What is the recommended management approach for a 60-year-old patient with lower back pain, mild degenerative anterolisthesis of L4-L5, and arthrosis of the lumbar facet joints?

Management of Degenerative Lumbar Spine Disease with Mild Anterolisthesis

This 60-year-old patient with mild degenerative anterolisthesis of L4-L5 and facet arthrosis should be managed with comprehensive conservative treatment for at least 3-6 months before considering any surgical intervention, as the imaging findings alone do not justify surgery and are extremely common in asymptomatic individuals of this age.

Initial Conservative Management (First-Line Treatment)

Begin with a structured physical therapy program focused on core strengthening, flexibility, and pain management techniques for a minimum of 6 weeks to 3 months 1, 2. This is the foundation of treatment and must be completed before any interventional procedures are considered.

Specific Conservative Interventions to Implement:

• Formal physical therapy program with documented compliance for at least 6 weeks, focusing on lumbar stabilization exercises and postural training 1, 3
• Trial of neuropathic pain medications (gabapentin or pregabalin) if radicular symptoms are present 1
• NSAIDs and activity modification as part of the comprehensive approach 1
• Consider acupuncture, massage, or spinal manipulation as moderately effective nonpharmacologic therapies with guideline support 2

Critical Context: Imaging Findings Do Not Equal Surgical Indication

The radiographic findings described are extremely common in asymptomatic individuals and do not justify surgical intervention alone. Here's why this matters:

• Facet arthrosis is present in 100% of individuals over 60 years old and 79% at the L4-L5 level specifically 4
• Mild degenerative changes and marginal osteophytes are universal findings in this age group and correlate poorly with symptoms 2, 4
• Imaging findings alone cannot justify surgery—there must be correlation between symptoms, physical examination findings, and imaging abnormalities 2

When Interventional Procedures May Be Considered

Epidural Steroid Injections:

• May provide short-term relief (less than 2 weeks) for radicular symptoms if present, but have limited evidence for chronic low back pain without radiculopathy 1
• Should only be considered after initial conservative management has been attempted 5, 1

Facet Joint Injections:

Therapeutic facet joint injections are NOT recommended as routine treatment based on Class III evidence showing they are ineffective for the majority of patients with low-back pain 5:

• Only 7.7% of patients selected for injection based on clinical criteria had complete relief of symptoms 5
• 90% of patients studied did not have facet joints as the primary source of back pain 5
• If considered at all, should only be done in the context of clinical governance, audit, or research 5

Surgical Consideration Criteria (Only After Conservative Failure)

Lumbar fusion should only be considered if ALL of the following criteria are met 1, 2, 3:

1. Failure of comprehensive conservative management for at least 3-6 months including formal physical therapy 1, 2, 3
2. Significant functional impairment persisting despite conservative measures 1, 3
3. Pain that correlates with the degenerative changes on imaging 1, 3
4. Documented instability on flexion-extension radiographs (not mentioned in this case) 1, 6

Important Surgical Evidence:

• For mild anterolisthesis WITHOUT documented instability on dynamic imaging, decompression alone may be sufficient if surgery becomes necessary 1
• Fusion is specifically reserved for cases with documented instability, spondylolisthesis with hypermobility, or when extensive decompression might create instability 1, 2
• The majority of cases of low-grade spondylolisthesis do not progress over 5 years with nonoperative management 7

Natural History and Prognosis

With appropriate conservative management, most patients improve without surgery:

• 31.8% of patients with degenerative spondylolisthesis show slip progression over 5 years, but physical function, disability scores, and leg pain improve regardless of progression 7
• SF12 physical scores, Oswestry Disability Index, and leg pain improved significantly with nonoperative management even in those with progression 7
• Back pain improved only in those without slip progression, suggesting careful monitoring is warranted 7

Common Pitfalls to Avoid

1. Do not proceed with fusion based on imaging findings alone—the degenerative changes described are age-appropriate and nearly universal 2, 4
2. Do not skip comprehensive conservative management—intensive rehabilitation programs can be as effective as fusion surgery for chronic low back pain without stenosis or documented instability 2, 3
3. Do not obtain flexion-extension radiographs initially—these are only needed if conservative management fails and surgery is being considered to document true instability 1, 8
4. Avoid therapeutic facet injections as routine treatment—evidence shows they are ineffective in 90% of patients 5

Monitoring and Reassessment

• Use validated outcome measures (Oswestry Disability Index, Visual Analog Scale) to objectively track treatment response 3, 7
• Reassess at 3 months to determine if conservative management is providing adequate relief 5, 1
• Consider surgical consultation only if there is progressive worsening despite comprehensive conservative management or development of neurological deficits 5, 3