What is the recommended treatment for a patient with lower back pain and an MRI showing multilevel spondylosis with disc bulges and protrusions, facet arthropathy, and mild canal stenosis at L2-3 and L3-4?

Treatment for Multilevel Lumbar Spondylosis with Mild Canal Stenosis

Begin with a structured 6-week course of conservative management including formal physical therapy, NSAIDs or COX-2 inhibitors, and activity modification before considering any surgical intervention. 1

Initial Conservative Management (First-Line Treatment)

The MRI findings show multilevel degenerative changes but only mild canal stenosis at L2-3 and L3-4, with moderate foraminal narrowing at specific levels. This presentation does not constitute severe pathology requiring immediate surgical consideration. 1

Required Conservative Treatment Components:

• Formal physical therapy program for minimum 6 weeks focusing on core strengthening, flexibility, and postural training 1
• NSAIDs or COX-2 inhibitors for pain control and inflammation management 2
• Prostaglandin E1 preparations may provide additional benefit for neurogenic symptoms 2
• Remain active - bed rest should be avoided as it worsens outcomes compared to maintaining activity 1
• Patient education on the generally favorable prognosis, as most cases improve substantially within the first month 1

Additional Conservative Options:

• 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 radiculopathy 3, 2
• Facet joint injections can be both diagnostic and therapeutic, as facet-mediated pain causes 9-42% of chronic low back pain 3
• Neuropathic pain medications (gabapentin or pregabalin) if radicular symptoms are prominent 3

When to Consider Advanced Imaging or Surgical Evaluation

Only proceed to surgical consultation if the patient fails 6 weeks of optimal conservative management AND is a candidate for surgery or intervention. 1

Critical Red Flags Requiring Urgent Evaluation:

• Progressive neurologic deficits (motor weakness, sensory loss)
• Cauda equina syndrome symptoms (bowel/bladder dysfunction, saddle anesthesia)
• Severe or progressive symptoms despite conservative care
• Suspicion of infection, cancer, or vertebral fracture 1

Surgical Consideration Criteria (All Must Be Met):

1. Completion of comprehensive conservative therapy for at least 6 weeks to 3 months 1, 3
2. Persistent disabling symptoms that significantly impair quality of life 1
3. Patient is a surgical candidate willing to accept surgical risks 1
4. Imaging findings correlate with clinical symptoms - the specific levels causing symptoms must match MRI findings 1, 3

Surgical Options (Only After Failed Conservative Management)

For Isolated Stenosis Without Instability:

• Decompression alone (laminectomy/foraminotomy) is appropriate when there is no documented instability or spondylolisthesis 3, 4
• Grade B evidence shows fusion does not improve outcomes in isolated stenosis without deformity or instability 3

For Stenosis With Instability:

• Decompression plus fusion is indicated only when:
  • Documented spondylolisthesis is present 3
  • Extensive decompression (>50% facet removal) creates iatrogenic instability 3
  • Dynamic instability is demonstrated on flexion-extension radiographs 3

Critical Pitfalls to Avoid

• Do not order routine imaging in uncomplicated low back pain - numerous studies show it provides no clinical benefit and increases healthcare utilization 1
• Do not proceed to surgery without completing adequate conservative therapy - the natural history shows improvement in most patients within 4 weeks 1
• Do not perform fusion for isolated disc bulges or mild stenosis without instability - this increases complications without proven benefit 3, 4
• Avoid bed rest - it worsens outcomes compared to remaining active 1
• Do not rely solely on MRI findings - many abnormalities are seen in asymptomatic individuals and imaging patients without red flags is often not beneficial 1

Expected Outcomes With Conservative Management

• More than 60% of patients with discogenic low back pain experience spontaneous remission with conservative care 5
• Most patients with subacute/chronic uncomplicated low back pain respond to medical management and physical therapy 1
• The natural history of lumbar disc herniation with radiculopathy shows improvement within the first 4 weeks in most patients 1

Monitoring and Reassessment

Reevaluate the patient at 4-6 weeks of conservative therapy. If symptoms persist or worsen despite optimal conservative management, and the patient desires surgical treatment, then referral to a spine surgeon is appropriate for consideration of decompression (with or without fusion based on presence of instability). 1