What is the recommended treatment for a patient with minor multilevel thoracic spinal spondylosis and midthoracic degenerative disc space height loss?

Management of Thoracic Spinal Spondylosis and Degenerative Disc Disease

Conservative management with NSAIDs at maximum tolerated dosage and physical therapy focused on thoracic spine mobility is the recommended first-line treatment for patients with minor multilevel thoracic spinal spondylosis and midthoracic degenerative disc space height loss 1.

Initial Evaluation and Treatment Approach

First-Line Treatment

• Start with NSAIDs/COXIBs at maximum tolerated dosage for 2-4 weeks 1
  • Consider cardiovascular, gastrointestinal, and renal risks when prescribing
  • If insufficient response after 2-4 weeks, consider NSAID rotation
• Implement physical therapy focused specifically on thoracic spine mobility 1
  • Land-based physical therapy is conditionally recommended over aquatic therapy 2
  • Active physical therapy and supervised exercise is strongly recommended over passive physical therapy 2

Treatment Response Evaluation

• Evaluate treatment response at 2-4 weeks 1
• If sufficient response, continue and re-evaluate at 12 weeks
• With sustained improvement, consider tapering to on-demand NSAID treatment 2

Second-Line Options for Inadequate Response

Medication Adjustments

• Consider short courses of oral prednisolone as bridging therapy while awaiting effects of other treatments 1
• Avoid long-term glucocorticoid use due to adverse effects

Physical Interventions

• External bracing (thoracolumbosacral orthosis) may be considered for temporary immobilization during acute pain episodes 1
• Avoid spinal manipulation, especially in patients with spinal fusion or advanced spinal osteoporosis 2

Imaging and Surgical Considerations

When to Obtain Advanced Imaging

• Consider MRI thoracic spine without contrast if 1:
  • Pain persists despite 6 weeks of conservative management
  • Neurological symptoms develop
  • Significant functional decline occurs

Surgical Indications

• Immediate surgical consultation is necessary if 1:
  • Signs of myelopathy develop
  • Progressive neurological deficits occur
  • Spinal cord compression is evident on imaging
• For patients with advanced hip arthritis related to thoracic spine issues, total hip arthroplasty is strongly recommended 2
• Surgical intervention for thoracic spondylosis should be considered only after failure of conservative management 3

Monitoring and Follow-up

• Regular monitoring using validated disease activity measures is conditionally recommended 2
• Avoid repeated spinal radiographs more frequently than every 2 years unless clinically indicated 1
• Remember that morphologic imaging changes of osteoarthritis do not correlate well with pain 1

Common Pitfalls to Avoid

• Misdiagnosis: Lower thoracic degenerative spondylolisthesis may be misdiagnosed as lumbar spondylosis 3
• Overtreatment: Avoid unnecessary interventions for asymptomatic imaging findings
• Undertreatment: Failing to recognize neurological symptoms that require surgical evaluation
• Improper imaging: Using inappropriate imaging modalities or obtaining images too frequently

Special Considerations

• Patients with concomitant lumbar spondylosis may have overlapping symptoms requiring comprehensive evaluation 3
• Neurological symptoms (myelopathy, radiculopathy) require prompt evaluation and may indicate need for surgical intervention 4
• Thoracic facet rhizotomy should only be considered after confirmed facet-mediated pain, appropriate imaging, and diagnostic blocks 1

By following this structured approach to management, most patients with minor multilevel thoracic spinal spondylosis and midthoracic degenerative disc space height loss can achieve significant symptom improvement with conservative measures, reserving surgical interventions for those with progressive neurological deficits or failure of conservative management.