Conservative Management of Lumbar Spondylotic Changes
Lumbar spondylotic changes should be managed with a structured 6-week minimum conservative program combining formal physical therapy, NSAIDs or COX-2 inhibitors, and neuropathic pain medications before considering any surgical intervention. 1
Initial Conservative Treatment Protocol
Pharmacologic Management
- NSAIDs and COX-2 inhibitors are the first-line medications for controlling pain and inflammation associated with lumbar spondylosis 2
- Neuropathic pain medications (gabapentin or pregabalin) should be trialed for radicular symptoms or lower extremity pain 3, 2
- Prostaglandins can be helpful for leg pain and intermittent claudication 2
- Avoid relying solely on narcotic pain medications; prioritize non-narcotic options 4
Physical Therapy Requirements
- Formal, structured physical therapy focusing on core strengthening and flexibility exercises is mandatory—not patient-directed home exercises 3, 5
- Flexion strengthening exercises are specifically beneficial for degenerative spondylolisthesis 6
- Therapy should continue for at least 6 weeks before reassessing treatment efficacy 1, 3
- Remaining active and incorporating regular exercise is essential 1
Injection Therapies
- Epidural steroid injections may provide short-term relief (typically less than 2 weeks) for radicular pain, though evidence is limited for chronic low back pain without radiculopathy 3, 4, 2
- Transforaminal injections can target specific nerve roots when radiculopathy is present 4, 2
- Facet joint injections are both diagnostic and therapeutic, as facet-mediated pain causes 9-42% of chronic low back pain 3
- Radiofrequency ablation (RFA) of medial branches at affected levels can provide sustained relief when diagnostic facet blocks demonstrate benefit, particularly before considering surgery 7
Supportive Measures
- Bracing may provide symptomatic relief in selected cases 6
- Assistive devices (walker or cane) should be used if give-way weakness is present to prevent falls 3
Duration and Expectations
Conservative management should continue for a minimum of 3-6 months before surgical intervention is considered, as the majority of patients with lumbar spondylosis either improve or remain stable with nonoperative treatment 1, 3, 5, 8, 6. Rapid deterioration is unlikely 8.
The prognosis for patients with degenerative spondylolisthesis is generally favorable with conservative care 6. However, patients with neurological symptoms such as intermittent claudication or bladder/bowel dysfunction are more likely to experience neurological deterioration without surgery 6.
When Imaging Is NOT Indicated
Routine imaging provides no clinical benefit in subacute to chronic uncomplicated low back pain without red flags and can lead to increased healthcare utilization 1. Imaging should be deferred during the initial 6-week conservative treatment period unless red flags are present 1.
Critical Pitfalls to Avoid
- Do not accept patient-directed exercises as adequate physical therapy—formal, supervised therapy is required 3, 5
- Do not order MRI or radiographs initially unless red flags are present (trauma, malignancy, infection, cauda equina syndrome, progressive neurological deficits) 1
- Do not proceed to surgery without completing the full conservative treatment course, as this fails to meet medical necessity criteria 3, 5
- Do not rely on imaging findings alone—many MRI abnormalities are seen in asymptomatic individuals and correlate poorly with symptoms 1
Escalation to Advanced Interventions
If conservative management fails after 6 weeks and the patient remains a surgical candidate, MRI lumbar spine without contrast becomes appropriate to identify actionable pain generators 1. For patients who decline surgery or are not surgical candidates, consider multidisciplinary pain management referral for comprehensive biopsychosocial assessment, high-intensity cognitive behavioral therapy, and potentially spinal cord stimulation 3.