What are the implications of levoconvex (left convex) scoliosis of the lumbar spine with multilevel degenerative disc disease, bilateral neural foramina narrowing, and nerve root impingement on the exiting left L4 and L5 nerve roots?

From the Guidelines

The patient with levoconvex scoliosis of the lumbar spine and multilevel degenerative disc disease should initially be managed with conservative therapy, including pharmacologic and nonpharmacologic treatments, as recommended by the American College of Radiology 1. Given the presence of bilateral neural foramina narrowing and impingement on the exiting left L5 and probable L4 nerve roots, treatment should focus on alleviating pain and improving function.

• Conservative measures should include physical therapy focusing on core strengthening and flexibility,
• Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 400-800mg three times daily with food for 2-3 weeks,
• And for more severe pain, a short course of muscle relaxants like cyclobenzaprine 5-10mg at bedtime may help, as these approaches are aligned with guidelines for managing chronic low back pain 1. If symptoms persist, epidural steroid injections targeting the L4-L5 and L5-S1 levels could provide relief, delivering anti-inflammatory medication directly to the affected nerve roots 1. For long-term management, maintaining proper posture, weight management, and regular exercise are essential. Imaging with MRI of the lumbar spine may be considered if diagnostic uncertainty remains or if the patient is believed to be a candidate for surgery or intervention after failing conservative therapy, as it provides excellent soft-tissue contrast and accurately depicts lumbar pathology 1. If conservative treatments fail and neurological symptoms worsen, surgical consultation may be necessary to consider decompression procedures to relieve nerve pressure.

From the Research

Diagnosis and Symptoms

• Levoconvex scoliosis of the lumbar spine with multilevel degenerative disc disease changes is a complex condition that can cause axial, radicular pain and neurological deficit 2.
• The condition is characterized by a lateral deviation of the spine, typically developing after age 50 years, and is associated with loss of lordosis, axial rotation, lateral listhesis, and spondylolisthesis 3.
• The degenerative process, including disc bulging, facet arthritis, and ligamentum flavum hypertrophy, contributes to the appearance of symptoms of spinal stenosis in patients with degenerative lumbar scoliosis 4.

Treatment Options

• Conservative treatment includes drugs and physical therapy, while epidural injections and facet blocks can improve short-term pain 2.
• Nonsurgical care focuses on patient education, exercise, and nonnarcotic medication 3.
• Surgical treatment is reserved for patients with intractable pain, radiculopathy, and/or neurological deficits, and aims to decompress neural elements, restore the three-dimensional shape deformity, and stabilize the coronal and sagittal balance 2.
• Surgical management should be considered carefully, balancing the benefits and risks for the patient, and satisfactory clinical results have been reported in relevant retrospective studies after operative treatment, ranging from 83% to 96% 4.

Specific Considerations

• The presence of bilateral neural foramina narrowing and impingement on the exiting left L5 nerve root at L5-S1 level, as well as probable impingement on the exiting left L4 nerve root at L4-L5 level, should be taken into account when considering treatment options 2, 3, 4.
• The goal of treatment is to provide pain relief and improved functional lifestyle with minimum intervention, and an algorithm for operative treatment corresponding to a newly proposed classification system of degenerative lumbar scoliosis with associated canal stenosis can be used to guide decision-making 4.