The Diagnosis and Treatment of Degenerative Changes of the Lumbar Spine

Background: Certain specific degenerative changes of the lumbar spine call for a meticulous assessment of the patient’s symptoms and of the findings on physical examination and diagnostic imaging. Degenerative disc disease, spinal canal stenosis, facet joint arthrosis, and the resulting deformities are discussed here, along with the appropriate treatment for each condition.

Methods: This narrative review is based on information from pertinent publications retrieved by a search in PubMed.

Results: The history and physical examination are determinative. The findings of imaging studies are not necessarily correlated with the clinical manifestations. In the absence of red flags such as a new neurologic deficit or a suspected tumor, the patient can be treated conservatively with analgesics, physiotherapy, or specific infiltrations. If no improvement ensues, or if there is an absolute indication for surgery, decompressive and/or fusion techniques are used, depending on the particular abnormality that is present. A randomized controlled trial has shown the superiority of decompression over nonsurgical management for lumbar spinal canal stenosis (Oswestry Disability Index [ODI] mean difference 7.8, 95% confidence interval [0.8; 14.9]). On the other hand, a study of pooled data on fusion procedures yielded a mean difference of −7.39 points in the ODI score favoring surgery [−20.26; 5.47] [p = 0.26]).

Conclusion: For many surgical techniques, the supporting scientific evidence is sparse. The authors recommend treatment in a specialized center.

Cite this as: Beyer F, Eysel P, Bredow J: The diagnosis and treatment of degenerative changes of the lumbar spine. Dtsch Arztebl Int 2025; 122: 249–56. DOI: 10.3238/arztebl.m2025.0056

Lumbar back pain is one of the more common reasons for medical consultation.

It can be subdivided into non-specific lower back pain and specific, degenerative (wear-related) changes in the lumbar spine. The latter require differential diagnosis and are the subject of this review. The S2k guideline on specific low back pain appeared in 2023 (DGOU Guideline 187–059 – Specific Low Back Pain [1]). The reported prevalences of individual diseases vary widely. In 1990, Boden et al. reported that one-third of asymptomatic subjects had abnormal findings on magnetic resonance imaging scans (2), including 57% of subjects over age 60: 36% had disc herniations, and 21% had spinal canal stenosis (2). According to data from the US, 11% of the population suffers from clinical spinal canal stenosis, a condition for which 600,000 operations are performed each year (3).

Kalichman et al. found spinal canal stenosis on the CT scans of 22% of 191 subjects aged 32 to 79 in a collective derived from a population-based cohort study (4). According to the S2k guideline, 10%–41% of chronic lower back pain is mainly due to facet joint syndrome, and 26%–39% is mainly due to discogenic lumbar syndrome (often accompanied by osteochondrosis) (1). It is generally recommended that treatment decisions should not be made solely on the basis of MRI abnormalities (5). In persons without symptoms, these have no predictive value for the development or duration of lumbar back pain, even in long-term follow-up (2, 6).

Learning objectives

This article is intended to enable readers to:

• name the most common chronic degenerative changes of the lumbar spine;
• recognize urgent indications for treatment and typical symptoms;
• assess the basic principles of treatment and its indications.

Methods

This narrative review of the basic clinical entities and their pathogenesis and treatment is based on pertinent publications retrieved by a literature search in PubMed (06/24–03/25). The focus is on the degenerative changes in the lumbar spine that are of practical relevance for treatment. This review covers only a portion of the field of spinal surgery, as back pain can also be due to trauma, neoplasia, or infection/inflammation. Precise and reliable information on the general frequency of morphological degenerative changes cannot be provided, as these are almost always present in combination. A major aim of this review is to explain the differential indications for treatment.

Results

History, physical examination, and diagnostic tests

The patient’s symptoms are the main determining factor for the treatment of specific degenerative spinal changes and should be documented in detail. Pain is a primary symptom; its duration, intensity, and localization should be noted. A key distinction is that between pain limited to the back and pain radiating into the buttocks or legs. Patients can generally draw this distinction themselves and describe their pain in percentages, e.g., 80% back pain and 20% leg pain. If the patient complains of radiating pain, the physician must determine whether it is radicular (attributable to a particular lumbar nerve root) or pseudoradicular. Peripheral nerve disorders should also be considered in the differential diagnosis and assessed by a neurologist if necessary. If spinal canal stenosis is suspected, the patient should be asked how far they are able to walk, and the examiner should feel the pulses in the lower limbs. Further important information for the history includes comorbidities, medications, the patient’s occupation and employment history, and evidence of a possible psychosomatic cause.

