What is the appropriate initial management for a middle‑aged adult with multilevel lumbar spondylosis and radicular symptoms?

Initial Management of Multilevel Lumbar Spondylosis with Radicular Symptoms

Begin with conservative management for at least 6 weeks before considering imaging or interventional procedures, unless red flag symptoms are present. 1

Immediate Assessment for Red Flags

Before initiating conservative therapy, screen for conditions requiring urgent imaging and specialist referral:

• Cauda equina syndrome (urinary retention/incontinence, bilateral lower extremity weakness, saddle anesthesia) 1
• Progressive motor deficits (e.g., foot drop with documented weakness) 1
• Suspected malignancy, infection, or fracture 1
• Severe or disabling radicular pain preventing normal daily activities 1

If any red flags are present, proceed immediately to MRI lumbar spine without contrast and specialist referral. 1 Do not delay for conservative therapy in these cases.

First-Line Conservative Management (Weeks 0-6)

Pharmacologic Interventions

• NSAIDs for pain control 1
• Muscle relaxants for associated muscle spasms 1
• Short-term opioids may be used judiciously for severe pain only 1

Important caveat: Recent evidence shows that standard neuropathic pain medications (nortriptyline, morphine, pregabalin, topiramate) have limited efficacy for lumbosacral radiculopathy. 1

Non-Pharmacologic Interventions

• Activity modification without complete bed rest - patients should remain active as tolerated 1
• Heat/cold therapy as needed for symptomatic relief 1
• Patient education emphasizing the favorable natural history (most disc herniations show reabsorption by 8 weeks) 1
• Physical therapy should begin immediately, not delayed while awaiting imaging 1

Critical pitfall to avoid: Do not prescribe bed rest; remaining active is more effective than bed rest for acute back pain. 1

Timeline for Escalation

At 2 Weeks

Review progress for patients with severe or disabling radicular pain. 1 Consider earlier specialist referral if pain prevents normal everyday tasks. 1

At 6 Weeks

If no improvement after 6 weeks of conservative therapy, consider:

• MRI lumbar spine without contrast (only if patient is a surgical candidate or candidate for epidural steroid injection) 1
• Specialist referral for assessment 1
• Image-guided epidural steroid injections (fluoroscopic guidance is the gold standard for transforaminal or interlaminar approaches) 1, 2

Important consideration: Imaging should only be ordered after 6 weeks of failed conservative therapy in patients who are actual intervention candidates. 1 Routine imaging provides no clinical benefit and increases healthcare utilization without improving outcomes. 1

At 3 Months

For patients with less severe radicular pain, specialist referral should occur no later than 3 months if symptoms persist. 1

Interventional Options After Conservative Failure

Epidural Steroid Injections

Indications:

• Failed 6 weeks of conservative therapy 1, 2
• MRI confirmation of nerve root compression correlating with clinical symptoms 2
• True radicular pain (radiating below the knee) 2
• Pain severity causing functional limitation 2

Technical requirements:

• Must be performed under fluoroscopic guidance 1, 2
• Should be part of a comprehensive multimodal pain management program including physical therapy, patient education, and oral medications 2
• Shared decision-making must include discussion of complications (dural puncture, infection, sensorimotor deficits, cauda equina syndrome, rare catastrophic events including paralysis) 2

Evidence for efficacy: Studies report back pain relief for 2 weeks to 3 months. 2 Repeat injections are only appropriate if initial injection provided at least 50% relief for at least 2 weeks. 2

Critical contraindication: Do not perform epidural injections for non-radicular axial back pain from spondylosis alone - they are specifically indicated for radicular pain from nerve root compression. 2

Surgical Consideration

Surgery is indicated for:

• Progressive neurological deficits despite conservative management 3
• Severe radicular pain refractory to conservative measures including epidural injections 3
• Persistent radicular symptoms with documented nerve root compression on imaging after failed conservative therapy 1

Important note: Lumbar fusion is not recommended for routine disc herniation and should be reserved for specific scenarios (significant chronic axial back pain, manual laborers, severe degenerative changes, documented instability). 1

Common Pitfalls to Avoid

• Do not order MRI without completing 6 weeks of conservative therapy unless red flags are present 1
• Do not delay physiotherapy while waiting for imaging 1
• Do not perform epidural injections for mechanical back pain from spondylosis without true radiculopathy 2
• Do not repeat epidural injections without documented 50% relief for at least 2 weeks from prior injection 2
• Remember that disc abnormalities are common in asymptomatic patients (29-43% prevalence) and do not always correlate with symptoms 1