What is the best treatment approach for a patient with spinal canal stenosis at L4/L5, mild disc bulge at L1/L2 and L5/S1, diffuse posterior disc bulge at L4 and L4/L5, impingement of the left L3/L4 nerve roots, and osteoarthritis (OA) of the facet joints?

From the Guidelines

The best treatment approach for a patient with spinal canal stenosis at L4/L5, mild disc bulge at L1/L2 and L5/S1, diffuse posterior disc bulge at L4 and L4/L5, impingement of the left L3/L4 nerve roots, and osteoarthritis (OA) of the facet joints should begin with conservative management, prioritizing oral NSAIDs, physical therapy, and activity modification. Initially, I recommend a combination of oral NSAIDs such as naproxen (500mg twice daily) or ibuprofen (600mg three times daily) for 2-4 weeks, along with physical therapy focusing on core strengthening and lumbar stabilization exercises 2-3 times weekly for 6-8 weeks, as suggested by recent guidelines 1. For pain management, acetaminophen (up to 3000mg daily in divided doses) can be added. If pain persists, a short course of muscle relaxants like cyclobenzaprine (5-10mg at bedtime) may help. Physical therapy should include specific exercises to improve spinal flexibility, strengthen supporting muscles, and correct posture. Activity modification to avoid positions that worsen symptoms is essential. Some guidelines, such as the 2022 American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain, recommend epidural injections for chronic low back pain due to disc disease or spinal stenosis 1. However, other guidelines like the 2021 American College of Occupational and Environmental Medicine Low Back Disorders Guideline recommend against lumbar epidural injections for spinal stenosis or chronic low back pain in the absence of significant radicular symptoms 1. Given the patient's symptoms and the recent evidence, a strong recommendation in favour of epidural injections (interlaminar, transforaminal, or caudal) of local anaesthetic, steroids, or their combination, for chronic low back pain due to disc disease or spinal stenosis is considered, as per the 2022 ASPN guideline 1. Surgery (decompressive laminectomy, possibly with fusion) should be considered only if conservative measures fail after 3-6 months or if neurological symptoms worsen, as suggested by the 2007 joint clinical practice guideline from the American College of Physicians and the American Pain Society 1. This stepped approach is recommended because conservative treatment often provides sufficient symptom relief while avoiding surgical risks, and the multiple-level involvement suggests addressing inflammation and mechanical factors is the most appropriate initial strategy. Key considerations in the treatment plan include:

• Oral NSAIDs for pain and inflammation
• Physical therapy for core strengthening, lumbar stabilization, and posture correction
• Activity modification to avoid exacerbating positions
• Potential use of epidural steroid injections for persistent symptoms
• Surgery as a last resort for failed conservative management or worsening neurological symptoms.

From the Research

Treatment Approach for Spinal Canal Stenosis

The treatment approach for a patient with spinal canal stenosis at L4/L5, mild disc bulge at L1/L2 and L5/S1, diffuse posterior disc bulge at L4 and L4/L5, impingement of the left L3/L4 nerve roots, and osteoarthritis (OA) of the facet joints may involve:

• Conservative management with medications, physical therapy, and epidural steroid injections for mild disease 2
• Surgical treatment, such as laminectomy, for severe disease 2
• Decompression and fusion for patients with degenerative spondylolisthesis or those with multilevel decompression 3
• Arthrodesis with instrumentation and decompression for patients with degenerative spondylolisthesis 3

Alternative Treatment Options

Alternative treatment options may include:

• Mesenchymal Stem Cell (MSC) injection into the epidural space and facet joints, which has shown promise in reducing inflammation and pain in patients with discogenic and arthritic back pain 4
• Translaminar MSC injection into the epidural space, which may effectively treat disc arthritis without the burden of sedation and the risks of disc space injection 4

Diagnostic Considerations

Diagnostic considerations for lumbar spinal stenosis include:

• Imaging studies, such as plain radiographs, MRI, or CT myelography, to confirm the diagnosis 2
• Clinical examination to assess symptoms, such as radicular pain, numbness, tingling, and weakness 2
• Differential diagnosis to rule out peripheral vascular disease, which presents similarly to lumbar spinal stenosis 2

Surgical Considerations

Surgical considerations for lumbar spinal stenosis include:

• Laminectomy, which continues to be the gold standard treatment for severe disease 2
• Full lateral decompression, with partial or total facetectomy if necessary, to relieve symptoms 5
• Enucleation of the intervertebral disc and removal of the posterolateral portions of the annuli fibrosi to decompress the nerve root 5