What is the best course of treatment for an older adult patient with a history of chronic back pain, presenting with multilevel degenerative changes, 24 degrees of leftward lumbar curvature, subluxation, and spinal stenosis, as shown on MRI?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: February 3, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

MRI Evaluation: Multilevel Degenerative Lumbar Spine with Scoliosis and Stenosis

Primary Assessment

This MRI demonstrates multilevel degenerative changes with mild spinal stenosis and scoliosis, but these findings do NOT currently warrant surgical intervention—comprehensive conservative management is the appropriate first-line treatment. 1

The imaging shows common age-related degenerative changes that are frequently present in asymptomatic individuals, with 29% of asymptomatic 20-year-olds having disc protrusions, rising to 43% by age 80. 1 The presence of these findings on imaging does not mandate treatment, as they correlate poorly with clinical symptoms. 2

Key Imaging Findings and Clinical Significance

Structural Alignment Issues

  • 24-degree leftward lumbar scoliosis: This degree of curvature is mild and does not independently indicate surgical need. 3
  • Grade 1 retrolisthesis at L2-L3 and L3-L4: These represent minimal displacement (less than 25% vertebral body translation) and do not constitute significant instability requiring fusion. 4
  • Grade 1 anterolisthesis at L4-L5: Similarly, this minimal forward slippage does not meet criteria for surgical stabilization without documented dynamic instability on flexion-extension radiographs. 4

Stenosis Severity Analysis

  • L1-L2: Lateral recess effacement with nerve root contact—this is a radiographic finding that may or may not be clinically significant depending on symptoms. 2
  • L2-L3: Mild spinal canal stenosis—does not meet threshold for surgical decompression. 5
  • L3-L4: Mild spinal canal stenosis with mild-to-moderate foraminal narrowing—insufficient severity for surgical intervention. 5
  • L4-L5: Mild-to-moderate spinal canal stenosis—still below the moderate-to-severe threshold required for surgical consideration. 4

Critical Point: None of these levels demonstrate moderate-to-severe or severe stenosis, which is the minimum radiographic threshold required before considering surgical decompression. 4

Recommended Treatment Algorithm

Phase 1: Comprehensive Conservative Management (Minimum 6 Weeks to 3 Months)

Formal physical therapy program with structured exercises focusing on core strengthening, lumbar flexion-based exercises (which relieve stenotic symptoms), and postural training for a minimum of 6 weeks. 1, 2 This is not optional—it is a mandatory prerequisite before any surgical consideration. 4

Activity modification: Reduce prolonged standing or walking periods, use assistive devices if needed, and avoid lumbar extension activities that provoke symptoms. 5

Pharmacologic management: NSAIDs for pain control, with consideration of neuropathic pain medications (gabapentin, pregabalin) if radicular symptoms are present. 4, 2

Patient education: Emphasize the benign, self-limiting nature of mechanical back pain and the high likelihood of spontaneous improvement—approximately one-third of patients with lumbar spinal stenosis improve without surgery, and 50% remain stable over 3 years. 5, 1

Phase 2: Interventional Options (If Conservative Management Fails)

Epidural steroid injections are NOT recommended for chronic axial back pain without radiculopathy, as recent high-quality guidelines issued strong recommendations against their use for chronic spine pain lasting 3 months or longer. 2 Long-term benefits have not been demonstrated for lumbar spinal stenosis. 5

Facet joint injections are NOT recommended based on 2025 BMJ guidelines that issued strong recommendations against joint-targeted injections for chronic spine pain. 2

Phase 3: Surgical Consideration Criteria (NOT Currently Met)

Surgery should only be considered if ALL of the following criteria are met:

  1. Failure of comprehensive conservative management for minimum 3-6 months, including formal physical therapy. 4, 2

  2. Moderate-to-severe or severe stenosis documented on imaging—your current findings show only mild-to-moderate stenosis. 4

  3. Documented instability (spondylolisthesis with dynamic movement on flexion-extension films) OR extensive decompression requirements that would create iatrogenic instability. 4

  4. Significant functional impairment with neurological symptoms that correlate directly with imaging findings. 4

  5. Progressive neurological deficits or unacceptable decrease in quality of life despite maximal conservative therapy. 6

Common Pitfalls to Avoid

Do not pursue repeat imaging in the near term—84% of patients with lumbar imaging abnormalities show unchanged or improved findings after symptoms develop, and repeat imaging rarely detects clinically meaningful changes. 1

