What is the recommended management for a patient with lower back pain due to spondylosis at multiple levels?

Management of Multilevel Lumbar Spondylosis with Lower Back Pain

Begin with an intensive course of conservative management including structured physical therapy, core strengthening exercises, and NSAIDs for at least 3-6 months before considering any surgical intervention. 1, 2, 3

Initial Conservative Management (First-Line Treatment)

Patient Education and Activity Modification

• Educate the patient about the generally favorable prognosis and emphasize that degenerative changes on imaging often correlate poorly with symptoms—the radiographic findings may not be the actual source of her pain 2, 3
• Instruct her to remain active rather than rest, as activity is more effective than bed rest for managing low back pain 2
• Advise gradual return to normal activities with avoidance of prolonged sitting or standing 2

Structured Physical Therapy Program

• Prescribe a comprehensive 3-month physical therapy program focused on core strengthening exercises, flexibility training, and pain management techniques 2, 3
• Consider both individual sessions and group therapy, as group physical therapy has shown better patient global assessment scores compared to home exercise alone 1
• Include functional restoration exercises rather than focusing solely on pain elimination 3

Pharmacological Management

• Start with NSAIDs or COX-2 inhibitors as first-line medication for pain and stiffness control 1, 4
• If she has increased gastrointestinal risk, use either non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors 1
• Limit medication use to short-term relief while emphasizing active rehabilitation 2
• Avoid opioids as first-line therapy due to risk of dependence and lack of evidence for superiority over NSAIDs 2

Advanced Conservative Management (If Inadequate Response After 4-6 Weeks)

Intensified Rehabilitation

• Escalate to more intensive physical therapy with functional restoration focus if initial measures provide insufficient relief 2, 3
• Add cognitive behavioral therapy to address pain beliefs, behaviors, and any psychological factors contributing to pain chronicity 1, 2, 3
• Consider manual therapies including massage or spinal manipulation for additional symptom relief 2

Interventional Options

• Consider epidural steroid injections or transforaminal injections if conservative measures fail, particularly for radiating leg pain 4, 5
• Prostaglandin injections may also be helpful for leg pain symptoms 4

Surgical Consideration (Reserved for Refractory Cases)

Lumbar fusion should only be considered if ALL of the following criteria are met: 1, 3

• Failure of comprehensive conservative management for at least 3-6 months 1, 3
• Disabling low back pain causing significant functional impairment despite conservative measures 1, 3
• Pain correlates with degenerative changes at specific levels (one or two levels maximum) 1
• No stenosis or spondylolisthesis present 1
• Patient is carefully selected and understands that intensive rehabilitation can be as effective as fusion surgery 3

Surgical Technique Options (If Surgery Indicated)

• Both posterolateral fusion (PLF) and interbody fusion techniques (PLIF, TLIF, or ALIF) are acceptable options for one or two-level degenerative disc disease 1
• Interbody grafts may improve fusion rates and functional outcomes but are associated with increased complication rates, particularly with combined anterior-posterior approaches 1
• Avoid routine use of multiple approaches (360° fusion) for low back pain without deformity due to increased complications without proportional benefit 1

Critical Pitfalls to Avoid

Imaging Interpretation

• Do not assume that radiographic findings of multilevel spondylosis are the definitive source of her pain—degenerative changes are common in asymptomatic individuals and correlate poorly with symptoms 2, 3
• Avoid ordering additional imaging (MRI, CT) unless red flags are present, as this rarely changes management in the first 4-6 weeks 2

Red Flags Requiring Urgent Evaluation

• Progressive neurological deficits 2
• Suspected cauda equina syndrome 2
• History of cancer or suspected spinal infection 2
• Significant trauma 2

Factors That Negatively Impact Outcomes

• Address smoking status, depression, and chronic pain syndrome before considering surgical intervention, as these significantly worsen surgical outcomes 3
• Screen for yellow flags (psychosocial factors) that predict chronicity and disability 6

Monitoring and Follow-Up

• Reassess treatment effectiveness at 4-6 week intervals using validated outcome measures such as the Oswestry Disability Index (ODI) and visual analog scale (VAS) 2, 3
• Most cases will improve within 4 weeks with appropriate conservative management 2
• Consider surgical consultation only if there is progressive worsening despite comprehensive conservative management for at least 3-6 months 3

The key principle is that this 48-year-old woman with multilevel spondylosis should receive an intensive trial of conservative management combining physical therapy and cognitive therapy, as this approach has been shown to be as effective as fusion surgery for chronic low back pain without stenosis or spondylolisthesis. 1, 3