What is the best initial treatment for chronic lower back pain with radiculopathy and spinal stenosis unresponsive to NSAIDs?

From the Guidelines

For chronic lower back pain with radiculopathy and spinal stenosis unresponsive to NSAIDs, the best initial treatment is a multimodal approach combining physical therapy, oral medications, and possibly epidural steroid injections. This approach is supported by recent guidelines, including the 2022 American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain, which strongly recommends epidural injections for chronic low back pain due to disc disease, spinal stenosis, or post-surgical syndrome 1.

Key Components of Treatment

• Physical therapy should focus on core strengthening, flexibility, and proper body mechanics, with sessions 2-3 times weekly for 4-6 weeks.
• Medication options include gabapentin (starting at 300mg daily, gradually increasing to 300mg three times daily as tolerated) or pregabalin (starting at 75mg twice daily, increasing to 150mg twice daily if needed) to address neuropathic pain from nerve compression.
• A short course of oral steroids such as prednisone (starting at 20mg daily for 5-7 days with a taper) may help reduce inflammation.
• For patients with significant functional limitations despite these interventions, epidural steroid injections can provide temporary relief for 1-3 months, as recommended by the 2021 American College of Occupational and Environmental Medicine Low Back Disorders Guideline 1.

Rationale for Treatment Approach

This multimodal approach targets different pain mechanisms: physical therapy improves biomechanics and strengthens supporting muscles, anticonvulsants address neuropathic pain, and steroids reduce inflammation around compressed nerve roots. The choice of treatment is also guided by the patient's specific condition, including the presence of radiculopathy and spinal stenosis, as well as the failure of previous treatments such as NSAIDs.

Consideration of Other Options

While prolotherapy injection is considered, the current evidence does not strongly support its use as a first-line treatment for chronic lower back pain with radiculopathy and spinal stenosis. The 2021 Epidural interventions in the management of chronic spinal pain: American society of interventional pain physicians (ASIPP) comprehensive evidence-based guidelines recommend fluoroscopically guided epidural injections for chronic spine pain associated with disc herniation, spinal stenosis, and axial discogenic pain 1.

Next Steps

If these conservative measures fail after 6-8 weeks of consistent implementation, surgical evaluation may be warranted, particularly if neurological symptoms are progressing. The 2020 NICE Guideline on Low back pain and sciatica in over 16s: assessment and management recommends against spinal injections for managing low back pain, but suggests radiofrequency denervation for chronic low back pain after a positive response to a medial branch block 1.

From the Research

Treatment Options for Chronic Lower Back Pain with Radiculopathy and Spinal Stenosis

• The patient's condition involves chronic lower back pain radiating to the right lower extremity, numbness, L5 radiculopathy, tender SI joints, and positive SLR, with decreased reflexes, sensation, and paresthesia, indicating a complex condition requiring careful management.
• Imaging studies reveal disc space narrowing at L4-5, L5-S1 spondylolisthesis, and spinal canal stenosis, which are consistent with the patient's symptoms.

Initial Treatment Approach

• According to the study by 2, first-line therapy for lumbar spinal stenosis includes activity modification, analgesia, and physical therapy.
• However, the patient has already shown no response to NSAIDs, indicating the need for alternative treatment options.
• The study by 3 suggests that the mild Procedure, a minimally invasive lumbar decompression, may be an effective treatment option for patients with lumbar spinal stenosis who have not responded to epidural steroid injections.

Role of Gabapentinoids

• The studies by 4, 5, and 6 investigate the efficacy and safety of gabapentinoids, such as pregabalin and gabapentin, in the treatment of neuropathic pain and spinal stenosis.
• While gabapentinoids may have some benefits in reducing pain, the evidence is limited, and they are associated with significant adverse effects, as reported in the study by 6.
• The study by 5 concludes that the use of gabapentinoids for chronic low back pain merits caution due to the lack of efficacy, risks, and costs associated with their use.

Surgical Intervention

• The study by 2 suggests that surgery, such as decompressive laminectomy, may be effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management.
• However, the decision to proceed with surgery should be made on a case-by-case basis, taking into account the patient's individual circumstances and the potential risks and benefits of surgical intervention.

Prolotherapy Injection

• There is no direct evidence in the provided studies to support the use of prolotherapy injection as a treatment option for chronic lower back pain with radiculopathy and spinal stenosis.
• Further research is needed to determine the efficacy and safety of prolotherapy injection in this context.