Do not interpret radiographic findings as surgical indications without corresponding clinical symptoms—spondylotic changes on MRI are common in patients over 30 years and correlate poorly with the presence of neck or back pain. 2

Do not consider fusion for isolated degenerative changes without documented instability—Grade B evidence states that in the absence of deformity or instability, lumbar fusion has not been shown to improve outcomes in patients with isolated stenosis. 4

Beware of apical vertebral rotation in the setting of degenerative scoliosis—higher degrees of rotation are associated with mechanical low back pain and may predict poor outcomes with decompression alone (odds ratio 8.16 for residual pain). 3 However, this does not change the initial conservative management approach.

Expected Natural History

With appropriate conservative management, the natural history shows: approximately one-third of patients improve, approximately 50% remain stable, and only 10-20% worsen over 3 years. 5 Intensive physical therapy with cognitive behavioral components shows equivalent outcomes to fusion surgery for chronic low back pain without stenosis or instability. 4

Red Flags Requiring Urgent Re-evaluation

Immediately reassess if any of the following develop:

  • Cauda equina symptoms (bowel/bladder dysfunction, saddle anesthesia)
  • Progressive neurological deficits with motor weakness
  • Constitutional symptoms suggesting infection or malignancy
  • Severe or progressive neurologic deficits 2

These would warrant prompt advanced imaging (MRI preferred over CT) and specialist referral. 2

References

1
Guideline

Treatment Approach for Mild Multilevel Degenerative Lumbar Spine Changes

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Research

Can decompression surgery relieve low back pain in patients with lumbar spinal stenosis combined with degenerative lumbar scoliosis?

European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2013

4
Guideline

Medical Necessity of Lumbar Fusion

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Related Questions

Is a 64-year-old female with severe lumbar stenosis at the L4-L5 level, lordosis, and preserved alignment, as well as multilevel degenerative disc disease, numbness, pain in the buttocks, low back pain, and weakness, who has undergone extensive conservative treatments including IcyHot, medical marijuana rubs, Hydrocodone (hydrocodone), and physical therapy, a candidate for surgical intervention with procedure 63048 - remove spinal lamina add-on x3?
What is the best treatment option for a 55-year-old female with chronic radicular low back pain, spinal stenosis, and degenerative disc disease, who has failed conservative treatment and has significant stenosis and instability of the spine?
Is a 3-day inpatient hospital stay from 10/29/25 through 10/31/25 medically necessary for a patient with severe, intractable low back pain and lumbar spinal stenosis, and are the procedures including revision of interbody fusion (CPT 22633), lumbar laminectomy (CPT 63052), and pedicle screw placement (CPT 22845) medically indicated?
Is medication or surgery medically indicated for a patient with a history of spine surgeries and chronic lumbar back pain with right-sided sciatica, spondylolisthesis, intervertebral disc displacement, and spinal stenosis?
Is lumbar spine fusion surgery medically indicated for this patient with chronic back pain and lumbar spinal stenosis?
What are the alternative diagnostic approaches for an elderly patient with hypertension, diabetes, and vascular disease who is suspected of having a pulmonary embolism (PE) but cannot undergo a computed tomography pulmonary embolism (CT PE) scan due to contrast immediately leaking out of vessels?
What imaging modalities are suitable to rule out a vasculitis flare in a patient with end-stage renal failure (ESRF), a history of central retinal artery occlusion (CRAO) with vasculopathy, and a recent stroke, given the high risk of nephrogenic systemic fibrosis (NSF) with MRI vessel wall imaging?
What other evidence-based nutrients, in addition to vitamin B, magnesium, vitamin D, and Omega 3, should be included in a basic patient education guide on supplements beneficial to mental health?
What is the best course of action for managing severe neck pain in a patient with degenerative cervical spine changes, who has not achieved adequate relief with Tramadol (tramadol) 50 mg, and has undergone relevant imaging studies?
What is the recommended treatment for a patient with allergic rhinitis, asthma, or chronic sinusitis using intranasal corticosteroids (INCS)?
What is the likely cause of a patient's auditory hallucinations, including hearing voices, music, and conversations, that started after initiating a new medication, and how should it be managed?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question