What is the recommended treatment for a patient with multilevel degenerative disc disease and facet arthropathy in the lumbar spine, presenting with lower back pain and bilateral S3 radiculopathy?

Management of Multilevel Degenerative Disc Disease with Moderate Canal Stenosis and Radiculopathy

Initial Conservative Treatment (4-6 Weeks)

Begin with a structured 4-6 week trial of conservative management including physical therapy focused on core strengthening and flexibility, non-opioid analgesics (NSAIDs as first-line), and activity modification—this is the mandatory first-line approach before considering any interventional procedures. 1, 2

• NSAIDs are the initial medication of choice for pain control 3
• Physical therapy should emphasize functional restoration rather than complete pain elimination 4
• Patients must remain active; bed rest should be avoided as it worsens outcomes 5, 6
• Incorporate cognitive behavioral therapy to address pain beliefs and maladaptive behaviors 1, 4

Interventional Management After Failed Conservative Treatment

For Radicular Symptoms (Primary Issue)

If conservative management fails after 4-6 weeks, epidural steroid injections targeting the L5-S1 and L4-5 levels should be the first interventional approach, as these address the nerve root compression causing your patient's radicular symptoms. 1

• Epidural steroid injections are appropriate for radicular pain from nerve root compression at L5-S1 (where the report notes "potentially impinging exiting L5 nerve") and L4-5 1, 2
• These provide short-term relief (greater than 6 weeks) for radicular symptoms from degenerative disease 7

For Facet-Mediated Axial Back Pain (Secondary Component)

If facet joint pain is suspected as a contributor to axial back pain, perform diagnostic medial branch blocks using the double-injection technique with an 80% improvement threshold before considering any therapeutic facet interventions. 7, 1

• The double-injection technique with 80% improvement threshold is the validated diagnostic standard 7
• Avoid intraarticular facet injections entirely—they have no therapeutic value and only 7.7% of patients achieve complete pain relief 1
• If diagnostic blocks provide temporary relief, proceed to radiofrequency ablation of medial branch nerves (80°C conventional or 67°C thermal), which provides 3-6 months of pain reduction 7, 1, 8
• Do not perform repeated facet injections at the same levels; there is insufficient evidence to support this practice 1

Surgical Considerations

Lumbar fusion should only be considered if pain remains refractory to all conservative and interventional treatments for at least 3-6 months, and should be limited to 1-2 level disease—however, given this patient's multilevel stenosis with nerve root contact, decompressive laminectomy may be more appropriate than fusion if surgery becomes necessary. 7, 1

Criteria for Surgical Evaluation:

• Failure of comprehensive conservative management for 3-6 months 4
• Significant functional impairment persisting despite all interventions 4
• Progressive neurologic deficits or cauda equina symptoms (immediate surgical referral) 6, 3

Important Surgical Considerations:

• The imaging shows moderate canal stenosis at L5-S1 and L4-5 with nerve root contact—decompressive procedures may be more beneficial than fusion 1
• Fusion is recommended only for carefully selected patients with 1-2 level disease without stenosis 7
• This patient has multilevel disease (L3-4, L4-5, L5-S1), which makes them a less ideal fusion candidate 7

Critical Pitfalls to Avoid

The imaging findings of multilevel degenerative changes often correlate poorly with symptoms—the radiographic severity does not predict surgical outcomes or necessity. 4, 5

• Address smoking status, depression, and chronic pain syndrome before considering surgery, as these negatively impact outcomes 4
• The report mentions "bilateral S3 radiculopathy" but shows no obvious foraminal stenosis at S1-2 or S2-3 levels—this clinical-radiographic discordance requires careful correlation 1
• Most patients with chronic low back pain will not benefit from surgery 2, 3
• Intensive rehabilitation programs can be as effective as fusion surgery for chronic low back pain without spondylolisthesis 4

Monitoring and Reassessment

• Use validated outcome measures (Oswestry Disability Index, Visual Analog Scale) to track treatment effectiveness 7, 4
• Reassess the treatment plan if the patient does not show improvement within 4-6 weeks of each intervention 6
• Consider surgical consultation only if there is progressive worsening despite comprehensive conservative and interventional management 4