What is the recommended first‑line treatment for an adult with mild multilevel degenerative spondylosis presenting with modest back pain, occasional stiffness, and no neurological deficits?

Treatment for Mild Multilevel Degenerative Spondylosis

For an adult with mild multilevel degenerative spondylosis presenting with modest back pain and occasional stiffness without neurological deficits, begin immediately with NSAIDs at maximum tolerated dose combined with a structured physical therapy program for at least 6 weeks before considering any imaging or advanced interventions. 1

First-Line Pharmacological Management

• NSAIDs are the mandatory first-line drug treatment for controlling pain and stiffness in degenerative spondylosis, with Level 1a evidence supporting their efficacy 2, 1
• Use NSAIDs at the maximum tolerated dose, taking individual risk factors into account 2
• For patients with gastrointestinal risk factors (history of ulcers, age >65, concurrent anticoagulation), prescribe either non-selective NSAIDs plus proton pump inhibitors or selective COX-2 inhibitors 1
• Continue NSAIDs regularly if the patient responds well; otherwise use them only during symptomatic periods 2

Mandatory Physical Therapy Component

• All patients must complete formal structured physical therapy for a minimum of 6 weeks as the cornerstone of conservative management 1, 3
• Group physical therapy demonstrates superior patient global assessment outcomes compared to unsupervised home exercises alone 2, 1
• The physical therapy program should focus on back extension exercises, core strengthening, and flexibility training 3
• Regular exercise programs improve function in the short term compared to no intervention 1

Additional Conservative Measures

• Educate the patient about the natural history of degenerative spondylosis, emphasizing that most patients improve within the first 4 weeks of conservative management 1, 3
• Encourage regular exercise on an ongoing basis beyond the formal physical therapy period 2
• Advise activity modification to avoid positions or movements that exacerbate symptoms 3
• If the patient smokes, strongly encourage smoking cessation as it negatively impacts spinal health 2

Second-Line Pharmacological Options

• If NSAIDs are insufficient, contraindicated, or poorly tolerated, consider acetaminophen or short-term opioid-like analgesics for residual pain 2, 1
• Muscle relaxants may be added as adjuvant therapy during acute flare-ups 4
• Avoid long-term systemic corticosteroids for axial degenerative disease 2

When Imaging Is NOT Indicated

• Do not obtain MRI or other imaging for mild multilevel degenerative spondylosis without red-flag features until at least 6 weeks of optimal conservative management have failed 1
• Imaging in the absence of failed conservative therapy provides no clinical benefit and increases unnecessary healthcare utilization 1
• Many MRI abnormalities are present in asymptomatic individuals and do not correlate with clinical symptoms 1

Monitoring and Reassessment

• Reassess symptoms at 4 weeks, as the natural history is generally favorable with most patients improving within this timeframe 1, 3
• If symptoms are improving but not fully resolved at 6 weeks, continue conservative management for up to 3-6 months 1, 3
• Monitor disease activity using validated measures at regular intervals, though not necessarily at every visit 2

Critical Pitfalls to Avoid

• Never proceed directly to imaging or surgical consultation without documented completion of at least 6 weeks of formal physical therapy 1, 3
• Do not prescribe unsupervised home exercises as a substitute for initial instruction by a physical therapist 2
• Avoid spinal manipulation with high-velocity thrusts if there is any concern for spinal fusion or advanced osteoporosis, as case reports document severe complications including fractures and spinal cord injury 2
• Do not treat mild degenerative spondylosis with disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine or methotrexate, as these are ineffective for purely axial degenerative disease 2

Expected Outcomes

• With appropriate conservative management, the majority of patients with mild multilevel degenerative spondylosis experience significant symptom improvement 1
• Most patients improve within the first 4 weeks of initiating NSAIDs and physical therapy 1, 3
• The prognosis for patients without neurological symptoms is favorable with conservative treatment alone 5

When to Consider Advanced Interventions

• Only consider epidural steroid injections if radicular symptoms develop and persist despite 6 weeks of conservative management 3
• Surgical intervention is never appropriate for mild multilevel degenerative spondylosis without documented failure of at least 3-6 months of comprehensive conservative treatment including formal physical therapy, NSAIDs, and activity modification 1, 3
• Even if conservative management fails, surgery is only indicated for 1-2 level disease with intractable symptoms, not for multilevel degenerative changes 1, 6