What is the best management approach for a patient with lower back pain, acute-subacute fracture of the L1 vertebra, multilevel disc disease, and transitional lumbosacral anatomy, as shown on MRI?

Management of Lower Back Pain with Acute L1 Fracture and Multilevel Disc Disease

Immediate Priority: Address the Acute L1 Vertebral Fracture

The acute-subacute L1 fracture with 30% height loss and bone marrow edema is the primary concern requiring immediate conservative fracture management, not the multilevel disc disease. 1, 2

Fracture-Specific Management

• Initiate strict activity modification with avoidance of flexion, heavy lifting, and high-impact activities until fracture healing is confirmed 1
• Prescribe a thoracolumbar orthosis (TLSO brace) for 6-12 weeks to limit spinal flexion and promote fracture healing 1
• NSAIDs are the first-line analgesic for both fracture pain and radicular symptoms from disc disease 2, 3
• Short-term opioids may be used judiciously for severe pain during the acute fracture healing phase, typically 1-2 weeks 2, 3
• Muscle relaxants are appropriate for associated paraspinal muscle spasms 2, 3
• Consider short-term oral corticosteroids to reduce nerve root inflammation from the L5-S1 lateral recess and foraminal narrowing 3

Critical Red Flag Assessment

You have already appropriately obtained MRI imaging because vertebral fracture constitutes a red flag requiring immediate diagnostic evaluation. 1 The MRI confirms no retropulsion, no traumatic canal stenosis, and no cauda equina syndrome, which are reassuring findings. 1

Management of Multilevel Disc Disease and Radiculopathy

Conservative Management Protocol (Minimum 6 Weeks)

The L5-S1 disc bulge with lateral recess narrowing and moderate left foraminal stenosis requires conservative management for at least 6 weeks before considering interventional options. 1, 2, 3

Pharmacologic Approach:

• Continue NSAIDs as primary analgesic for radicular pain 2, 3
• Muscle relaxants for spasm 2, 3
• Heat/cold therapy as needed for symptomatic relief 2, 3

Non-Pharmacologic Approach:

• Activity modification without complete bed rest - patients should remain active as tolerated rather than prescribed bed rest 1, 2, 3
• Immediate referral to physiotherapy - ideally within 2 weeks of symptom onset for optimal outcomes 2, 3
• Stabilization exercises have moderate evidence supporting their use over no treatment 2, 3
• Patient education emphasizing the favorable natural history - the majority of disc herniations show reabsorption or regression by 8 weeks after symptom onset 1, 2, 3

Monitoring and Reassessment Timeline

• Review progress within 2 weeks of initiating treatment, particularly if radicular pain is severe or disabling 2, 3
• Continue conservative management for at least 6 weeks before escalating to interventional options 1, 2, 3
• Reassess at 6 weeks - if no improvement and patient is a surgical candidate, consider MRI-guided interventions 1, 2

When to Escalate Treatment

Indications for Epidural Steroid Injection (After 6 Weeks):

If radicular symptoms persist despite 6 weeks of conservative therapy, fluoroscopic-guided epidural steroid injections targeting the L5-S1 level may be considered. 2, 3

• Fluoroscopic guidance is the gold standard - blind injections should not be performed 2, 3
• Target the affected nerve roots at L5-S1 where lateral recess narrowing affects the descending S1 nerve roots 2, 3

Indications for Surgical Evaluation:

Surgery should be considered only after 6 weeks of failed conservative therapy with documented nerve root compression on imaging (which you already have). 1, 2, 3

Specific surgical indications include:

• Progressive motor deficits (e.g., foot drop, progressive weakness) 1, 2, 3
• Cauda equina syndrome (urinary retention/incontinence, bilateral lower extremity weakness, saddle anesthesia) 1, 2
• Persistent, disabling radicular pain refractory to 6 weeks of conservative management and epidural steroid injections 1, 2, 3

Lumbar fusion is NOT recommended for routine disc herniation cases and should be reserved for specific scenarios such as documented instability, which is not present in this case despite the 2-3mm retrolisthesis at L5-S1. 2, 3

Critical Pitfalls to Avoid

• Do not prescribe bed rest - remaining active is more effective than bed rest for acute low back pain 1, 2, 4
• Do not delay physiotherapy while waiting for fracture healing - modified physiotherapy can begin immediately with appropriate precautions 2, 3
• Do not order repeat imaging before 6 weeks unless progressive neurological deficits develop 1, 2
• Recognize that disc abnormalities are present in 29-43% of asymptomatic individuals - the L2-L3 and L3-L4 disc protrusions (2mm each) are likely incidental and not contributing to symptoms 1, 2, 3
• The chronic T12 fracture and transitional lumbosacral anatomy are incidental findings that do not require specific treatment 1, 5

Specific Algorithm for This Patient

1. Weeks 0-2: TLSO brace, NSAIDs, muscle relaxants, activity modification for fracture, immediate physiotherapy referral with fracture precautions 1, 2, 3
2. Week 2: Reassess pain and neurological status - if severe/disabling radicular pain persists, consider short-term oral corticosteroids 2, 3
3. Week 6: Reassess fracture healing and radicular symptoms - if radiculopathy persists despite conservative therapy, consider fluoroscopic-guided epidural steroid injection at L5-S1 2, 3
4. Week 12: If symptoms remain disabling despite injections, refer for surgical evaluation with neurosurgery or orthopedic spine surgery 1, 2, 3

Immediate surgical referral is warranted only if progressive motor deficits, cauda equina syndrome, or other red flags develop during conservative management. 1, 2