What is the appropriate management for a patient with intact intervertebral disc spaces, no listhesis or compression fracture, and normal vertebral alignment, height, and bony density, with no evidence of compression fracture or spondylolysis?

Management of Normal Spine Imaging Without Pathology

For a patient with completely normal spine imaging showing intact disc spaces, no listhesis, no compression fracture, preserved alignment and height, and normal bone density, no surgical intervention is indicated and conservative management should be pursued based on clinical symptoms. 1, 2

Clinical Assessment Framework

The imaging findings described represent a structurally normal spine without any of the key pathologies that would warrant surgical consideration:

• No evidence of instability (no listhesis, preserved alignment) 1
• No neural compression (intact disc spaces, no stenosis mentioned) 2
• No structural failure (no compression fracture, normal bone density) 3
• No spondylolysis (explicitly stated as absent) 1, 4

Evidence-Based Management Algorithm

When Surgery is NOT Indicated

Decompression alone is only recommended when there is documented neural compression causing symptoms. 2 In the absence of stenosis or neural compression, decompression provides no benefit and increases surgical risk without proven outcomes improvement. 1

Fusion is only indicated when specific criteria are met:

• Presence of spondylolisthesis of any grade 2, 5
• Radiographic evidence of instability on flexion-extension films 2
• Significant deformity (scoliosis, kyphotic malalignment) 2
• Documented neural compression with instability 2

Multiple systematic reviews have conclusively demonstrated that in the absence of deformity or instability, lumbar fusion is not associated with improved outcomes compared to conservative management alone. 1

Conservative Management Approach

For patients with normal imaging but symptomatic back pain:

• Physical therapy focusing on core strengthening and spinal stabilization 4, 6
• Activity modification to avoid aggravating movements 6
• Pain management with NSAIDs and appropriate analgesics 5, 3
• Bracing may be considered for symptomatic relief in select cases 6, 3

Critical Pitfalls to Avoid

Do not perform prophylactic fusion in patients without documented instability. Studies demonstrate that only 9% of patients without preoperative evidence of instability develop delayed slippage after decompression, and prophylactic fusion increases operative time, blood loss, and surgical risk without proven benefit. 2

Patients with less extensive surgery tend to have better outcomes than those undergoing extensive decompression and fusion when instability is absent. 1, 2

When to Reconsider Imaging

Advanced imaging with MRI should be obtained if:

• New neurological deficits develop 1
• Progressive motor weakness occurs 7
• Symptoms worsen despite appropriate conservative management 7
• Clinical examination suggests myelopathy or radiculopathy 1

SPECT imaging may be considered if there is high clinical suspicion for stress reaction or early spondylolysis not visible on plain radiographs, particularly in young athletes with focal back pain. 1 However, this is only warranted when clinical findings strongly suggest pars pathology despite negative initial imaging. 1

Outcome Expectations

With normal structural imaging, the focus should be on symptom management and functional restoration rather than surgical intervention. 5, 6 Conservative treatment is usually successful in controlling symptoms and restoring function in patients without structural pathology. 6