What is the treatment for severe mid to low back pain?

From the Guidelines

For severe mid to low back pain, I recommend starting with a combination of non-pharmacological and pharmacological approaches, prioritizing the most recent and highest quality evidence from the 2017 study 1. Begin with rest for 24-48 hours, but avoid prolonged bed rest as this can worsen symptoms. Apply ice for the first 48-72 hours (20 minutes on, 20 minutes off), then switch to heat therapy. Take over-the-counter medications like ibuprofen (400-600mg every 6-8 hours with food) or naproxen (220-440mg twice daily with food) for up to 10 days to reduce inflammation and pain, as suggested by the 2007 study 1. Acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) can be used if NSAIDs are contraindicated. For muscle spasms, cyclobenzaprine 5-10mg three times daily for up to 3 weeks may help. Gentle stretching and activities like walking should be gradually introduced as pain allows. Physical therapy focusing on core strengthening exercises is beneficial for long-term recovery, as supported by the 2017 study 1. If pain is severe or persists beyond 4-6 weeks, radiates down the legs, or is accompanied by numbness, weakness, or bladder/bowel changes, seek medical evaluation promptly as these may indicate nerve compression requiring different treatment approaches.

Some key points to consider:

• Non-pharmacologic therapies, such as spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation, have been shown to have small to moderate benefits for low back pain, as reported in the 2017 study 1.
• Medications, including NSAIDs, acetaminophen, and opioids, can provide short-term relief, but each has unique risks and benefits, as discussed in the 2007 study 1.
• The 2007 study 1 also highlights the importance of considering individual patient factors, such as risk factors for complications, concomitant medication use, baseline severity of pain, duration of low back symptoms, and costs, when weighing treatment options.

Overall, a comprehensive approach that incorporates both non-pharmacological and pharmacological strategies, while prioritizing the most recent and highest quality evidence, is recommended for managing severe mid to low back pain.

From the FDA Drug Label

NSAID medicines are used to treat pain and redness, swelling, and heat (inflammation) from medical conditions such as: different types of arthritis menstrual cramps and other types of short-term pain Cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients. One study compared cyclobenzaprine hydrochloride tablets 5 and 10 mg t.i. d. to placebo; and a second study compared cyclobenzaprine hydrochloride tablets 5 and 2.5 mg t.i. d. to placebo. Primary endpoints for both trials were determined by patient-generated data and included global impression of change, medication helpfulness, and relief from starting backache. The efficacy of the maximum recommended dose of pregabalin for the management of neuropathic pain associated with diabetic peripheral neuropathy was established in three double-blind, placebo-controlled, multicenter studies with three times a day dosing

The treatment for mid to low back pain that is severe may include:

• NSAIDs such as naproxen 2 to treat pain and inflammation
• Muscle relaxants such as cyclobenzaprine 3 to relieve muscle spasms
• Pregabalin 4 for neuropathic pain associated with diabetic peripheral neuropathy Key considerations:
• The choice of treatment depends on the underlying cause of the back pain
• It is essential to follow the recommended dosage and usage guidelines for each medication to minimize the risk of adverse effects
• Patients should consult their healthcare provider to determine the best course of treatment for their specific condition.

From the Research

Treatment Options for Mid to Low Back Pain

• For patients with nonspecific low back pain, acetaminophen and nonsteroidal anti-inflammatory drugs are first-line medications 5
• Tramadol, opioids, and other adjunctive medications may benefit some patients who do not respond to nonsteroidal anti-inflammatory drugs 5
• Nonpharmacologic treatment is first-line management and may include therapies such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy 6
• Epidural corticosteroid injections are not recommended except for short-term symptom relief in patients with radicular pain 6

Diagnostic Approach

• A history and physical examination should place patients into one of several categories: nonspecific low back pain, back pain associated with radiculopathy or spinal stenosis, back pain referred from a nonspinal source, or back pain associated with another specific spinal cause 5
• Routine imaging is not recommended but is indicated when red flags are present, there is a neuromuscular deficit, or if pain does not resolve with conservative therapy 6, 7
• Magnetic resonance imaging or computed tomography may establish the diagnosis and guide management for patients with back pain associated with radiculopathy, spinal stenosis, or another specific spinal cause 5

Surgical Evaluation

• Most patients with chronic low back pain will not benefit from surgery 5, 6
• A surgical evaluation may be considered for select patients with functional disabilities or refractory pain despite multiple nonsurgical treatments 5, 6
• Evaluation for surgery may be considered in those with persistent functional disabilities and pain from progressive spinal stenosis, worsening spondylolisthesis, or herniated disk 6