Treatment for Mild Disc Bulge, Ligament Hypertrophy, and Facet Arthritis
Start with physical therapy focusing on extension exercises combined with NSAIDs as first-line treatment before considering any interventional procedures. 1
Initial Conservative Management (First 3 Months)
Conservative management is the standard of care and should be implemented for at least 2-3 months before considering interventional options 1, 2:
- Physical therapy with extension-based exercises is strongly recommended as the foundation of treatment 1
- NSAIDs should be used concurrently with physical therapy for pain control 1
- This approach yields satisfactory results in a high proportion of patients with mild to moderate nerve root compression within a few months 2
When Conservative Treatment Fails
After at least 3 months of failed conservative treatment, proceed with diagnostic confirmation before any interventional procedures 1:
Diagnostic Confirmation for Facet-Mediated Pain
- Diagnostic medial branch blocks are essential to confirm facet joint pain as the primary source before proceeding to definitive treatment 1
- A threshold of >50% pain relief confirms facet-mediated pain 1
- Look specifically for pain aggravated by extension and imaging showing no other obvious cause 1
Definitive Treatment Options
For confirmed facet-mediated pain (>50% relief from diagnostic blocks lasting ≥2 months):
- Radiofrequency ablation of the medial branch nerves is the recommended definitive treatment, demonstrating 66% success rates compared to 38% in control groups, with decreased narcotic requirements 1
- Multiple therapeutic medial branch blocks with local anesthetics can provide significant pain relief for up to 44-45 weeks, with each injection providing approximately 15 weeks of relief 1
What NOT to Do
Critical contraindications and ineffective treatments:
- Avoid intraarticular facet joint injections as primary treatment, as only 7.7% of patients achieve complete pain relief and facet joints are not the primary pain source in 90% of patients 1
- Do not perform additional sets of facet injections at the same levels, as these are considered experimental and lack proven value 1
- Phenol or alcohol should not be used in routine care of patients with facet-mediated pain 1
- Strong recommendation against spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced osteoporosis due to catastrophic risks of fractures, spinal cord injury, and paraplegia 1, 3
Clinical Algorithm
Step 1 (Months 0-3): Physical therapy with extension exercises + NSAIDs 1
Step 2 (After 3 months if no improvement): Diagnostic medial branch blocks to confirm facet-mediated pain 1
Step 3 (If >50% relief for ≥2 months from diagnostic block): Proceed to radiofrequency ablation rather than repeat injections 1
Important Clinical Pearls
The pathophysiology involves disc degeneration, facet joint hypertrophy, and ligamentum flavum hypertrophy that typically progress together with age 4, 5. Increased translational movements occur in severe disc degeneration accompanied by facet joint degeneration or ligamentum flavum hypertrophy 4. However, stenotic images on imaging studies are present in many symptom-free individuals, emphasizing that treatment decisions must be based on clinical symptoms rather than imaging alone 5.
Surgery should only be considered if patients do not respond after at least 2 months of conservative treatment, and even then, results often deteriorate in the long term due to recurrence of pain 2.