Treatment for Lumbar Spondylosis
Begin with mandatory conservative management for at least 6 weeks before considering any surgical intervention, as most patients improve within the first 4 weeks. 1
Initial Conservative Treatment (First-Line for All Patients)
All patients with lumbar spondylosis must start with conservative treatment regardless of imaging findings. 1 This approach is supported by the American College of Physicians and should be maintained for 6 weeks to 3 months before considering surgery. 1
Non-Pharmacological Management
Formal structured physical therapy for a minimum of 6 weeks is mandatory before considering any surgical options. 1 This is non-negotiable and must be documented.
Regular exercise programs improve function in the short term compared to no intervention. 2
Group physical therapy shows better patient global assessment outcomes than home exercise alone. 2
Patient education about the condition and self-management strategies is essential. 1
Pharmacological Management
NSAIDs are the first-line drug treatment for pain and stiffness control. 1, 2 There is Level Ib evidence that NSAIDs improve spinal pain, peripheral joint pain, and function over 6-week periods. 2
For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors. 1, 2
Acetaminophen and opioids may be considered when NSAIDs are insufficient, contraindicated, or poorly tolerated. 1
Prostaglandin, epidural injections, and transforaminal injections are helpful for leg pain and intermittent claudication. 3
Surgical Management (Only After Failed Conservative Treatment)
Lumbar fusion is recommended (Grade B) for carefully selected patients with intractable low-back pain refractory to conservative treatment due to 1- or 2-level degenerative disc disease without stenosis or spondylolisthesis. 2
Surgical Indications
Surgery should only be considered when:
- Formal physical therapy has been completed for at least 6 weeks with documented failure. 1
- Pain is disabling and refractory to all conservative measures including NSAIDs, physical therapy, and injections. 2
- Disease is limited to 1 or 2 levels. 2
Surgical Options
Lumbar fusion or comprehensive rehabilitation incorporating cognitive therapy are equivalent treatment alternatives for chronic low-back pain refractory to traditional conservative treatment. 2 Multiple Level II studies support both approaches equally.
Instrumented fusion with pedicle screws provides optimal biomechanical stability with fusion rates up to 95%. 1
For patients with severe stenosis who have failed 3-6 months of conservative management, decompression combined with fusion is superior to decompression alone. 1
Evidence Supporting Surgery
Randomized controlled trials demonstrate that surgical groups achieve better clinical outcomes than conservatively treated cohorts, with back pain reduced by 33% in surgical groups versus 7% in controls (p = 0.0002), and Oswestry Disability Index scores improving by 25% versus 6% (p = 0.015). 2 Return-to-work rates are 36% in surgically treated patients versus 13% in controls (p = 0.002). 2
Critical Pitfalls to Avoid
Never proceed to surgery without documented completion of formal physical therapy for at least 6 weeks. 1 This is the most common error in management.
Do not perform fusion for purely radiological findings without correlating clinical symptoms. 1 MRI changes lack specificity and do not determine treatment. 2
Do not use instrumented fusion routinely, as it produces higher fusion rates but does not improve clinical outcomes and may be associated with higher complication rates. 4
Expected Outcomes
Most patients improve within the first 4 weeks of conservative management. 1
Clinical improvement occurs in 86-97% of appropriately selected surgical candidates when surgery is eventually needed. 1
At 2-year follow-up, surgically treated patients maintain superior outcomes compared to those treated conservatively when properly selected. 2