What is the management plan for a patient with numbness in the gluteal region and bilateral S2-S3 and L2-L3 dermatomes, with CT scan findings of multilevel degenerative disc disease and facet joint arthropathy?

Management of Multilevel Degenerative Disc Disease with Radicular Symptoms

For a patient with numbness in bilateral gluteal region and S2-S3/L2-L3 dermatomes with multilevel degenerative disc disease and facet joint arthropathy, an MRI of the lumbar spine is strongly recommended as the next step in management, followed by conservative therapy for 6 weeks before considering interventional options.

Imaging Findings Interpretation

The CT scan reveals significant multilevel degenerative changes:

• Multilevel disc bulges from L1-S1 with varying degrees of canal and foraminal stenosis 1
• Moderate facet joint arthropathy at L3-S1 levels 1
• Most significant findings at L3-4 to L5-S1 with moderate canal and foraminal stenosis 1
• Potential nerve root impingement affecting L3, L4, and L5 exiting nerve roots 1

Recommended Management Approach

Step 1: Additional Imaging

• MRI of the lumbar spine without contrast is recommended as the next diagnostic step 1
  • MRI provides superior soft tissue contrast for better visualization of nerve roots, thecal sac, and disc pathology 1
  • CT is less sensitive than MRI for evaluation of nerve root compression, particularly in cases of herniated disc 1
  • Clinical correlation between symptoms and imaging findings is essential as MRI findings can be nonspecific 1

Step 2: Initial Conservative Management (6 weeks)

• Physical therapy focusing on core strengthening and lumbar stabilization 1
• NSAIDs for pain and inflammation control 1
• Activity modification with emphasis on remaining active rather than bed rest 1
• Patient education regarding the generally favorable prognosis of radicular symptoms 1

Step 3: If Symptoms Persist After 6 Weeks

• Consider interventional options based on clinical-radiological correlation:
  • Facet joint injections for predominant facet-mediated pain 2, 3
  • Epidural steroid injections for radicular symptoms with evidence of nerve compression 1
  • Referral to spine specialist for surgical evaluation if significant neurological deficits persist 1

Clinical Correlation Considerations

• The patient's bilateral S2-S3 and L2-L3 dermatomal symptoms should be correlated with imaging findings 1
• The radiologist appropriately questions whether there is pain along L3, L4, and L5 dermatomes, which would correlate with the levels of stenosis identified 1
• Facet joint arthropathy may contribute significantly to axial back pain, present in up to 15% of patients with chronic low back pain 2

Important Caveats

• CT findings alone have moderate reliability for evaluating facet joint degeneration (kappa 0.47-0.48), while MRI provides additional soft tissue detail 4
• Imaging findings often do not correlate with symptom severity - up to 30-50% of asymptomatic individuals may have significant degenerative findings on imaging 1
• Baastrup disease (kissing spinous processes) noted on the CT is a common incidental finding and may not be clinically significant 1
• The presence of multilevel pathology requires careful clinical correlation to identify the symptomatic level(s) before any targeted interventions 1, 3

Follow-up Recommendations

• Reassess after 6 weeks of conservative management 1
• If symptoms persist or worsen, consider interventional pain management referral for diagnostic and therapeutic injections 2, 3
• Surgical consultation should be reserved for patients with persistent symptoms despite conservative measures or those with progressive neurological deficits 1