Thoracolumbar Spondylosis N004

Current RMA Instruments

Changes from previous Instruments

ICD Coding

ICD-10-AM Codes: M47.14, M47.15, M47.16, M47.17, M47.24, M47.25, M47.26, M47.27, M47.84, M47.85, M47.86, M47.87, M47.94, M47.95, M47.96, M47.97 or M51.3

Brief description

Thoracolumbar spondylosis is a degenerative disease affecting the joints in the thoracic and lumbar spine, i.e. the intervertebral discs and the facet joints (zygapophyseal joints).  It results in back pain and stiffness and there may be nerve-related referred pain or other symptoms in the legs.  The thoracolumbar spine includes all thoracic vertebra from T1 to T12, the lumbar vertebrae from L1 to L5, and the lumbosacral junction (L5/S1).

Confirming the diagnosis

The diagnosis requires both clinical manifestations (symptoms and signs) and evidence of relevant bone/joint pathology (osteophytes, disc space narrowing, facet joint degeneration).  A diagnosis that is based on imaging (X-ray, CT, MRI) evidence is required for the SOP to apply (see further comments below).  

The relevant medical specialist is an orthopaedic surgeon, neuro/spinal surgeon, or rheumatologist.

Diagnostic labelling

The appropriate diagnostic labelling will depend on the circumstances of the case.

Diagnoses of lumbar spondylosis or thoracic spondylosis can be made when the spondylosis is limited to the lumbar or thoracic spine.  A combined diagnosis of thoracolumbar spondylosis is also now an option and this should generally be used if there is involvement of both parts.

Some SOP factors apply to lumbar spondylosis only.  If one of those SOP factors is being contended then lumbar spondylosis would generally be the appropriate diagnostic label.

Some other SOP factors apply only to an affected joint or the adjacent vertebral level (for e.g. an intra-articular fracture or surgical fusion procedure).  If one of those restricted SOP factors is contended and no other more general factors are applicable then a diagnosis that specifies particular vertebrae is an option, but a broader diagnosis would generally be preferable to avoid potential operational difficulties at a later time for both liability and impairment considerations.

It may be appropriate to consider making separate diagnoses if there are separated areas of spondylosis in the spine with different causal factors involved, or different dates of clinical onset.  But if, say, lumbar spondylosis has been previously diagnosed and the degeneration now involves the lower thoracic spine then that will generally be best considered as part of the original diagnosis.  

Additional diagnoses covered by these SOPs

• Degenerative disc disease of the thoracolumbar spine.
• Disc desiccation of the thoracolumbar spine.
• Facet joint osteoarthritis of the thoracolumbar spine.
• Lumbar spondylosis
• Thoracic spondylosis

Conditions which may be covered by these SOPs

• Thoracolumbar disc prolapse or herniation – An isolated thoracolumbar disc prolapse is covered by the intervertebral disc prolapse SOP. However, if the disc prolapse occurs in the presence of pre-existing spondylosis, it is likely that the new disc prolapse is an integral manifestation of the spondylosis rather than a separate disease.
• Thoracolumbar spinal stenosis – The stenosis may be a separate additional pathology or may be an integral manifestation of the spondylosis rather than a separate disease. Separate spinal stenosis may be due to congenital/developmental anomaly, disc prolapse, or other space occupying lesions such as neoplasia.

Conditions not covered by these SOPs 

• Ankylosing spondylitis*                                  
• Costotransverse and costovertebral joint osteoarthritis*
• Diffuse Idiopathic Skeletal Hyperostosis (DISH) #
• Isolated bulging of a disc# – A disc bulge without any other concomitant signs of disc pathology such as disc desiccation, annular tears, endplate changes, osteophytes, is likely to be a physiological change and hence not a disease or injury.
• Musculoligamentous strain or sprain of the thoracolumbar spine* - Sprain and strain SOP   
• Scheuermann’s disease*

* another SOP applies 

# non-SOP condition

Clinical onset

The thoracolumbar spondylosis SOP includes a condition-specific defintion of clinical onset (cervical spondylosis is the only other SOP with such a definition).

It is likely that clinical onset will predate the first imaging evidence of degenerative change.  This will be a matter of medical judgement, based on the relevant associated symptoms.  Back pain is a non-specific symptom, with other possible causes. The nature and pattern of the symptoms (location, temporal connection, persistence etc.) needs to be consistent with a degenerative origin.  Difficulties in assessing onset may arise where a prior acute back injury, or surgery (e.g. for a disc prolapse) has occurred and symptoms have persisted subsequently.  The time to develop clinically apparent spondylosis post injury is variable and dependent on factors such as the nature and extent of the injury and age.  Most commonly, spondylosis onset following a joint injury occurs between ages 40 and 50.  Onset may be as soon as 5 years post injury, particularly if of older age at the time of injury, but is more likely to be 10 years or more (and up to several decades later), particularly if the injury occurred at a young age (<25). The clinical onset will not be at the time of an initiating trauma/injury.  The degeneration takes time to develop following a trauma.

Imaging evidence of joint degeneration does not establish a clinical onset, as clinical manifestations from the degeneration are also required.  An attempt should be made to backdate onset to before the time of first imaging evidence, based on the clinical picture and medical advice.  However, in the case of a prior injury or joint disorder, in the absence of a change in symptoms, and where a diagnosis of spondylosis has been made, date of first imaging showing degeneration may provide the only available marker for the time of clinical onset.

Clinical worsening

The natural history of thoracolumbar spondylosis is for the degenerative changes to slowly progress and worsen.  The symptoms may fluctuate over time and may improve in some cases.  Conventional medical therapy and operative treatment may alleviate symptoms but will not slow or reverse the condition.

Further comments on diagnosis

In exceptional circumstances the diagnosis may be confirmed without imaging, in a person > 50 years, with typical clinical manifestations, and in whom imaging cannot reasonably be undertaken or obtained.