Initial Treatment for Lumbar Spondylosis
Begin with conservative management combining patient education, regular exercise/physical therapy, and NSAIDs as first-line pharmacological treatment—this approach should be maintained for at least 6 weeks before considering any advanced interventions. 1
Non-Pharmacological Treatment (Foundation of Management)
All patients with lumbar spondylosis must start with conservative treatment regardless of imaging findings. 1 The evidence strongly supports non-pharmacological interventions as the cornerstone:
- Patient education about the condition and self-management strategies is mandatory 1
- Regular exercise programs improve function in the short term compared to no intervention (Level Ib evidence) 1
- Formal structured physical therapy for a minimum of 6 weeks is required before considering any surgical options 1
- Group physical therapy demonstrates better patient global assessment outcomes than home exercise alone, though both home and supervised programs improve function 2, 1
- Flexion-based strengthening exercises are superior to extension exercises for symptomatic relief, with 62% recovery rates at 3 years versus 0% for extension-based programs 3
The natural history is generally favorable—most patients improve within the first 4 weeks of conservative management 1. This self-limiting nature makes aggressive early intervention unnecessary and potentially harmful 2.
Pharmacological Management
NSAIDs are the first-line drug treatment for pain and stiffness control with Level Ib evidence showing improvement in spinal pain, peripheral joint pain, and function over 6-week periods 2, 1, 4:
- For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors 2, 1
- No single NSAID preparation has been shown clearly superior to others 2
- Analgesics including acetaminophen and opioids may be considered when NSAIDs are insufficient, contraindicated, or poorly tolerated 2, 1
Additional interventional options include prostaglandin therapy, epidural steroid injections, and transforaminal injections for leg pain and intermittent claudication 4, 5.
Activity Modification and Bracing
- Physical methods such as bracing and flexion strengthening exercises are appropriate adjuncts 6
- Instructions on proper posture and lifting techniques should be provided 3
- Heat application may provide symptomatic relief 3
Duration of Conservative Management
Conservative management must be documented for at least 6 weeks to 3 months before considering surgical intervention 1, 7, 5. The American College of Physicians specifically recommends this timeframe given the favorable natural history 1.
Critical Pitfalls to Avoid
- Never proceed to surgery without documented completion of formal physical therapy for at least 6 weeks 1
- Do not perform routine imaging in the initial evaluation—subacute to chronic uncomplicated low back pain is self-limiting and responsive to medical management in most patients, and routine imaging provides no clinical benefit while increasing healthcare utilization 2
- Do not use extension-based exercise programs—they show significantly worse outcomes (0% recovery at 3 years) compared to flexion-based programs (62% recovery) 3
When Conservative Management Fails
Surgery should only be considered when formal physical therapy has been completed for at least 6 weeks with documented failure, and pain is disabling and refractory to all conservative measures including NSAIDs, physical therapy, and injections 1. Even then, 86-97% of appropriately selected surgical candidates show clinical improvement 1.