What is the recommended treatment plan for a patient with mild to moderate multilevel degenerative disc disease, facet joint arthropathy, and canal stenosis at L4-5, who also has atheroma of the aorta and moderate aortoiliac calcification?

Treatment Plan for Multilevel Lumbar Degenerative Disease with Spinal Stenosis

Begin with conservative management for at least 6 months before considering any surgical intervention, starting with acetaminophen up to 4g daily or ibuprofen 1.2g daily, combined with physical therapy focused on core strengthening and flexibility exercises. 1, 2

Initial Conservative Management (First 6-8 Weeks)

Pharmacological Treatment

• Start with acetaminophen (paracetamol) up to 4g daily as first-line therapy 1, 2
• If acetaminophen provides inadequate relief, switch to ibuprofen 1.2g daily 1, 2
• For insufficient relief with initial NSAID therapy, escalate by either:
  • Increasing ibuprofen to 2.4g daily
  • Adding acetaminophen to ibuprofen
  • Switching to alternative NSAIDs (diclofenac or naproxen) 1, 2
• Add gastroprotective agents if the patient has high risk for NSAID-induced gastrointestinal complications 1, 2
• Monitor regularly for NSAID-related adverse effects, particularly gastrointestinal and cardiovascular complications 2

Non-Pharmacological Interventions

• Physical therapy is mandatory and should focus on core strengthening and flexibility exercises 1, 2
• Consider acupuncture as an adjunct to conventional therapy 1, 2

Management of Persistent Symptoms (2-3 Months)

• For persistent radicular pain after 2-3 months of conservative management, consider epidural steroid injections 1
• For persistent facet-related pain, consider conventional radiofrequency ablation of the medial branch nerves when previous diagnostic or therapeutic injections have provided temporary relief 1, 2

Addressing the Vascular Component

The moderate aortoiliac calcification and atheroma warrant attention as they may contribute to disc degeneration. The correlation between atherosclerotic disease and lumbar degenerative disc disease is well-established, with lumbar artery and aortic atherosclerosis showing positive correlation with disc degeneration, facet arthritis, and spinal stenosis even after controlling for age 3, 4. The intervertebral disc relies on passive diffusion from arteries at the periphery for nutrition, and vascular occlusion can accelerate degeneration 3, 4.

• Optimize cardiovascular risk factors including smoking cessation and cholesterol management, as these have the most consistent associations with disc degeneration and low-back pain 4
• Consider cardiology consultation for comprehensive vascular risk assessment given the moderate aortoiliac calcification 3

Surgical Consideration (Only After ≥6 Months Failed Conservative Management)

Surgery should only be considered after at least 6 months of comprehensive conservative management has failed to provide adequate relief. 1, 2, 5

Surgical Options for Multilevel Disease

• For this patient with mild to moderate canal stenosis at L4-5 and L5-S1, decompression alone may be considered if there is no evidence of instability on flexion-extension radiographs 6
• If fusion becomes necessary, the evidence shows mixed outcomes:
  • Fusion may provide more rapid pain reduction compared to decompression alone, though long-term functional outcomes may be similar 6
  • Instrumented fusion has higher fusion rates (87-91%) compared to non-instrumented fusion (72%), but also higher complication rates (18-31% vs 6%) 6
  • Fusion may accelerate adjacent segment degeneration, which is a significant long-term concern 7

Important Surgical Caveats

• Total disc arthroplasty is NOT appropriate as a first-line surgical option and should not be considered before exhausting conservative management 5
• If surgery becomes necessary, lumbar fusion—not arthroplasty—would be the appropriate consideration 5
• Patient must demonstrate significant functional impairment with validated outcome measures (ODI, VAS) before considering surgery 5

Critical Pitfalls to Avoid

• Do not rush to surgery: 75-90% of patients achieve symptomatic improvement through conservative measures 1
• Do not ignore the vascular component: The atherosclerotic disease may be contributing to disc degeneration and should be addressed 3, 4
• Do not use chemical denervation for routine care of chronic non-cancer pain 2
• Correlation with clinical symptoms is essential: MRI findings must always be correlated with clinical symptoms, as false positives and false negatives are common 1

Neuropathic Pain Component

If the patient develops neuropathic pain features (burning, shooting pain, numbness):

• Consider tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors, starting at low doses and titrating gradually 1, 2

Expected Outcomes

• At 12 months, physical therapy can achieve comparable clinical improvements to surgical interventions 1
• Surgical approaches may provide more rapid relief (within 3-4 months) if conservative management fails 1
• The presence of moderate aortoiliac calcification suggests that addressing cardiovascular risk factors may slow the progression of degenerative changes 3, 4