What is the best management approach for a 71-year-old patient with right L5 and S1 radiculopathy, multilevel degenerative disc disease, and minimal retrolisthesis of L5 on S1, as shown on lumbar spine MRI?

Management of 71-Year-Old with Right L5 and S1 Radiculopathy and Multilevel Degenerative Disc Disease

Begin with a structured 6-week trial of comprehensive conservative management before considering any surgical intervention, as this patient's imaging findings—while demonstrating nerve root impingement at L5 and S1—represent degenerative changes commonly seen in asymptomatic individuals of this age, and the absence of red flags makes conservative treatment the evidence-based first approach. 1

Initial Conservative Management (6 Weeks Minimum)

The American College of Radiology guidelines establish that patients with subacute or chronic low back pain with radiculopathy should receive conservative therapy before imaging-guided interventions, as most cases respond to medical management and physical therapy 1. Your patient requires:

• Formal structured physical therapy focusing on core strengthening, flexibility training, and proper body mechanics—not just home exercises 2, 3
• Neuropathic pain medication trial with gabapentin (starting 300mg daily, titrating to 300-600mg three times daily) or pregabalin (150-600mg/day in divided doses) for the radicular symptoms 2, 4
• NSAIDs or acetaminophen as first-line analgesics for axial back pain 3, 5
• Activity modification while remaining physically active rather than bed rest, as activity is more effective for low back pain 3, 5
• Patient education about the generally favorable prognosis, emphasizing that degenerative disc findings are extremely common in asymptomatic 71-year-olds 1, 5

Critical Imaging Interpretation

The MRI findings must be interpreted with extreme caution in this age group. A systematic review found disc protrusion prevalence increases from 29% at age 20 to 43% at age 80 in completely asymptomatic individuals 1. The reported impingement of L5 and S1 nerve roots may or may not be the pain generator, particularly since:

• The clinical history mentions L1 radiculopathy, but imaging shows no L1 nerve root impingement [@MRI report]
• The S3 radiculopathy mentioned clinically has no corresponding imaging findings [@MRI report]
• This discordance between symptoms and imaging is common and suggests the degenerative changes may be incidental 1

When to Escalate to Interventional or Surgical Consideration

Only proceed to advanced interventions if the patient fails 6 weeks of optimal conservative management AND remains a surgical candidate. 1, 2 Specific criteria include:

• Persistent disabling symptoms despite comprehensive conservative treatment for 3-6 months 2, 3
• Documented instability on flexion-extension radiographs (note: minimal retrolisthesis on static MRI does not constitute instability) 2, 3, 6
• Progressive neurological deficits such as worsening weakness, sensory loss, or bowel/bladder dysfunction 3, 5
• Significant functional impairment that prevents activities of daily living despite conservative measures 2, 3

Interventional Options Before Surgery

If conservative management fails at 6 weeks but symptoms are not severe enough for surgery:

• Epidural steroid injections may provide short-term relief (typically less than 2 weeks) for radicular symptoms, though evidence is limited for chronic low back pain without acute radiculopathy 2
• Diagnostic facet injections can identify facet-mediated pain (responsible for 9-42% of chronic low back pain) and guide treatment 2

Surgical Considerations (Only After Failed Conservative Management)

Decompression alone would be the appropriate initial surgical approach if surgery becomes necessary, NOT fusion. 2 The evidence is clear:

• Fusion should be reserved for documented instability, spondylolisthesis, or when extensive decompression might create iatrogenic instability 2, 3
• Your patient has only minimal retrolisthesis (not spondylolisthesis), which does not constitute instability requiring fusion 3, 7, 8
• Retrolisthesis at L5-S1 in patients with disc herniation is present in 23% of cases and does not correlate with worse baseline pain or function 7
• Routine fusion is not recommended for isolated disc pathology or radiculopathy without documented instability (Grade C recommendation) 2

If Surgery Is Eventually Required

For the L5 and S1 nerve root impingement:

• Selective nerve root decompression (foraminotomy) at L4-5 for the L5 nerve root and L5-S1 for the S1 nerve root 2
• Preserve facet joints whenever possible—removal of >50% of facet requires fusion consideration 2
• For far lateral L5 nerve root impingement at L4-5, a minimally invasive intermuscular approach preserves facet joint integrity and prevents postoperative instability 9

Common Pitfalls to Avoid

1. Do not order surgery based on imaging alone—84% of patients with lumbar imaging abnormalities before symptom onset had unchanged or improved findings after symptoms developed 1

2. Do not assume retrolisthesis requires fusion—minimal retrolisthesis is common and does not predict worse outcomes after discectomy 7, 8

3. Do not skip formal physical therapy—home exercises are insufficient; structured PT for 6 weeks minimum is required before surgical consideration 2, 3

4. Do not rely on single epidural injections—these provide only temporary relief (<2 weeks) and do not satisfy conservative treatment requirements 2

5. Recognize that multilevel degenerative changes are age-appropriate—the extensive degenerative findings (L1/2 through L5/S1) are expected in a 71-year-old and most are likely asymptomatic 1

Monitoring and Follow-Up

• Reassess at 6 weeks after initiating conservative treatment to determine response 3, 5
• Obtain flexion-extension radiographs only if considering surgery, to document dynamic instability (static retrolisthesis on MRI is insufficient) 2, 3, 6
• Consider repeat upright weight-bearing MRI if symptoms worsen or fail to improve, as positional imaging may reveal dynamic changes not apparent on recumbent MRI 6

Expected Outcomes with Conservative Management

Most patients (60-80%) with radiculopathy from disc pathology improve within 6-12 weeks with conservative management, and 80-90% improve long-term (≥1 year) 5. Even disc herniations show some degree of reabsorption or regression by 8 weeks after symptom onset 1.