What is the recommended treatment for a patient with intervertebral disc space narrowing at L1-L2 through L4-L5 levels with mild endplate hypertrophic changes and degenerative changes?

Treatment for Intervertebral Disc Space Narrowing at L1-L2 through L4-L5 Levels

Conservative management should be the initial treatment for patients with intervertebral disc space narrowing at L1-L2 through L4-L5 levels with mild endplate hypertrophic changes and degenerative changes. 1, 2

Initial Conservative Management (First 4-6 Months)

Physical Therapy and Exercise

• Structured rehabilitation program focusing on:
  • Core strengthening exercises
  • Lumbar stabilization techniques
  • Gradual return to activities
  • Flexion strengthening exercises 3, 2

Medication Management

• Non-narcotic analgesics (acetaminophen)
• NSAIDs for pain and inflammation control 3
• Muscle relaxants for acute muscle spasm

Additional Conservative Measures

• Activity modification to avoid aggravating movements
• Proper body mechanics education
• Weight management if overweight/obese
• Bracing for short-term pain relief (not for long-term use) 3

Second-Line Interventions (If Initial Conservative Management Fails)

Injection Therapies

• Epidural steroid injections may provide short-term relief, though evidence shows limited benefit 1, 2
• Facet joint injections may be considered if facet-mediated pain is suspected 1
• Diagnostic selective nerve root blocks can help identify specific pain generators 4

When to Consider Surgical Options

Surgery should only be considered after failure of a comprehensive 6-month conservative management program 4. The ACR Appropriateness Criteria emphasizes that imaging abnormalities are common in asymptomatic patients and should not be the sole basis for surgical decisions 1.

Surgical Considerations

• For isolated disc degeneration without instability: Lumbar fusion is recommended only for patients with chronic low-back pain refractory to conservative treatment due to 1-2 level degenerative disc disease 1
• For patients with disc herniation: Lumbar spinal fusion is not recommended as routine treatment following primary disc excision 1
• For recurrent disc herniations: Reoperative discectomy and fusion may be considered if associated with instability or chronic axial low back pain 1

Important Caveats

1. Imaging findings often don't correlate with symptoms: Disc abnormalities are common in asymptomatic patients, with disc protrusion prevalence increasing from 29% at age 20 to 43% at age 80 1

2. Early imaging leads to increased healthcare utilization: Studies show that patients receiving early imaging (within 4-6 weeks) have increased likelihood of injections, surgery, and disability compensation 1

3. Degenerative changes are often normal aging phenomena: Most patients with symptomatic degenerative changes respond appropriately to nonsurgical management 5

4. Modic changes impact treatment decisions: Patients with Modic changes and moderate disc height loss may be more suitable for fusion procedures than disc replacement if surgery becomes necessary 4

5. Intensive rehabilitation with cognitive components has shown comparable outcomes to surgical intervention in many studies 4

The evidence strongly supports starting with a structured conservative approach for at least 6 months before considering any surgical intervention for patients with intervertebral disc space narrowing and degenerative changes.