From the Guidelines
Patients with multilevel degenerative disc disease and facet osteoarthritis should be managed conservatively with a multimodal approach, including physical therapy, medication, and lifestyle modifications, as outlined in the most recent evidence-based guidelines 1. The clinical presentation of these patients typically includes chronic axial back pain that worsens with activity and improves with rest, possible radicular symptoms into the extremities, stiffness particularly in the morning, and decreased range of motion.
Key Components of Conservative Management
- Physical therapy focusing on core strengthening and spine stabilization exercises 2-3 times weekly for 6-8 weeks
- Medication options:
- Acetaminophen (up to 3000mg daily in divided doses)
- NSAIDs such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 2-4 weeks
- Muscle relaxants like cyclobenzaprine (5-10mg at bedtime) for acute flares
- Lifestyle modifications:
- Activity modification to avoid aggravating movements while maintaining function
- Heat therapy for 15-20 minutes several times daily to help muscle spasms
- Ice may reduce inflammatory pain
- Weight management is crucial as excess weight increases spinal loading
- Patients should be educated about proper ergonomics and body mechanics
Additional Considerations
- Referral to evidence-based adjunct conservative therapies such as physiotherapy for supervised exercise or pain management for more detailed education on pain management strategies and a goal-oriented plan of care 1
- Consideration of other therapies, such as local heat or cold applications, manipulation and stretching, and transcutaneous electrical nerve stimulation (TENS) 1
- Avoidance of electroacupuncture and insufficient evidence exists to recommend acupuncture or the use of glucosamine and chondroitin products 1 If symptoms persist beyond 6-8 weeks of conservative care, consider referral for interventional procedures such as epidural steroid injections or facet joint blocks.
From the Research
Clinical Presentation
The clinical presentation of a patient with multilevel degenerative disc disease and facet osteoarthritis may include:
- Low back pain
- Radiating leg pain
- Muscle weakness
- Limited mobility and flexibility
- Difficulty performing daily activities
Conservative Management Options
Conservative management options for a patient with multilevel degenerative disc disease and facet osteoarthritis may include:
- Physical therapy program to improve pain and function, as demonstrated in a study by 2
- Epidural steroid injections to reduce pain and inflammation, as shown in studies by 2, 3, and 4
- Exercise and home-based programs to improve mobility and strength
- Analgesics and nonsteroidal anti-inflammatory drugs to manage pain
- Facet-joint injections may produce pain relief in some patients with common low back pain, as noted in 4
- Intradiscal steroid injections into discs with concordant pain at the time of discography may lead to significant improvement in patients with inflammatory end-plate changes, as found in 3
Diagnostic Tools
Diagnostic tools such as magnetic resonance imaging (MRI) and computed tomography (CT) scans can help identify the underlying cause of the patient's symptoms, as discussed in 5. However, it is essential to consider the risks and limitations of imaging, including the potential for overdiagnosis and overtreatment.
Treatment Considerations
Treatment considerations should take into account the patient's individual needs and circumstances, including the presence of inflammatory end-plate changes, as noted in 3. A comprehensive treatment plan may involve a combination of conservative management options, as well as consideration of emerging treatment options, such as regenerative nerve therapies, as mentioned in 6.