What is the best course of action for a 71-year-old patient with lumbar back pain and radiation, showing no fracture, a 7 mm listhesis at L4-5, and chronic/degenerative changes on X-ray (X-ray), with reported right-sided radiculopathy?

From the Guidelines

For a 71-year-old patient with lumbar back pain, radiation, and right-sided radiculopathy with a 7 mm listhesis at L4-5 and degenerative changes, I recommend starting with a lumbar spine MRI to evaluate the extent of spinal stenosis and nerve root compression, as recommended by the American College of Radiology 1. This approach is supported by the most recent evidence, which suggests that MRI is the initial imaging modality of choice for patients with subacute or chronic low back pain who have failed conservative therapy and are potential candidates for surgery or intervention 1. The patient's symptoms of radiculopathy and the presence of a 7 mm listhesis at L4-5 suggest the possibility of nerve root compression, which can be accurately depicted by MRI 1. Some key points to consider in the management of this patient include:

• The importance of conservative management, including physical therapy and activity modification, as the initial treatment approach for low back pain with radiculopathy 1
• The role of MRI in evaluating the extent of spinal stenosis and nerve root compression, and in guiding surgical or interventional options 1
• The potential benefits and risks of surgical options, such as decompression with or without fusion, and the importance of reserving these options for cases with progressive neurological deficits or intractable pain 1 Overall, the goal of management should be to alleviate the patient's symptoms, improve their quality of life, and minimize the risk of complications or adverse outcomes. Key management strategies may include:
• Conservative management with physical therapy and activity modification
• Imaging with MRI to evaluate the extent of spinal stenosis and nerve root compression
• Consideration of surgical or interventional options for patients who have failed conservative therapy and have evidence of nerve root compression or spinal stenosis.

From the Research

Diagnosis and Treatment Options

The patient's X-ray results show no fracture, a 7 mm listhesis at L4-5, and chronic/degenerative changes, which could contribute to neurologically significant spinal canal and/or neural foraminal stenosis at any level. Given the reported right-sided radiculopathy, a lumbar spine MRI is recommended to further evaluate the patient's condition.

Conservative Treatment Approaches

• Conservative approaches to treatment are generally recommended initially, especially in the elderly, as stated in the study by 2.
• Epidural corticosteroid injections can provide significant but temporary pain relief and are a commonly performed procedure in pain management, as mentioned in the study by 2.
• Ultrasound-guided caudal epidural injections have been shown to be effective in treating symptoms of lumbar spinal stenosis, with significant pain reduction and improvement in disability, as reported in the study by 3.
• Nonoperative treatment options, such as activity modification, oral medications, and physical therapy, can also be considered, as discussed in the study by 4.

Surgical Intervention

• Surgery may be considered for patients who do not improve with conservative management, as stated in the study by 4.
• Decompressive laminectomy has been shown to improve symptoms in patients with symptomatic and radiographic degenerative lumbar spinal stenosis, as reported in the study by 4.
• Lumbar fusion may be considered for patients with concomitant spondylolisthesis, but the precise indications for this procedure remain unclear, as discussed in the study by 4.

Treatment Outcomes

• The outcome of transforaminal epidural steroid injection (TFESI) has been shown to be superior in patients with mild to moderate lumbar foraminal spinal stenosis compared to those with severe stenosis, as reported in the study by 5.
• TFESI can provide significant pain relief for at least 3 months after treatment, regardless of the severity of lumbar foraminal spinal stenosis, as stated in the study by 5.
• Epidural steroid injections can also be effective in managing symptoms of spinal stenosis, including urinary urgency, as reported in the study by 6.