What are the treatment options for a patient with lower back pain?

Treatment Options for Lower Back Pain

For patients with lower back pain, a stepwise approach starting with self-care and non-opioid medications, followed by non-pharmacological therapies if needed, is recommended based on pain duration and severity. 1

Initial Assessment and Classification

• Acute low back pain: <4 weeks duration
• Subacute low back pain: 4-12 weeks duration
• Chronic low back pain: >12 weeks duration

Red Flags Requiring Immediate Attention

• Progressive motor or sensory loss
• New urinary retention or overflow incontinence
• History of cancer
• Recent invasive spinal procedure
• Significant trauma relative to age 2

First-Line Treatment Options

Self-Care Approaches

• Remain active within pain limits
• Avoid bed rest
• Apply heat for short-term relief of acute pain
• Return to normal activities as soon as possible 1, 3

First-Line Medications

1. Acetaminophen:

   • Reasonable first option due to favorable safety profile
   • Slightly weaker analgesic than NSAIDs
   • Maximum dose: 4g/day (monitor for liver effects) 1

2. NSAIDs (e.g., ibuprofen):

   • More effective for pain relief than acetaminophen
   • Use lowest effective dose for shortest duration
   • Assess cardiovascular and gastrointestinal risk factors before prescribing
   • Consider gastroprotection (e.g., proton pump inhibitor) in high-risk patients 1, 4

Second-Line Treatment Options

Muscle Relaxants

• Option for short-term relief of acute low back pain
• Associated with central nervous system effects (primarily sedation)
• Effectiveness demonstrated in clinical trials comparing cyclobenzaprine to placebo
• No compelling evidence that different muscle relaxants vary in efficacy 1, 5

Non-Pharmacological Therapies

• For acute low back pain: Spinal manipulation shows small to moderate short-term benefits 1

• For subacute/chronic low back pain:

  1. Exercise therapy (particularly programs with individual tailoring, supervision, stretching, and strengthening)
  2. Intensive interdisciplinary rehabilitation
  3. Acupuncture
  4. Massage therapy
  5. Yoga
  6. Cognitive-behavioral therapy
  7. Progressive relaxation 1, 6

Third-Line Treatment Options

For Persistent Pain

• Tricyclic antidepressants: Option for chronic low back pain (assess and treat comorbid depression)
• Gabapentin: Small, short-term benefits for radiculopathy
• Opioid analgesics: Consider only when:
  • Patient has failed first and second-line treatments
  • Pain is severe and disabling
  • Benefits outweigh risks
  • After discussing risks and realistic benefits with patient
  • Used for limited duration 1

Treatments Not Recommended

• Systemic corticosteroids (not effective for low back pain with or without sciatica)
• Bed rest
• Continuous or intermittent traction
• Transcutaneous electrical nerve stimulation (TENS) 1

Special Considerations

For Radiculopathy

• Gabapentin may provide small short-term benefits
• Limited evidence for other specific medications 1

For Chronic Pain

• Exercise remains first-line treatment 6
• Physical therapy using McKenzie method may decrease recurrence and healthcare utilization 2
• Yoga shows strong evidence for short-term and moderate evidence for long-term effectiveness 2

Common Pitfalls to Avoid

1. Overuse of imaging: Reserve for suspicion of serious pathology (fracture, infection, malignancy, cauda equina)
2. Prolonged bed rest: Leads to deconditioning and delayed recovery
3. Extended medication courses: Limit to patients showing clear benefits without major adverse events
4. Early surgical referral: Not indicated in absence of red flags
5. Reliance on passive treatments: Active strategies like exercise are associated with better outcomes than passive methods 1, 3, 6

Remember that 90% of acute low back pain episodes resolve within 6 weeks regardless of treatment, though minor flare-ups may occur in the subsequent year 3.