The history provides an initial basis for deciding whether urgent action is needed. Specific so-called red flags have been established for spinal disorders. In a review of 21 guidelines on lumbar back pain, Verhagen et al. identified 46 red flags (8). Simply stated, urgent diagnostic evaluation (and, possibly, urgent treatment) is indicated if it seems possible or probable that the cause lies in one of the four MINT categories (eBox 1).

eBox 1

Indications for urgent diagnostic evaluation of low back pain with or without radiation into the lower limbs

The basic diagnostic evaluation of degenerative changes consists of lumbar spine plain films in the anterior-posterior (a. p.) and lateral positions with the patient standing and a noncontrast magnetic resonance imaging (MRI) scan. If MRI is contraindicated, computerized tomography (CT) can be used, or myelographic CT if necessary. So-called functional plain films taken in inclination and reclination can be used in specialized consultation to answer specific questions. MRI with contrast can be useful for differential diagnosis, e.g., in the early stages of spondylodiscitis.

The pathophysiological mechanisms depicted in Figure 1 bunderlie the clinical entities discussed below. They generally arise in combination and are due to one or more of the degenerative diseases that will be described.

Figure 1

The typical course of lumbar spinal stenosis

Figure 2

Flow chart for the diagnosis and treatment of lumbar pain

Abnormalities of the intervertebral discs

Degenerative disease in a spinal segment is thought to begin with wear-related changes in the intervertebral disc (9). The discs undergo a natural aging process which is primarily not pathological (10). In 2001, Pfirrmann et al. described five types that can be reliably distinguished from each other in T2-weighted MRI images; the main finding is of gradual dehydration and loss of disc height (11). In a Japanese cross-sectional study of persons over 60, plain films revealed Kellgren and Lawrence grade III or IV lumbar disc abnormalities in 50.4% (12). This change becomes clinically apparent when osteochondrosis arises in the adjacent vertebral bodies and manifests itself as back pain as the main or only symptom. Ito et al. described the multifactorial origin of pain from a combination of indirect factors, such as instability and mechanical, nociceptor-mediated pain from adjacent structures in the affected segment, and direct factors, such as nociception and inflammatory processes in the intervertebral disc itself (13). The origin of the pain can sometimes be localized to a particular segment with the deliberate provocation of pain by the infiltration of fluid into a disc; this procedure, known as discography, is no longer recommended, both because it is painful and because it may lead to the progression of disc degeneration (14).

Spinal canal stenosis

Spinal canal stenosis is most common in older people. According to a meta-analysis, its prevalence ranges from 11% to 38%, and persons who suffer from it have an average age of 62 years (range, 19 to 93) (15). It often arises through the combination of a broad-based disc protrusion, hypertrophic facet arthrosis, and hypertrophy of the ligamentum flavum (16). Hypertrophy of the epidural fat (epidural lipomatosis) can contribute to it as well (eFigure 1). Lipomatosis is sometimes the result of long-term steroid use (17, 18). The main clinical symptom of lumbar spinal canal stenosis is a reduced walking distance, with improvement of symptoms when the patient leans forward. The latter observation, along with an absence of limitation of the distance that the patient can travel by bicycle (if applicable), can help distinguish the intermittent claudication of lumbar spinal canal stenosis from that of peripheral arterial occlusive disease (PAOD). Radicular symptoms and signs can also arise as a consequence of stenoses of individual neuroforamina, or of lateral recess stenosis with intraspinal narrowing affecting a more distally exiting nerve root. Paresis is rarely severe. Egli et al. described a group of patients for whom surgery was already planned. Over 80% had no more than minor sensorimotor deficits, and 85–100% of the segmental muscles tested were found to be of normal strength. The electrophysiological findings were, however, abnormal in 87% of the patients (19).

eFigure 1

“Absolute” spinal canal stenosis

Facet arthrosis

Arthrosis affecting the facet joints (spondylarthrosis) is rarely an isolated finding, as it is usually accompanied by progressive loss of disc height and ensuing changes in mechanical load and asymmetry of the articular processes (20). This is clinically expressed as segmental back pain, with pain elicitable by local pressure during physical examination or by forced inclination or reclination of the lumber spine (21). Facet joint hypertrophy can lead to spinal canal stenosis and spinal claudication and/or to foraminal stenosis and radicular symptoms. Because spondylarthrosis is generally seen in combination with osteochondrosis, isolated treatment for spondylarthrosis is only considered in cases of mild or moderate degeneration of the associated intervertebral disc.

