How should degenerative lumbar spine osteoarthropathy (spondylosis) be initially managed?

Management of Degenerative Lumbar Spine Osteoarthropathy (Spondylosis)

Begin with at least 6 weeks of conservative management combining physical therapy, NSAIDs, and activity modification before considering any imaging or surgical intervention, as this approach resolves symptoms in the majority of patients and routine early imaging provides no clinical benefit. 1, 2

Initial Conservative Treatment (First-Line for All Patients)

Mandatory Non-Pharmacological Interventions

• Formal structured physical therapy for a minimum of 6 weeks is mandatory before considering any surgical options 2
• Regular exercise programs improve function in the short term compared to no intervention 2
• Group physical therapy demonstrates better patient global assessment outcomes than home exercise alone 2
• Patient education about the condition and self-management strategies is essential 2

Pharmacological Management

• NSAIDs are first-line drug treatment for pain and stiffness control 2
• For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus gastroprotective agents (PPIs reduce serious GI events by 60%) or selective COX-2 inhibitors (reduce serious GI events by 82% compared to traditional NSAIDs) 3
• Analgesics including acetaminophen and opioids may be considered when NSAIDs are insufficient, contraindicated, or poorly tolerated 2

Duration and Expectations

• Most patients improve within the first 4 weeks of conservative management 2
• Continue conservative treatment for 6 weeks minimum before any consideration of imaging or intervention 1, 2
• Comprehensive non-surgical treatment including transforaminal epidural steroid injections (TFEs) and exercise programs can avoid surgery in 78.4% of patients with degenerative spondylolisthesis at 3-year follow-up 4

When to Consider Imaging

Timing for Initial Imaging

• Do NOT obtain imaging initially in subacute or chronic low back pain without red flags, as routine imaging provides no clinical benefit and leads to increased healthcare utilization 1
• Imaging should only be obtained after 6 weeks of optimal conservative management has failed AND the patient is a candidate for surgery or intervention 1

Appropriate Imaging Modality

• MRI lumbar spine without contrast is the initial imaging modality of choice when imaging is indicated after failed conservative therapy 1
• Upright radiographs with flexion/extension views are complementary to identify segmental motion, which is important in surgical management of spondylolisthesis 1
• CT myelography is useful for patients with MRI-incompatible devices or significant metallic hardware artifact 1

Surgical Considerations

Indications for Surgery

Surgery should only be considered when ALL of the following criteria are met: 2

• Formal physical therapy completed for at least 6 weeks with documented failure
• Pain is disabling and refractory to all conservative measures including NSAIDs, physical therapy, and injections
• Patient is a surgical candidate who desires surgical treatment

Specific Surgical Recommendations by Pathology

For Degenerative Disc Disease (1-2 levels without stenosis or spondylolisthesis)

• Lumbar fusion is recommended (Grade B) for carefully selected patients with intractable low-back pain refractory to conservative treatment 2
• Lumbar fusion or comprehensive rehabilitation incorporating cognitive therapy are equivalent treatment alternatives for chronic low-back pain refractory to traditional conservative treatment 2
• Instrumented fusion with pedicle screws provides optimal biomechanical stability with fusion rates up to 95% 2

For Stenosis with Degenerative Spondylolisthesis

• Surgical decompression combined with fusion is recommended (Grade B) as an effective treatment for symptomatic stenosis associated with degenerative spondylolisthesis 1
• Decompression combined with fusion is superior to decompression alone for patients with severe stenosis who have failed 3-6 months of conservative management 2
• The patient's anatomy, desires, and concerns as well as surgeon experience should be factored into determining the optimal fusion strategy 1

Expected Surgical Outcomes

• Clinical improvement occurs in 86-97% of appropriately selected surgical candidates 2
• Back pain reduced by 33% in surgical groups versus 7% in controls 2
• Oswestry Disability Index scores improve by 25% versus 6% in controls 2
• Return-to-work rates are 36% in surgically treated patients versus 13% in controls 2
• At 2-year follow-up, surgically treated patients maintain superior outcomes compared to those treated conservatively when properly selected 2

Critical Pitfalls to Avoid

• Never proceed to surgery without documented completion of formal physical therapy for at least 6 weeks 2
• Do not perform fusion for purely radiological findings without correlating clinical symptoms 2
• Do not obtain routine imaging in the initial evaluation of subacute or chronic low back pain without red flags, as it provides no clinical benefit and increases healthcare utilization 1
• Recognize that many MRI abnormalities can be seen in asymptomatic individuals and imaging patients without failed conservative therapy is often not beneficial 1

Special Populations

Multilevel Spondylolysis

• For patients with multilevel lumbar spondylolysis without neurological symptoms and with slippage <25%, conservative treatment with regular follow-up is recommended 5
• Nonsteroidal anti-inflammatory drugs initially, followed by physical therapy for 8 weeks typically improves low back pain 5