What is the best treatment approach for a patient with a history of spinal fusion at levels L2-L5, presenting with significant neck and upper back pain, mild thoracic spine kyphosis, and degenerative changes, including mild dextroscoliosis and intervertebral disc space narrowing?

Management of Neck and Upper Back Pain Following Prior Lumbar Fusion

Direct Recommendation

Your patient requires comprehensive MRI imaging of the cervical and thoracic spine to guide treatment, followed by structured conservative management including formal physical therapy for at least 6 weeks before considering any surgical intervention. 1, 2

Immediate Diagnostic Workup

Obtain cervical and thoracic spine MRI immediately. The CT scan has already excluded acute fracture and high-grade stenosis, but MRI is essential to evaluate soft tissue pathology, neural compression, cord signal changes, and the degree of foraminal stenosis that may be causing your patient's radicular-type symptoms. 3 Your chiropractor was correct—you cannot determine appropriate treatment without MRI, as degenerative changes visible on x-ray and CT do not correlate reliably with the source of neck pain or predict treatment response. 4

Conservative Management Algorithm (Minimum 6 Weeks Required)

Once MRI excludes myelopathy or progressive neurological deficits, implement the following structured approach:

Phase 1: Formal Physical Therapy (6-12 weeks)

• Core strengthening and cervical stabilization exercises targeting the paraspinal musculature and addressing the postural asymmetry noted on examination. 2
• Manual therapy and soft tissue mobilization for the muscle spasms and upper neck stiffness, which may include gentle cervical mobilization (NOT manipulation given the thoracic deformity and prior fusion). 5
• Postural retraining to address the shoulder misalignment and thoracic kyphosis contributing to mechanical neck pain. 2

Phase 2: Pharmacologic Management

• Trial of neuropathic pain medications (gabapentin or pregabalin) for the radiating pain to shoulder blades, as this suggests a radicular component. 1
• NSAIDs and muscle relaxants for the axial neck pain and muscle spasms during the acute phase. 6
• Avoid long-term opioid therapy—the evidence does not support this for chronic degenerative spine pain. 1

Phase 3: Interventional Options (If Conservative Fails)

• Cervical epidural steroid injections may provide short-term relief (typically less than 2 weeks) for radicular symptoms if MRI demonstrates nerve root compression. 1
• Facet joint injections can be both diagnostic and therapeutic, as facet-mediated pain causes 9-42% of chronic neck pain in degenerative disease. 1

Critical Decision Points Based on MRI Findings

If MRI Shows Myelopathy or Cord Compression

Urgent neurosurgical referral is mandatory. Myelopathic patients show stepwise deterioration without surgical decompression and stabilization. 4 This would be the ONLY scenario where you bypass the 6-week conservative requirement. 6

If MRI Shows Significant Foraminal Stenosis with Radiculopathy

• Complete the full 6-month conservative protocol first unless progressive motor deficits develop (MRC grade 4 or worse). 6
• Decompression alone (foraminotomy) is appropriate if no instability is present—fusion is NOT indicated for isolated radiculopathy. 1, 2

If MRI Shows Only Degenerative Changes Without Neural Compression

• Surgery is NOT indicated. The natural history of axial neck pain from degenerative disease suggests most patients improve with conservative management alone. 4
• Continue conservative therapy for at least 6 months before considering any surgical consultation. 2, 6

Addressing the Adjacent Segment Disease Concern

Your patient's prior L2-L5 fusion places them at risk for adjacent segment degeneration, but the thoracic spine changes appear pre-existing (unchanged from prior imaging). The mild dextroscoliosis and kyphosis are NOT surgical indications unless progressive deformity develops or neurological compromise occurs. 1, 6

Common Pitfalls to Avoid

Do not proceed to fusion based solely on imaging findings. The CT shows "mild" degenerative changes without high-grade stenosis—this does NOT meet surgical criteria. 1, 2 Fusion "increases complexity of surgery, prolongs surgical time, and potentially increases complication rates without proven medical necessity" in cases like this. 6

Do not accept "bone spurs" as an indication for surgery. Degenerative changes are ubiquitous and mostly asymptomatic—correlation with clinical symptoms via MRI is essential. 4

Do not skip formal physical therapy. Your patient's lack of structured PT is a critical deficiency that must be addressed before any surgical consideration. 1

Expected Outcomes with Conservative Management

For patients with axial neck pain and degenerative changes without myelopathy, conservative treatment provides equivalent outcomes to surgical intervention in properly selected patients. 2, 6 The muscle spasms, stiffness, and radiating pain typically improve significantly with 6-12 weeks of structured physical therapy and appropriate pharmacologic management. 5

When to Refer to Neurosurgery

Refer only if:

• MRI demonstrates myelopathy or cord compression (immediate referral). 4
• Progressive motor deficits develop (MRC grade 4 or worse). 6
• Six months of comprehensive conservative therapy fails AND imaging demonstrates surgically correctable pathology with clear correlation to symptoms. 2, 6