Initial Management of Multilevel Degenerative Disc and Facet Changes
The MRI findings of multilevel degenerative disc and facet changes should not drive initial management—instead, initiate conservative therapy with both pharmacologic and nonpharmacologic treatment (exercise, remaining active) for at least 6 weeks, as these imaging findings are extremely common in asymptomatic individuals and do not correlate with clinical symptoms. 1
Understanding the Clinical Context
The critical first step is recognizing that degenerative disc and facet changes on MRI are frequently seen in asymptomatic patients and correlate poorly with pain symptoms. 1, 2 The ACR Appropriateness Criteria emphasize that many MRI abnormalities can be seen in asymptomatic individuals, and imaging patients with uncomplicated back pain is often not beneficial. 1
- A systematic review found disc protrusion prevalence increases from 29% in 20-year-olds to 43% in 80-year-olds in completely asymptomatic populations. 1
- Morphologic imaging changes of facet joint osteoarthritis do not correlate with pain. 2
- There are no effective correlations between clinical symptoms and degenerative spinal changes on imaging. 2
Conservative Management Protocol (First 6 Weeks)
All patients with multilevel degenerative changes should receive at least 6 weeks of optimal conservative therapy before considering any interventional procedures. 1
Pharmacologic Management
- Analgesics and NSAIDs for pain control 3
- Consider epidural steroid injections if radicular symptoms are present 3
Nonpharmacologic Management
- Exercise programs and remaining active 1
- Physical therapy 1
- Flexion strengthening exercises 3
- Bracing may be considered in specific cases 3
When to Consider Advanced Intervention
Imaging findings should only guide surgical or interventional decisions if the patient has failed 6 weeks of optimal conservative therapy AND is considered a surgical/intervention candidate with persistent or progressive symptoms. 1
Red Flags Requiring Immediate Attention
If any of the following are present, the management pathway changes entirely:
- Cauda equina syndrome symptoms (bladder/bowel dysfunction, saddle anesthesia) 1
- Progressive neurologic deficits 1
- Suspected infection, malignancy, or fracture 1
Clinical Scenarios Where MRI Findings Become Relevant
Only after failed conservative therapy should the MRI findings be used to identify potential actionable pain generators for intervention or surgery. 1
- Radiculopathy with nerve root compression: MRI may be helpful when there is back pain with radiculopathy or signs of spinal stenosis suggesting demonstrable nerve root compression. 1
- Spinal stenosis: Patients with degenerative stenosis demonstrate the most severe lumbar spine degeneration and may benefit from targeted intervention after conservative failure. 4
- Facet joint pain: Diagnostic facet joint blocks (not MRI findings alone) can indicate facet joints as the pain source, after which patients may benefit from radiofrequency ablation or cryoablation. 2
Critical Pitfalls to Avoid
The most common error is allowing MRI findings to drive management decisions in the absence of clinical correlation and failed conservative therapy. 1
- Early imaging leads to increased healthcare utilization without clinical benefit. 1
- A study of 1,770 patients showed that those receiving MRI within 6 weeks (nonadherent to guidelines) had increased likelihood of injections, surgery, and disability compensation. 1
- Patients with lumbar imaging abnormalities before symptom onset had 84% unchanged or improved findings after symptoms developed. 1
Never use MRI findings alone to diagnose the pain source—always correlate with clinical examination and response to conservative therapy. 1, 2
Prognosis and Natural History
The natural history of degenerative disc disease is generally favorable with conservative management. 3, 5
- Most disc herniations show reabsorption or regression by 8 weeks after symptom onset. 1
- 75-100% of broad-based protrusions, extrusions, and sequestrations improve on follow-up MRI. 5
- Patients with degenerative spondylolisthesis have favorable prognosis with conservative treatment, though those with neurological symptoms may experience deterioration without surgery. 3
Special Considerations
Smoking has a greater impact on back pain intensity and treatment response than MRI findings, particularly in patients with degenerative stenosis. 4