What is the best course of action for a patient with back pain, mild to moderate multilevel degenerative changes, no acute fracture or subluxation, and mild dextroscoliosis?

Management of Back Pain with Degenerative Changes

For this patient with mild to moderate multilevel degenerative changes, no acute fracture, and mild dextroscoliosis, the best course of action is conservative management with patient education, activity modification, and NSAIDs, without proceeding to advanced imaging unless red flag symptoms develop or symptoms persist beyond 6-12 weeks despite comprehensive treatment. 1

Initial Management Strategy

Patient Education and Activity Modification

• Inform the patient of the generally favorable prognosis, with a high likelihood for substantial improvement within the first month, as most nonspecific low back pain resolves with conservative care 1
• Advise the patient to remain active rather than rest in bed, as activity is more effective than bed rest for acute or subacute low back pain 1
• Provide evidence-based self-care education materials to supplement clinician advice, as these are inexpensive and nearly as effective as costlier interventions like supervised exercise or manipulation 1
• Encourage return to normal activities as soon as possible, even if brief periods of rest are needed for severe symptom relief 1

Pharmacologic Management

• Initiate NSAIDs such as naproxen 375-500 mg twice daily or ibuprofen 400-600 mg three times daily for pain control, as these are first-line medications for mechanical back pain 2, 3
• Consider adding a muscle relaxant like cyclobenzaprine 5-10 mg at bedtime if muscle spasm is prominent, though drowsiness is a common side effect 4
• Apply heat with heating pads or heated blankets for short-term relief of acute symptoms 1

When NOT to Pursue Advanced Imaging

The x-ray findings of degenerative changes without fracture or subluxation do NOT warrant immediate MRI or CT in the absence of red flag symptoms. 1 This is a critical pitfall to avoid, as:

• Early routine imaging does not identify a precise cause, does not improve patient outcomes, and incurs unnecessary expenses 1
• Degenerative changes on imaging are extremely common and often do not correlate with symptoms—40-85% of adults have radiographic spine degeneration 5
• MRI findings like disc bulging are frequently nonspecific and present in asymptomatic individuals 1

Indications for Advanced Imaging (MRI Preferred)

Only proceed to MRI or CT if the patient develops any of the following:

Red Flag Symptoms Requiring Immediate Imaging

• Severe or progressive neurological deficits (motor weakness, sensory loss, reflex changes) 1
• Symptoms of cauda equina syndrome (bowel/bladder dysfunction, saddle anesthesia) 1
• Suspected infection, malignancy, or fracture based on clinical presentation 1

Persistent Symptoms After Conservative Management

• Radiculopathy (leg pain with nerve root distribution) persisting beyond 4 weeks despite noninvasive therapy, if the patient is a potential candidate for epidural steroid injection or surgery 1
• Symptoms of spinal stenosis (neurogenic claudication) persisting beyond 6-12 weeks, if the patient would consider surgical decompression 1
• Chronic axial back pain lasting more than 3 months that has failed comprehensive conservative management including formal physical therapy for at least 6 weeks 6

Conservative Treatment Timeline

The minimum duration before considering specialist referral or advanced imaging is 6-12 weeks of comprehensive conservative management, which should include: 1

• Formal structured physical therapy (not just home exercises) 6
• Appropriate medication trials including NSAIDs and potentially neuropathic pain medications if radicular symptoms develop 6
• Activity modification and self-care education 1
• Consider brief individualized educational interventions for workers with subacute symptoms to reduce sick leave 1

Critical Pitfalls to Avoid

• Do not order MRI or CT based solely on x-ray findings of degenerative changes—this leads to overdiagnosis of incidental findings that do not correlate with symptoms 1, 7
• Do not assume that radiographic severity correlates with pain severity—the relationship between imaging findings and clinical symptoms is complex and often discordant 5
• Do not proceed to interventional procedures (injections, surgery) without exhausting conservative options first—most patients improve with time and conservative care 1
• Avoid firm mattresses in favor of medium-firm mattresses for patients with chronic symptoms 1

When to Reassess

Schedule follow-up in 4-6 weeks to evaluate response to conservative management. At that visit, reassess for:

• Development of any red flag symptoms requiring immediate imaging 1
• Presence of radiculopathy or neurogenic claudication that might warrant specialist evaluation 1
• Adequate trial of conservative measures before considering advanced imaging 1