What is the recommended management for a patient with low back pain and radiographic findings of disc disease and facet arthrosis in the lumbar spine?

Management of Low Back Pain with Disc Disease and Facet Arthrosis

For this patient with chronic low back pain (>1 year duration) and radiographic findings of disc disease at L5-S1 and L4-5 with facet arthrosis, initial management should consist of conservative therapy including medical management and physical therapy for at least 6 weeks before considering advanced imaging or interventional procedures. 1

Initial Conservative Management

• No additional imaging is currently indicated since plain radiographs have already been obtained and show degenerative changes 1
• The radiographic findings of disc space narrowing and facet arthrosis are extremely common in asymptomatic individuals and do not correlate reliably with pain 1
  • Disc abnormalities are present in 29-43% of asymptomatic adults depending on age 1
  • Facet arthrosis is present in 82% of 30-39 year-olds and 93% of 40-49 year-olds in cadaveric studies 2
• Initiate a 6-week trial of optimal medical management including NSAIDs, analgesics, and structured physical therapy 1
• The acute injury described (lifting heavy objects with a "pop") occurred over a year ago, making this chronic rather than acute low back pain 1

When to Advance to MRI

MRI lumbar spine without IV contrast becomes appropriate only if:

• The patient fails to improve after 6 weeks of conservative therapy 1
• AND the patient is considered a candidate for surgery or interventional procedures 1
• OR new red flags develop (progressive neurologic deficits, cauda equina symptoms, suspicion for infection/malignancy) 1

Critical pitfall: Early imaging (before 6 weeks of conservative therapy) leads to increased healthcare utilization, higher rates of injections and surgery, and increased disability compensation without improving outcomes 1

Interventional Options After Failed Conservative Therapy

If conservative management fails after 6 weeks and MRI is obtained:

For Facet-Mediated Pain:

• Diagnostic medial branch blocks should precede any ablative procedure 1
• Radiofrequency ablation of medial branches is weakly supported after positive diagnostic blocks 1
• Intraarticular facet injections with corticosteroids may provide temporary relief but have limited long-term efficacy 3, 4

For Discogenic Pain:

• Epidural steroid injections are NOT recommended for non-radicular axial low back pain 1
• These are only appropriate if radiculopathy develops 1

For Sacroiliac Joint Involvement:

• If SI joint is suspected as pain generator, diagnostic SI joint injection should be performed first 1
• Cooled radiofrequency ablation is weakly supported after positive diagnostic injection 1

Key Clinical Considerations

The retrolisthesis of L5 on S1 noted on imaging:

• Requires assessment for segmental instability if surgical intervention is considered 1
• Flexion-extension radiographs would be complementary to MRI for surgical planning 1

Important caveats:

• The presence of radiographic degenerative changes does not establish causation for the patient's pain 1, 4
• Morphologic imaging changes of facet osteoarthritis do not correlate with pain 1, 4
• Most disc herniations show reabsorption by 8 weeks, making early imaging particularly unhelpful 1

Red flags requiring immediate advanced imaging:

• New bowel/bladder dysfunction (cauda equina syndrome) 1
• Progressive motor weakness 1
• Fever, unexplained weight loss, or immunosuppression (infection/malignancy concern) 1
• Significant trauma in elderly or osteoporotic patients (fracture risk) 1