What is the diagnosis for a patient with low back pain, presenting with stable subtle levoscoliosis, slight retrolisthesis of L4 relative to L5, diffuse lumbar facet osteoarthropathy, and multilevel degenerative disc disease?

From the Guidelines

The patient's low back pain is likely due to chronic degenerative changes, and treatment should focus on pain management, physical therapy, and core strengthening exercises, as evidenced by the lack of significant interval change on the X-ray and the presence of stable multilevel lumbar degenerative disc disease and mid to lower lumbar facet osteoarthropathy 1. The X-ray shows no significant changes compared to the previous study from August 30,2023. The patient has several stable conditions in their lower back, including a slight leftward curvature of the spine (levoscoliosis), a minor backward slippage of the L4 vertebra relative to L5, widespread joint degeneration in the lumbar facet joints, and multilevel degenerative disc disease throughout the lumbar spine. The sacroiliac joints appear normal, and there are surgical clips visible in the right upper quadrant of the abdomen from a previous surgery. Some key points to consider in the management of this patient's low back pain include:

• The use of MRI as the initial imaging modality of choice for patients with subacute or chronic low back pain who have failed 6 weeks of conservative therapy, as it provides excellent soft-tissue contrast and accurately depicts lumbar pathology, including disc degeneration 1.
• The potential benefits of CT myelography in assessing the patency of the spinal canal/thecal sac and of the subarticular recesses and neural foramen, particularly in patients with significant artifact from metallic surgical hardware on MRI 1.
• The importance of incorporating flexion and extension radiographs to identify segmental motion, which is crucial in the surgical management of spondylolisthesis 1.
• The potential utility of SPECT/CT bone scan in identifying the source of low back pain in some patients, particularly when related to facet arthropathy or sacroiliac joint dysfunction 1. However, given the stable nature of the patient's conditions and the lack of significant interval change, a conservative approach to management is likely the most appropriate, with a focus on pain management, physical therapy, and core strengthening exercises, as well as consideration of anti-inflammatory medications if necessary 1.

From the Research

Lumbar Spine Degeneration

• The patient's lumbar spine shows signs of degeneration, including multilevel degenerative disc disease and mid to lower lumbar facet osteoarthropathy 2, 3.
• The study by 2 found that disc degeneration and facet joint osteoarthritis affect the stability of the motion segment in the lumbar spine.
• Another study by 3 found that degenerative disc and facet pathology is ubiquitous in older adults, regardless of clinical status, and that higher radiographic severity scores are associated with the presence of chronic low back pain.

Facet Joint Osteoarthritis

• The patient's lumbar spine also shows signs of facet joint osteoarthritis, which can contribute to instability in the motion segment 2.
• The study by 2 found that abnormal tilting movement on flexion and anteroposterior translatory instability are negatively associated with facet joint osteoarthritis.
• However, anterior translatory instability was positively associated with disc degeneration and facet joint osteoarthritis 2.

Clinical Assessment

• The patient's condition is being assessed through radiographic evaluation, which provides additional information about the patient's spinal pathology 3.
• However, the clinical utility of radiographic evaluation for diagnostic purposes is still in question 3.
• A study on intensive care nurses found that assessing changes in a patient's condition requires a sensitive and attentive approach, including being present at the bedside and working in a concentrated and systematic manner 4.