What is the initial management for lumbar spondylosis?

Initial Management of Lumbar Spondylosis

All patients with lumbar spondylosis must begin with conservative management combining physical therapy, NSAIDs, and activity modification for at least 6 weeks before any surgical consideration, as most patients improve within the first 4 weeks. 1

Non-Pharmacological Treatment (First-Line)

Structured physical therapy is mandatory and must be completed for a minimum of 6 weeks before considering any other interventions. 1

• Home exercise programs improve function in the short term compared to no intervention, with Level Ib evidence supporting this approach 1
• Group physical therapy demonstrates superior patient global assessment outcomes compared to home exercise alone, making it the preferred delivery method when available 1
• Patient education about the condition and self-management strategies is essential and has been shown to improve motivation, reduce anxiety, and is cost-effective over 12 months 2
• Regular exercise should be continued throughout the disease course regardless of symptom severity 2

Pharmacological Management (Concurrent with Physical Therapy)

NSAIDs are the first-line drug treatment for pain and stiffness control, with Level Ib evidence demonstrating improvement in spinal pain, peripheral joint pain, and function over 6-week periods 2, 1, 3

• For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus gastroprotective agents OR selective COX-2 inhibitors 1, 3
• COX-2 inhibitors show equivalent efficacy to traditional NSAIDs with improved GI safety profiles 2
• Acetaminophen and opioids may be considered only when NSAIDs are insufficient, contraindicated, or poorly tolerated 1

Activity Modification

• Avoid prolonged static postures and heavy lifting during the acute phase 4
• Encourage maintenance of daily activities within pain tolerance rather than complete rest 5

Expected Timeline and Outcomes

• Most patients (86-97%) improve within the first 4 weeks of conservative management 1
• Continue conservative treatment for 6 weeks to 3 months minimum before considering any advanced interventions 1
• The natural history is generally favorable, making aggressive early intervention unnecessary 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 fusion based purely on radiological findings without correlating clinical symptoms 1
• Avoid prescribing opioids as first-line therapy when NSAIDs and physical therapy have not been adequately trialed 1

When to Consider Advanced Interventions

Only after documented failure of 6 weeks of formal physical therapy combined with NSAIDs should you consider:

• Epidural steroid injections for radicular symptoms 4, 5
• Transforaminal injections for specific nerve root involvement 4
• Surgical consultation for patients with intractable pain refractory to all conservative measures 1