Management of L5-S1 Annular Fissure with Disc Protrusion and Mild Stenosis
Begin with a structured 6-week course of conservative management including formal physical therapy focused on core strengthening, NSAIDs or acetaminophen for pain control, and education about the favorable natural history of disc pathology—most disc herniations show reabsorption by 8 weeks and imaging abnormalities frequently do not correlate with symptoms. 1, 2
Initial Conservative Management (First 6 Weeks)
Conservative treatment is the mandatory first-line approach for your presentation, as guidelines strongly recommend against routine imaging-based interventions for non-specific low back pain without completing adequate conservative therapy. 1, 2
Specific Treatment Components:
- Remain physically active rather than bed rest, as activity is more effective for acute or subacute low back pain 2
- Formal physical therapy for at least 6 weeks focusing on core strengthening exercises, flexibility training, and proper body mechanics 3, 2
- Pain management with over-the-counter NSAIDs or acetaminophen, plus heat or cold therapy application 2
- Patient education about the generally favorable prognosis—disc abnormalities are common in asymptomatic individuals and may not be the pain source 2
Critical Pitfall to Avoid:
Do not pursue interventional procedures or surgery based solely on MRI findings. Annular fissures and small disc protrusions are frequently found in asymptomatic individuals, and early imaging without red flags leads to increased healthcare utilization and unnecessary interventions. 2
Reassessment at 6 Weeks
If symptoms persist after 6 weeks of comprehensive conservative management, consider:
- Epidural steroid injections (ESI) may provide short-term relief (less than 2 weeks duration) for radicular symptoms, though evidence for non-radicular low back pain is limited 1, 3
- Facet joint injections can be both diagnostic and therapeutic, as facet-mediated pain causes 9-42% of chronic low back pain 3
However, ESIs are strongly recommended against for non-radicular low back pain according to moderate-quality guidelines. 1
When to Consider Advanced Interventions
Surgical intervention should only be considered if:
- Conservative measures fail after 3-6 months of comprehensive treatment 3, 4
- Progressive neurological deficits develop (weakness, sensory changes, bowel/bladder dysfunction) 2
- Documented instability or spondylolisthesis is present on flexion-extension films 3, 4
- Significant functional impairment persists despite conservative measures 3
Your current imaging shows mild stenosis and foraminal narrowing without documented instability or spondylolisthesis, which does not meet surgical criteria at this time. 3
Radiofrequency Procedures
If discogenic pain is suspected after failed conservative treatment, radiofrequency (RF) to the dorsal ramus is weakly supported, but disc RF is strongly recommended against according to low-quality guidelines. 1
Important Considerations
The small annular fissure you describe may represent granulation tissue invasion rather than a surgical lesion, and conservative treatments are generally effective for single annular fissures without calcification. 5
L5-S1 foraminal stenosis can cause radiculopathy and is characterized by exacerbation with lumbar extension (Kemp's sign), but your "mild" stenosis should respond to conservative management initially. 6