of these, a very small number will suffer
permanent paralysis or other severe disability.

4.3

Lumbar spondylosis may advance radiologically, but in most cases this does not cause
any real morbidity. In a small proportion of patients, narrowing of the nerve root canals
or the spinal canal can produce serious symptoms, and even in some cases, paralysis or
bowel and bladder problems.

4.4

Most patients with episodes of acute low back pain from lumbar disc degeneration are
free of symptoms within one week, and almost all are better within 3 months. With
patients who have more severe degenerative changes, their symptoms may fluctuate
and/or progress at a variable rate. Psychosocial factors may have some influence on the
degree of disability. The nerve roots and spinal cord may be compressed as the anatomy
becomes more disrupted. Disc herniations may also give rise to pressure effects, usually
on the spinal nerves, but occasionally on the spinal cord.

4.5

Lumbar facet arthropathy is common, but may or may not be responsible for
producing low back pain in an individual patient. It may certainly contribute to the
overall problem when the normal anatomy and alignment of the spine is disrupted.

5.

Summary
5.1

Spondylosis describes a range of degenerative conditions of the spine.

5.1.1

Cervical spondylosis includes all the changes that occur in the cervical spine.

5.1.2

Disease of the lumbar spine is usually divided into lumbar spondylosis

(osteophyte formation), lumbar degenerative disc disease (deformation,
herniation) and lumbar facet arthropathy.

5.2

Degenerative disease of the spine is an inevitable consequence of ageing. Radiological

changes are seen with increasing frequency in relation to age, and are almost universal
in later life.

5.3

There is a poor correlation between the extent of degenerative disease seen on imaging
and the severity of symptoms or disability. Many people are asymptomatic despite
advanced radiological changes.

5.4

Although the prevalence of degenerative disease of the spine has not changed
significantly in the last 15 years, the amount of perceived disability and absence from
work has increased greatly. This may be related to alterations in attitudes in society.

5.5

The aetiology of symptomatic degenerative disease of the spine is complex and not fully
understood. Repeated loading and torsion producing sub-clinical injury certainly plays
some part, and associations have been established with certain work-related activities,
the most important being repeated heavy lifting, particularly involving bending and
twisting, and with exposure to whole body vibration from using machine tools and
driving motor vehicles. However spondylosis is common in those with sedentary
occupations and research over the past decade, including twin studies, has confirmed
the importance of genetics. A recent literature review found that heredity was the
dominant influence in disc degeneration with sport- and occupation-associated physical
loading playing only a minor part.

5.6

Psychosocial factors are important in defining the degree of disability caused, and
explanatory models are being developed from a systems perspective which bring
together biomechanical, physiological, psychological, psychosocial and biochemical
aspects.

5.7

A cause and effect relationship for the origin of symptoms can be very difficult to
establish in an individual patient.

10

6.

Related synopses
Spondylolisthesis
Low Back Pain
Neck Pain

11

7.

Glossary
annulus fibrosus

The outer fibrous ring of an intervertebral disc.

arthropathy

Pathological process affecting a joint.

cervical

Referring to the neck region. There are seven cervical

vertebrae.

facet (zygapophyseal) joint

The part of a vertebra which articulates with a paired part

on the next vertebra. Thus there are two facets on the
superior aspect and two on the inferior aspect of each
vertebra.

foramen (plural foramina)

Channels in bone, through which blood vessels or nerves

travel.

herniation

Bulging through a weakness in supporting structures.

lower motor neurone

The nerve cell found in peripheral nerves. Damage causes

wasting of muscles and a flaccid weakness.

lumbar

Referring to the lower back region. There are five lumbar

vertebrae.

myelopathy

Any pathological process affecting the spinal cord.

nucleus pulposus

The central part of an intervertebral disc

osteophyte

A spur-like outgrowth of bone.

paraesthesiae

Abnormal sensations burning, prickling, pins and

needles.

psychosocial

Involving both psychological aspects and social

background; e.g. the patients age, education, occupation,
family and related factors.

radiculopathy

Dysfunction of a nerve root, usually due to compression.

scoliosis

A lateral curvature of the spine.

12

8.

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