What is the recommended management for a 70‑year‑old woman with low back pain and MRI showing partial sacralization of L5, mild‑to‑moderate central canal stenosis at L2‑L3 and L3‑L4, and right‑sided L4‑L5 neuroforaminal narrowing?

Management of Low Back Pain with Multilevel Spinal Stenosis and Neuroforaminal Narrowing

Begin with a structured 6-week trial of conservative management combining NSAIDs, physical therapy with stabilization exercises, and activity modification before considering any interventional procedures. 1

Initial Conservative Management (First 6 Weeks)

Pharmacologic Treatment

• Start NSAIDs as first-line analgesic for both axial back pain and any radicular symptoms from the L4-L5 neuroforaminal narrowing 2
• Add muscle relaxants if muscle spasm is present 2
• Apply heat or cold therapy as needed for symptomatic relief 2
• Avoid routine opioid prescriptions - reserve only for severe, disabling pain and limit to 1-2 weeks maximum 1, 2

Physical Therapy

• Refer to physical therapy within 2 weeks of presentation - earlier referral correlates with better outcomes 2
• Focus on stabilization exercises, which have moderate evidence supporting their use over no treatment 2
• Maintain activity as tolerated - do not prescribe bed rest, as remaining active is more effective than bed rest for low back pain 1, 2

Activity Modification

• Avoid prolonged standing, walking, and lumbar extension activities that typically worsen spinal stenosis symptoms 3
• Encourage forward-flexed postures (shopping cart sign) which may relieve stenotic symptoms 4

Reassessment Timeline

At 2 Weeks

• Reevaluate if radicular pain is severe or disabling - this warrants earlier consideration of escalation 1
• Assess for any progressive neurological deficits (motor weakness, sensory changes, bowel/bladder dysfunction) 1

At 6 Weeks

• If symptoms persist despite conservative therapy, consider escalation to interventional options 1, 5
• Document specific functional limitations and pain patterns (axial vs. radicular) 5

Interventional Management (After Failed Conservative Therapy)

Critical Decision Point: Axial vs. Radicular Pain

This distinction is crucial because treatment recommendations differ dramatically based on pain type. 5

For Predominant Radicular Pain (Pain radiating below the knee from L4-L5 neuroforaminal narrowing):

• Fluoroscopy-guided epidural steroid injection targeting the L4-L5 level is appropriate 1, 5
• The British Pain Society emphasizes that fluoroscopic guidance is the gold standard - blind injections should never be performed 1
• Transforaminal approach may be considered for isolated L4-L5 neuroforaminal stenosis with corresponding radicular symptoms 5
• Shared decision-making must include discussion of risks: dural puncture, infection, cauda equina syndrome, sensorimotor deficits, and rare catastrophic complications including paralysis 5

For Predominant Axial Back Pain (From central canal stenosis at L2-L3 and L3-L4):

• Epidural steroid injections are explicitly NOT recommended for axial back pain from spinal stenosis without significant radicular symptoms 5
• The 2025 BMJ guideline provides a strong recommendation against epidural injections for chronic axial spine pain, stating "all or nearly all well-informed people would likely not want such interventions" 5
• Consider radiofrequency ablation if facet-mediated pain is suspected 5

Common Pitfalls to Avoid

Imaging Interpretation

• The partial sacralization of L5 is an incidental finding - do not attribute symptoms to this anatomical variant 1
• Mild-to-moderate stenosis on MRI may not correlate with symptom severity - clinical presentation takes precedence 1
• Do not order repeat imaging before 6 weeks unless progressive neurological deficits develop 2

Treatment Errors

• Never perform epidural injections for non-radicular back pain from spinal stenosis alone - this exposes patients to significant risks without evidence of benefit 5
• Do not delay physical therapy while pursuing other treatments - it should begin immediately 2
• Avoid prescribing complete bed rest, which worsens outcomes 1, 2

Documentation Requirements

• Before any epidural injection, document: minimum 4-6 weeks of failed conservative therapy including physical therapy, whether pain radiates below the knee (true radiculopathy), and MRI correlation with clinical symptoms 5
• For repeat injections, document at least 50% pain relief lasting at least 2 weeks from the prior injection 5

Surgical Evaluation Criteria

Consider surgical consultation only after 6 weeks of failed conservative therapy AND documented nerve root compression on MRI correlating with clinical symptoms. 1, 2

Specific Surgical Indications:

• Progressive motor deficits (weakness worsening over time) 1
• Cauda equina syndrome (bowel/bladder dysfunction, saddle anesthesia) 1
• Severe neurogenic claudication limiting ambulation to less than one block despite conservative management 4
• Multilevel stenosis with significant functional impairment after exhausting conservative options 6

Surgical Approach Considerations:

• Decompression laminectomy at L2-L3, L3-L4 for central canal stenosis 3, 4
• Foraminotomy at L4-L5 for neuroforaminal narrowing 7
• Fusion is NOT routinely indicated unless segmental instability or spondylolisthesis is present 1, 3
• The partial sacralization does not necessitate fusion 1

Red Flags Requiring Urgent Evaluation

If any of the following develop, obtain urgent MRI and surgical consultation: 1

• New-onset bowel or bladder dysfunction (urinary retention, incontinence) 1
• Saddle anesthesia or perianal numbness 1
• Progressive bilateral lower extremity weakness 1
• Rapidly progressive neurological deficits 1

Expected Outcomes

• Most patients with mild-to-moderate stenosis improve with conservative management within the first month 1
• For those requiring epidural injections for true radiculopathy, expect pain relief for 2 weeks to 3 months 5
• Surgical decompression halts disease progression in cervical stenosis and provides short-term benefit in lumbar stenosis 4