What are the treatment options for back pain?

Treatment Options for Back Pain

For patients with back pain, a stepwise approach starting with self-care and nonpharmacologic options, followed by appropriate medications if needed, and considering specialized interventions for those who don't respond to initial treatment is recommended. 1

Initial Assessment and Classification

Back pain should be classified based on duration:

• Acute: <4 weeks
• Subacute: 4-12 weeks
• Chronic: >12 weeks 1

Important assessment elements:

• Evaluate for "red flags" indicating serious underlying conditions:
  • Significant trauma
  • Progressive neurologic deficits
  • Suspected cancer, infection, or cauda equina syndrome
  • New bowel/bladder dysfunction 1, 2
• Assess for radicular symptoms or spinal stenosis
• Identify psychosocial "yellow flags" that may contribute to chronicity 3

Treatment Algorithm

Step 1: Self-Care Options (First-Line for All Patients)

• Remain physically active and avoid bed rest 1
• Apply superficial heat for acute/subacute pain 1
• Self-care education about the typically favorable prognosis 1
• Avoid routine imaging for nonspecific back pain 1

Step 2: Nonpharmacologic Therapies

For acute back pain:

• Spinal manipulation by trained providers 1

For chronic back pain (choose based on patient preference and availability):

• Exercise therapy (especially supervised programs with individual tailoring) 1
• Multidisciplinary rehabilitation 1
• Cognitive behavioral therapy 1
• Acupuncture 1
• Massage therapy 1
• Yoga 1
• Mindfulness-based stress reduction 1
• Progressive relaxation 1

Step 3: Pharmacologic Therapy (When Nonpharmacologic Options Are Insufficient)

For acute back pain:

• First-line: NSAIDs or acetaminophen 1
• Second-line: Skeletal muscle relaxants (e.g., cyclobenzaprine) for short-term use 1, 4
  • Start with 5 mg dose for patients with mild hepatic impairment 4
  • Be aware of common side effects including drowsiness and dry mouth 4

For chronic back pain:

• First-line: NSAIDs 1
• Second-line: Tramadol or duloxetine 1
  • For tramadol, gradual titration (50 mg increments every 3 days) reduces discontinuation due to dizziness 5
• For neuropathic pain/radiculopathy: Consider gabapentin 1
• Not recommended: Long-term opioids (consider only when other options have failed and benefits outweigh risks) 1
• Not recommended: Systemic corticosteroids 1

Step 4: Interventional and Surgical Options

• MRI or CT imaging only for patients with:

  • Persistent symptoms despite conservative treatment
  • Candidates for surgery or epidural steroid injection 1
  • Progressive neurologic deficits 1

• Surgical evaluation should be considered for:

  • Progressive or unrelenting nerve root compression 6
  • Persistent functional disabilities despite multiple nonsurgical treatments 7
  • Progressive spinal stenosis or worsening spondylolisthesis 3

Special Considerations

• Radiculopathy: Gabapentin may provide small short-term benefits 1
• Recurrence prevention: Exercise programs that incorporate individual tailoring, supervision, stretching, and strengthening 1
• Depression screening: Depression is common with chronic back pain and should be assessed and treated 1

Common Pitfalls to Avoid

• Overuse of imaging: Routine imaging for nonspecific back pain doesn't improve outcomes and increases costs 1, 2
• Prolonged bed rest: This can delay recovery and worsen outcomes 1, 2
• Premature surgery: Most patients with back pain don't require surgery 3
• Extended medication use: Long-term medication should be reserved for patients showing clear benefits without major adverse effects 1
• Underutilization of nonpharmacologic options: These should be first-line for chronic pain 1

By following this evidence-based approach, most patients with back pain can achieve significant improvement in pain and function while minimizing risks associated with unnecessary interventions.