What is the best course of action for a patient with concave depression deformities of the superior endplates of L2 and L3, possibly representing insufficiency fractures, and degenerative facet joint (Degenerative Joint Disease) arthropathy in the lower lumbar spine?

From the Guidelines

The best course of action for a patient with concave depression deformities of the superior endplates of L2 and L3, possibly representing insufficiency fractures, and degenerative facet joint arthropathy in the lower lumbar spine is to initiate conservative management, prioritizing pain control, physical therapy, and bone health optimization, as outlined in the most recent guidelines 1.

Initial Management

This approach should include pain control with acetaminophen (up to 3000mg daily in divided doses) or NSAIDs like ibuprofen (400-800mg three times daily) if not contraindicated by other medical conditions.

• Physical therapy focusing on core strengthening and spine stabilization exercises should be initiated for 6-8 weeks.
• Activity modification to avoid high-impact activities while maintaining mobility is essential.

Bone Health Optimization

For bone health, calcium supplementation (1000-1200mg daily) and vitamin D (800-1000 IU daily) are recommended, along with consideration of bone density testing to evaluate for osteoporosis 1.

• If osteoporosis is confirmed, bisphosphonate therapy such as alendronate 70mg weekly may be appropriate.
• The latest guidelines suggest that radiographs should be the initial imaging modality in patients with low back and/or pelvic pain, but if the findings are inconclusive, further evaluation by nuclear medicine bone scan or CT may be necessary, as indicated by the patient's symptoms and clinical presentation 1.

Further Evaluation and Intervention

For persistent pain, a short course of muscle relaxants like cyclobenzaprine 5-10mg at bedtime for 1-2 weeks may help.

• If conservative measures fail after 6-12 weeks, referral to a spine specialist for consideration of interventional procedures such as facet joint injections or, in severe cases, surgical evaluation may be necessary.
• This approach addresses both the potential insufficiency fractures and the degenerative changes while minimizing risks and promoting healing and stability of the affected vertebrae, in line with the most recent recommendations for managing stress and insufficiency fractures, including those in the sacrum and pelvis 1.

From the Research

Diagnosis and Evaluation

• The patient's concave depression deformities of the superior endplates of L2 and L3, possibly representing insufficiency fractures, require further evaluation to determine the age of the fractures and the best course of action 2, 3.
• If there is concern regarding recent fractures, further evaluation by nuclear medicine bone scan or CT is suggested to confirm the diagnosis and rule out other potential causes of the patient's symptoms 3, 4.
• Degenerative facet joint arthropathy in the lower lumbar spine should also be taken into consideration when developing a treatment plan for the patient 5.

Treatment Options

• For insufficiency fractures, treatment options may include conservative medical management, minimally invasive intervention, or surgical intervention, depending on the severity of the fractures and the patient's overall health 2, 6.
• Sacroplasty, a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is inserted into the bone to improve its structural integrity and alleviate symptoms, may be a viable option for some patients 2.
• Kyphoplasty or vertebroplasty may also be considered to provide symptom relief for patients with vertebral compression fractures 5.
• For patients with sacral insufficiency fractures, treatment options may include non-operative, conservative management or surgical intervention with lumbopelvic fixation, depending on the severity of the fractures and the patient's overall health 6.

Imaging and Diagnostic Techniques

• Radiographs are the basic modality used for screening of insufficiency fractures, but may have limited sensitivity depending on the location of the fractures 3.
• Magnetic resonance imaging (MRI) is a sensitive tool for visualizing bone marrow abnormalities associated with insufficiency fractures and can help differentiate between benign and malignant fractures 3, 5.
• Computed tomography (CT) scans can depict subtle fracture lines and allow direct visualization of cortical and trabecular bone, making them a useful diagnostic tool for insufficiency fractures 3, 6.
• Bone scintigraphy and positron emission tomography-CT (PET-CT) may also be used to detect fractures and differentiate between benign and malignant fractures 3, 4.