What is the initial management for a patient with multilevel mild degenerative disc space narrowing and facet joint degenerative change in the lower lumbar spine, without a discrete fracture?

From the Guidelines

The initial management for a patient with multilevel mild degenerative disc space narrowing and facet joint degenerative change in the lower lumbar spine without discrete fracture should focus on conservative treatment. Begin with a combination of physical therapy twice weekly for 4-6 weeks focusing on core strengthening, flexibility, and proper body mechanics. Prescribe non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 400-800mg three times daily with food or naproxen 500mg twice daily for 2-3 weeks to reduce inflammation and pain. Recommend activity modification to avoid aggravating activities while maintaining general mobility. Weight loss should be encouraged if the patient is overweight, as excess weight increases spinal loading. Heat therapy for 15-20 minutes several times daily can help relax muscles, while cold packs can reduce acute inflammation. If pain persists after 4-6 weeks of conservative management, consider referral for evaluation for epidural steroid injections. This conservative approach is recommended because most mild degenerative changes respond well to non-surgical interventions, allowing the body's natural healing processes to work while minimizing pain and inflammation, as supported by recent guidelines 1. Surgery is rarely indicated for mild degenerative changes without neurological deficits or severe, persistent pain unresponsive to conservative measures. Key points to consider in management include:

• Avoiding unnecessary imaging in the absence of red flags or severe symptoms, as it may not alter treatment plans and can lead to increased healthcare utilization 1.
• Focusing on functional restoration and pain management through a multidisciplinary approach.
• Considering the patient's overall health, preferences, and potential risks associated with interventions when deciding on the best course of treatment.

From the Research

Initial Management

The initial management for a patient with multilevel mild degenerative disc space narrowing and facet joint degenerative change in the lower lumbar spine, without a discrete fracture, may involve the following:

• Conservative management approaches, such as physical therapy and pain management with non-steroidal anti-inflammatory drugs (NSAIDs) or epidural steroid injections 2, 3
• Therapeutic exercises to improve mobility and reduce pain 2
• Postural education and activity modification to reduce strain on the lower back 4

Treatment Options

Treatment options for patients with degenerative lumbar spine conditions may include:

• Caudal epidural injections, which have been shown to be effective in reducing pain and improving function in patients with low back pain and radicular symptoms 2
• Epidural steroid injections, which may be used to reduce inflammation and relieve pain in patients with lumbar spinal stenosis 3
• Conservative rehabilitation strategies, such as interferential current, taping, and rehabilitative exercise prescription, which may be effective in treating osteoporotic patients with mild to moderate osteoporotic vertebral compression fracture of the lumbar spine 4

Potential Risks and Complications

Potential risks and complications of epidural injections include:

• Spinal epidural hematoma, which is a rare but potentially serious complication of epidural injections 5
• Infection, such as epidural abscess, which can occur after epidural steroid injections 6
• Increased risk of bleeding due to the use of antiplatelet medications, such as ketorolac and fluoxetine, in the peri-procedural period 5