Degenerative spondylolisthesis

Spondylolisthesis is vertebral slippage, i.e., an abnormal position of a vertebra in relation to the vertebra immediately below, as revealed by imaging studies (22). Degenerative spondylolisthesis (sometimes called “pseudospondylolisthesis”) arises because of segmental degeneration with loss of disc height, while non-degenerative (“true”) spondylolisthesis is due to a defect or insufficiency of the pars interarticularis (4, 23). The degenerative type often results from advanced facet joint degeneration that can no longer be compensated for by joint hypertrophy. An unfavorable change of the center of rotation of the facet joint is regularly observed and is also a cause of local pain in the lower back (22). Back pain is only mild or occasional in early degenerative spondylolisthesis; later on, mechanical back pain, with a feeling of suddenly giving way, is generally combined with secondary spinal canal stenosis or foraminal stenosis (eFigure 2). For the treatment of spondylolisthesis, see also eBox 2.

eBox 2

Degenerative spondylolisthesis

eBox 3

De novo scoliosis

eFigure 2

Sagittal and axial T2-weighted magnetic resonance images without contrast

De novo scoliosis

Older adults may develop three-dimensional degenerative spinal curvature, particularly in the lumbar spine (25, 26).

Treatment options

Gibson et al. stated in a Cochrane Review in1999, “There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative management.” (30) Resnick et al. pointed out a decade later that absence of proof is not proof of absence (31), but the evidence base remains sparse to this day.

Conservative measures

Chronic degenerative changes in the lumbar spine do not usually require surgery unless so-called red flags are present. The first line of treatment is certainly conservative. In practice, this generally means the prescription of oral analgesics according to the stepwise approach of the WHO (the “analgesic ladder”). It was concluded in two Cochrane reviews that non-steroidal anti-inflammatory drugs (NSAIDs) alleviate both acute and chronic back pain. The reported effect sizes (on a pain scale from 0 to 100) were −6.97 points [−10.74 to −3.19] for chronic back pain and −7.20 points [−10.98 to −3.61] for acute back pain, and no active ingredient was found to be superior to the others (32, 33). Deyo et al. also concluded that opioids alleviate chronic back pain over the short term, but no studies are available on opioid administration for longer than four Opioid side effects and the risk of dependence in (3.7–26% of patients) must be considered as well (34). Werber et al. determined, on the basis of data from Barmer GEK

(a statutory health insurance carrier), that one-third of opioid prescriptions in Germany are for back pain (35).

Physical therapy for acute back pain was classified as ineffective by Karlsson et al. in a systematic review (36), while active exercise programs are recommended in multiple guidelines for the treatment of chronic low back pain (37, 38, 39). Active exercise programs are those that are mainly carried out by the patients themselves, as opposed to mobilization techniques and manual therapy, which are mainly carried out by professionals (36). Coulter et al. found a moderate degree of evidence favoring manual therapy over active exercise programs for the treatment of chronic back pain: in an inverse Revman model, the standardized mean difference was –0.43, with high heterogeneity ([–0.86 to 0.00]; p = 0.05, I² = 79%) (40).

Infiltrations play an important role in the diagnosis and treatment of chronic back and leg pain. Nerve root blocks, facet joint infiltrations, and single-shot peridural anesthesia are the most commonly used techniques (“epidural infiltration” is the usual term for the latter in English-speaking countries).

Nerve root blocks are usually carried out as periradicular therapy (PRT) under CT or fluoroscopic guidance. They are a suitable treatment not only for the radicular pain associated with disc herniation, but also for neuroforaminal stenosis (e1). Facet joint blocks, too, should be carried out under imaging guidance (e2). Both of these procedures can have therapeutic and diagnostic relevance. In particular, if the MRI reveals many different degenerative abnormalities, exploratory infiltrations at individual sites, with a suitable temporal interval in between, can be used to localize the origin of the patient’s symptoms. Symptoms due to disc herniation or (with less evidence) lumbar spinal stenosis can be relieved by the application of local anesthetics and corticosteroids (e3, e4). Level I evidence exists for symptom relief for up to three months after the intervention, and Level II evidence for continued relief on follow-up at six and twelve months (e5). Epidural corticosteroid infiltration can cause epidural lipomatosis (17, 18) as well as an increased risk of dural injury in operations performed up to six months afterward (e6). If lumbar back pain responds well to facet joint infiltration, a neuroablative procedure such as radiofrequency denervation can also be considered. In a meta-analysis, Lee et al. found that such procedures lead to statistically significant and clinically relevant pain relief (on a visual analog scale) for up to twelve months (e7). An S3 guideline on this topic was published in 2024 (e8).

