From the Guidelines
Given the X-ray findings of moderate degenerative change with multilevel foraminal narrowing in the lumbar spine, I strongly recommend an initial approach of conservative therapy, including pharmacologic and nonpharmacologic treatments, as outlined in the ACR Appropriateness Criteria for low back pain 1. This approach should prioritize nonpharmacologic interventions such as exercise and remaining active, as these have been shown to be effective in managing chronic low back pain 1. For patients with subacute or chronic low back pain who have failed 6 weeks of conservative therapy, imaging with MRI of the lumbar spine is recommended as the initial imaging modality of choice, due to its excellent soft-tissue contrast and ability to accurately depict lumbar pathology, including disc degeneration and neural structures 1. Some key points to consider in the management of this condition include:
- The use of over-the-counter pain medications like acetaminophen or NSAIDs such as ibuprofen for pain relief, as needed and under medical guidance.
- Applying heat for 15-20 minutes several times daily to relax muscles and improve blood flow.
- Maintaining proper posture, using ergonomic furniture, and avoiding activities that worsen pain.
- Considering weight loss if the patient is overweight, as this can help reduce the strain on the spine.
- Monitoring for any worsening symptoms such as numbness, weakness, or bladder/bowel issues, which may necessitate further imaging or specialist referral. It's essential to note that while radiography alone is not sufficient for guiding surgical or interventional options without MRI and/or CT imaging, it can provide useful functional information about axial loading and segmental motion, which is important in the surgical management of conditions like spondylolisthesis 1.
From the Research
Diagnosis and Management of Multilevel Foraminal Narrowing
- Moderate degenerative change with multilevel foraminal narrowing on lumbar x-ray is a common cause of low back pain and radiculopathy, as discussed in 2, 3.
- The diagnosis of multilevel lumbar foraminal stenosis can be made using radiological examinations such as X-ray, CT, and MRI, which play an important role in evaluating the severity of foraminal narrowing, as stated in 4, 5.
- The clinical manifestation of isolated lumbar foraminal stenosis can include radiculopathy, pseudoclaudication, and back pain, which can be evaluated using visual analogue score (VAS) and Oswestry Disability Index (ODI), as mentioned in 4.
Treatment Options
- Conservative management options for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication may include physical therapy, epidural steroid injection, and pain medications, as suggested in 2.
- Surgical options for patients with multilevel lumbar foraminal stenosis may include decompression alone or decompression and fusion, with segmental decompression offering promising and reproducible clinical and radiological results, as discussed in 6.
- The choice of surgical approach depends on the severity of the disease, the presence of instability, and the patient's overall health status, as mentioned in 3.
Radiological Characteristics
- Radiological characteristics of multilevel lumbar foraminal stenosis include narrowing of the intervertebral disc space, foraminal narrowing, and degenerative changes in the facet joints, as described in 4, 5.
- The foraminal area can be measured using CT and MRI, with a decrease in the foraminal area on the affected side compared to the unaffected side, as stated in 4.