What is the initial treatment for lumbar spondylosis without myelopathy?

Initial Treatment for Lumbar Spondylosis Without Myelopathy

Conservative therapy with both pharmacological and non-pharmacological interventions should be the initial treatment for lumbar spondylosis without myelopathy, as it is considered a self-limiting condition responsive to medical management and physical therapy in most patients. 1

Non-Pharmacological Management

Physical Therapy and Exercise

• Regular exercise is the cornerstone of non-pharmacological treatment
• Focus exercises on:
  • Maintaining spinal mobility
  • Improving posture
  • Strengthening core muscles
  • Gentle stretching
• Supervised exercise programs are preferred over home exercises alone for better outcomes
• Land-based physical therapy is generally preferred over aquatic therapy

Patient Education

• Provide education on proper body mechanics and posture maintenance
• Guidance on activity modifications to reduce pain while maintaining function
• Information about expected disease course and management expectations

Pharmacological Management

First-Line Medications

• NSAIDs at full anti-inflammatory doses
  • Consider continuous treatment over on-demand use for persistent symptoms
  • For elderly patients, start with lower doses and titrate carefully
  • Use gastroprotective agents concurrently in high-risk patients
  • Consider selective COX-2 inhibitors if conventional NSAIDs are not tolerated

Second-Line Medications

• Acetaminophen for residual pain when NSAIDs are contraindicated, poorly tolerated, or insufficient

Treatment Algorithm

1. Initial 6-Week Conservative Management Period:

   • NSAIDs + Physical therapy/exercise program
   • Activity modification as needed
   • Patient education

2. Reassessment at 6 Weeks:

   • If improving: Continue conservative management
   • If persistent symptoms: Consider additional interventions

3. For Persistent Symptoms After 6 Weeks:

   • Consider epidural steroid injections or transforaminal injections 2, 3
   • Imaging may be appropriate at this point if patient is a potential surgical candidate 1

Important Considerations

Avoid Unnecessary Imaging

• Routine imaging provides no clinical benefit in uncomplicated lumbar spondylosis 1
• Imaging early or prior to conservative treatment leads to increased healthcare utilization 1
• Imaging should be considered only after 6 weeks of failed optimal medical management if the patient is a potential surgical candidate 1

Common Pitfalls to Avoid

• Using inadequate NSAID dosing before declaring treatment failure
• Neglecting the importance of regular exercise and physical therapy
• Relying on systemic corticosteroids for axial disease (not supported by evidence)
• Ordering unnecessary imaging studies before an adequate trial of conservative management

Prognosis

• The prognosis for patients with lumbar spondylosis without myelopathy is generally favorable 3
• In patients with lumbar spinal stenosis followed for up to 3 years without operative intervention:
  • Approximately one-third report improvement
  • Approximately 50% report no change in symptoms
  • Approximately 10-20% report worsening of back pain, leg pain, and walking 4

Remember that surgical management should only be considered for well-selected patients who fail conservative management strategies 2, 5.