Surgical techniques

In principle, surgical treatment is never absolutely necessary for the degenerative conditions discussed above, unless red flags are present. The patient’s quality of life determines the appropriate time to talk about surgery. The degenerative changes that are seen on imaging studies and that are to be operated on must clearly be responsible for the patient’s symptoms and signs. If this is the case, then the potential benefits of the surgical methods described below, as well as their risks, can be discussed with the patient.

In lumbar spinal surgery, a variety of techniques are used, and sometimes combined, depending on the pathology and the clinical manifestations. The common techniques are stability-preserving decompression of the spinal canal (including foraminotomy), resecting disc surgery (nucleotomy or sequestrectomy), and fusion procedures for individual or multiple spinal segments, e.g., posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF). Interbody fusions are also possible via anterior, oblique, and lateral approaches (ALIF, OLIF, and XLIF/LLIF). The reader is referred to the eTable for the effects of fusion procedures and the evidence supporting them.

eTable

The evidence base for lumbar spinal fusion in degenerative disc disease and osteochondrosis

Stenosis causing compression of a nerve root or of the dural sac (cauda equina), as confirmed by MRI, with relevant clinical manifestations and without any significant degree of motion-induced back pain can be treated with decompression of the spinal canal and the neuroforamina. Total laminectomy has been abandoned, because it can cause segmental instability (e9). As a rule, the ligamentum flavum is resected and the spinal canal is widened through an interlaminar window, with undercutting of the laminae in a way that preserves stability (e10). A unilateral opening with extension of surgical access across to the other side, dorsally to the dura, is called over-the-top decompression and should always be attempted for maximal preservation of stability, so that segmental instability and the ensuing rapid progression of osteochondrosis can be avoided. Decompression has been shown to yield better long-term results than conservative treatment for lumbar spinal stenosis (e11, e12). The multicenter SPORT trial by Weinstein et al. involved a randomized cohort of 289 patients and an observational cohort of 365 patients with lumbar spinal stenosis. In the randomized cohort, 138 patients were assigned to surgery, of whom 94 (68%) underwent surgery within 4 years; 151 subjects were assigned to non-surgical treatment, of whom 74 (49%) nonetheless underwent surgery within 4 years. In the observational cohort, 219 opted for surgery, and at 4 years 213 (97%) had actually undergone surgery. Thirty-eight (26%) of the 146 subjects who opted for conservative treatment had undergone surgery by the time of the 4-year follow-up. The intention-to-treat analysis did not reveal any statistically significant differences between surgery and conservative therapy. On the other hand, in the as-treated analysis, taking the many crossovers into account, the Oswestry Disability Index (ODI) score, which was 43.2 points at baseline (standard error 0.6), improved by −18.7 points (standard error 1.1) in the surgical group and −9.3 points (standard error 1.3) in the non-surgical group (effect size −9.4, [−12.6 ; −6.2] (e11). Malmivaara et al. likewise showed improvements in the ODI score and in back and leg pain (on a 0–20 scale): the mean differences on follow-up at 2 years were, for back pain, 2.1 [1.0; 3.3], and for leg pain, 1.5 [0.3; 2.8] (see also the Table)(e12).

Table 1

Treatment options for other specific degenerative changes, with evidence

A variety of surgical techniques are available for the fusion of one or more spinal segments. The goal is to lessen motion-induced pain in a degenerated segment, er else to relieve pain by elevating the affected facet joint through a bony fusion (e13). Among these techniques, PLIF and TLIF have been most widely used and studied. In both, the vertebral bodies are held in place with screw-rod systems and, once the intervertebral disc has been resected, one or two intervertebral cages are inserted to achieve a ventral fusion. The difference between these two techniques lies in the mode of access to the disc space, which also serves as the path for decompression of the spinal canal. In PLIF, this is usually done through a bilateral interlaminar fenestration, while in TLIF, a facet joint is resected (sometimes both, if both facet joints are diseased or in the presence of spondylolisthesis) (e14). PLIF and TLIF are particularly effective when back pain is the main symptom, with or without spinal canal stenosis, as is generally the case in patients with osteochondrosis (e15). Moreover, they enable treatment for sciatica and spinal intermittent claudication. For the treatment of de novo scoliosis, see eBox 4.

