What is the best course of treatment for a patient with mild DDD, contour deformity of the distal coccyx, and left SI joint fusion, experiencing pain relief with lidocaine patches and Naproxen (naproxen), but unable to attend in-person physical therapy due to childcare responsibilities?

Optimal Management Strategy for Multilevel Degenerative Spine Disease with Barriers to Physical Therapy

Continue the current conservative regimen with lidocaine patches and naproxen while aggressively pursuing alternative physical therapy solutions, and proceed with MRI of the SI joint to exclude spondyloarthropathy before considering any surgical intervention. 1, 2

Conservative Management Remains the Priority

The patient has not completed adequate conservative therapy, which is the critical prerequisite before any surgical consideration. 1, 2 The evidence is clear:

• Comprehensive physical therapy for at least 6 weeks to 3 months is mandatory before fusion can be considered medically necessary for degenerative disc disease without significant instability or stenosis. 1, 2, 3
• Level II evidence demonstrates that intensive rehabilitation programs with cognitive behavioral therapy components show equivalent outcomes to lumbar fusion for chronic low back pain without stenosis or spondylolisthesis. 1, 4
• The patient's two virtual PT sessions are grossly inadequate and do not satisfy guideline requirements. 2

Addressing the Physical Therapy Barrier

The childcare obstacle must be solved creatively rather than abandoning PT entirely:

• Explore home-based physical therapy programs that can be performed while supervising the child. 3
• Investigate community resources, family support, or childcare assistance programs that could enable in-person PT attendance. 3
• Consider hybrid approaches combining telehealth instruction with home exercise programs, even if insurance won't cover virtual sessions, the patient can use recorded instructions. 3

Current Medication Strategy is Appropriate

Continue naproxen 500 mg twice daily as currently prescribed. 5

• Naproxen has demonstrated efficacy in degenerative joint disease and provides anti-inflammatory effects for up to 12 hours per dose. 5, 6, 7
• The current dosing (1000 mg/day) is within the recommended range for chronic conditions and below the maximum daily dose of 1500 mg. 5
• Add diclofenac (Voltaren) gel topically to the lumbar and SI joint regions as an adjunct to systemic therapy. 3
• Continue lidocaine patches for localized pain relief, as the patient reports benefit. 3

Essential Diagnostic Workup Before Surgical Consideration

The MRI of the left SI joint is critical and must be completed to exclude inflammatory spondyloarthropathy. 2

• Left SI joint fusion on X-ray requires differentiation between degenerative fusion and ankylosing spondylitis/spondyloarthropathy. 2
• The negative CRP and absence of inflammatory symptoms (morning stiffness >30 minutes, improvement with exercise, alternating back pain, awakening due to pain) make inflammatory arthropathy less likely, but MRI is needed for definitive exclusion. 2
• Referral to rheumatology should follow the MRI results, not precede them, as the imaging will guide the rheumatologist's assessment. 2

Surgical Considerations Are Premature

Fusion surgery is NOT indicated at this time based on current evidence. 1

The 2021 BMJ umbrella review of level 1 evidence found:

• No differences in Oswestry Disability Index scores between lumbar spine fusion and non-operative management (physical therapy, patient education, exercise) for degenerative disc disease. 1
• Lumbar spine fusion was associated with surgical complications without demonstrable superiority over conservative treatment. 1
• Both surgical and conservative treatment groups showed improvement during follow-up with no difference in functional outcomes. 1

Specific Findings That Do NOT Meet Fusion Criteria

• Mild DDD at L5-S1 with loss of vertebral height but no active osteophyte formation does not constitute significant instability requiring fusion. 1, 2
• The contour deformity of the distal coccyx is likely a sequela of previous injury and does not require surgical intervention unless there is specific coccygeal pain warranting targeted treatment. 2
• Left SI joint fusion alone, without confirmed inflammatory arthropathy or symptomatic instability, is not an indication for surgical intervention. 2

Timeline for Reassessment

Reassess in 4-6 weeks with the following specific criteria:

• Completion of structured home-based or in-person PT program (minimum 6 weeks). 1, 2, 3
• Results of SI joint MRI and rheumatology evaluation if indicated. 2
• Response to optimized conservative management including naproxen, lidocaine patches, and Voltaren gel. 3, 5
• Functional assessment using validated outcome measures (Oswestry Disability Index, Visual Analog Scale for pain). 3, 4

Only consider MRI of the lumbar spine and orthopedic referral if:

• Comprehensive conservative therapy for 3-6 months has failed. 1, 2, 3
• Significant functional impairment persists despite maximal medical management. 1, 3
• New neurological deficits develop (progressive weakness, bowel/bladder dysfunction, cauda equina symptoms). 3
• Pain correlates definitively with specific anatomical findings that would be amenable to surgical correction. 1, 2

Critical Pitfalls to Avoid

Do not proceed to MRI and orthopedic referral prematurely. 1, 2 The evidence demonstrates that:

• Imaging findings often correlate poorly with symptoms in degenerative disc disease. 3, 4
• Early surgical referral without adequate conservative management leads to unnecessary procedures with complication rates of 31-40% for fusion procedures. 2
• Factors such as incomplete conservative therapy, psychosocial stressors (like childcare responsibilities), and chronic pain behaviors negatively impact surgical outcomes and must be addressed first. 3, 4

The patient's inability to attend in-person PT due to childcare is a solvable logistical problem, not a reason to escalate to surgery. 3 This barrier must be overcome through creative problem-solving, not bypassed through premature surgical intervention.