eBox 4

The treatment of de novo scoliosis

General statements on outcomes after spinal surgery should be made very cautiously. When performed for strict indications, fusion surgery brings about significant long-term improvement (29, e16, e17, e18). Eck et al. found level II evidence supporting surgical fusion over physical therapy (alone) for intractable back pain in patients without spinal canal stenosis or spondylolisthesis, but the superiority of surgical treatment was no longer evident when physical therapy was combined with behavioral therapy. The efficacy of fusion surgery for this group of patients is generally based only on case series or cohorts of evidence level IV (e19). For patients with degenerative spondylolisthesis, the RCT of Weinstein et al. showed the superiority of surgery over non-surgical treatment. The observed differences [with 95% CI] were 12.6 points [15.5; 9.7] for the ODI score, 17.0 points [13.0; 20.9] for the SF-36 pain subscore, and 16.1 points [12.3; 19.8] for the SF-36 physical function subscore (e20). Adjacent-segment degeneration after fusion remains a major unsolved problem (e21, e22): after fusion surgery on the lumbar spine, degeneration of the adjacent segment is radiologically present in 26.6% [21.3; 31.9%] of cases, and symptomatic in 8.5% [6.4; 10.7%] of cases (e23). See also eBox 5.

eBox 5

The significance of pelvic incidence

In general, the patient’s age, comorbidities, and prior hospitalizations are independent risk factors for life-threatening complications of spinal surgery (e29). In a systematic review of 455 reports of clinical studies in spinal surgery (entire spine), 163 (35.8%) contained no information on complications. Complications were mentioned and classified in 89 (30.4%); 11 different classification systems were used. The follow-up period was 30 days in 47 studies, 90 days in 31 studies, and the total follow-up of each patient in 88. 126 reports contained no information on the duration of follow-up (e30). In general, thoracolumbar procedures had 17.8% more complications than cervical procedures (8.9%; p < 0.001; odds ratio [OR] 2.23). Studies with a prospective design yielded higher complication rates (19.9% versus 16.1%, p < 0.001) (e31). The reported frequency of intraoperative dural injury ranges from 3.5% to 15.9% (e32), while that of wound infection ranges from 1.0%–2.6% in prospective studies (e31). Neurologic deficits are seen after 0.82% of spinal operations (e33), including paraparesis or paraplegia (ASIA A-C) in 0.178% (e34). The choice of the particular surgical technique to be used must, therefore, be made on the basis of a detailed medical history, lumbar spine plain films in two planes in the standing position, lumbar spine MRI, and, if necessary, diagnostic infiltrations. The structural changes to be addressed and the surgical techniques used to treat them, along with their supporting evidence, are presented in the Table and the eTable.

Conclusions

The most common degenerative conditions of the lumbar spine are spinal canal stenosis, foraminal stenosis, facet arthrosis, osteochondrosis, degenerative spondylolisthesis, and de novo scoliosis. The choice of treatment depends on the symptoms and signs, the imaging findings, and individual patient factors.

There have been no more than a few clinical studies and meta-analyses comparing surgical to conservative treatment. Particular methodological aspects must be considered as well. For example, patients were included in the RCT of Fairbank et al. when neither they nor their treating physicians had a clear preference for either surgical or conservative treatment (e39). Some studies permitted multiple surgical procedures within a group or specified no diagnosis beyond “chronic lumbar back pain” (e39, e40), which makes it difficult to analyze individual pathological entities.

In the authors‘ view, the correlation between imaging findings and clinical manifestations is low. Complication rates are high, especially in older patients, and economic pressure on hospitals creates inappropriate incentives for treatment. Certification by the German Spine Society is an established and structured opportunity for further training in this area. In the authors‘ opinion, the provision of appropriate treatment to patients in need of it could be improved by better cooperation between general practitioners and specialists across the outpatient and hospital sectors.

Conflict of interest statement
The authors declare that no conflicts of interest exist.

Manuscript received on 27 August 2024, revised version accepted on 24 March 2025.

Translated from the original German by Ethan Taub, M.D.

Corresponding author
Dr. med. Frank Beyer

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