What is the treatment for mid back pain with radiculopathy?

Treatment for Mid Back Pain with Radiculopathy

For mid back pain with radiculopathy, first-line treatment should include NSAIDs combined with remaining active, while reserving epidural steroid injections or surgery for cases with persistent symptoms after 4 weeks of conservative management. 1

Initial Approach and Evaluation

• MRI (preferred) or CT is recommended for patients with persistent back and leg pain with radiculopathy who might be candidates for invasive interventions 2
• Routine imaging is not recommended for non-specific back pain, as it does not improve outcomes 1
• Prompt imaging with MRI is indicated for:
  • Severe or progressive neurologic deficits
  • Suspected serious underlying conditions (vertebral infection, cauda equina syndrome, cancer) 2

Pharmacological Treatment Algorithm

First-line options:

• NSAIDs: Provide small improvement in pain intensity compared to placebo for acute back pain (moderate-quality evidence) 1

  • Use with caution in patients with GI bleeding history, cardiovascular disease, or chronic renal disease 1

• Muscle relaxants: Consider as adjunctive therapy when combined with NSAIDs for short-term pain relief, especially with muscle spasm component 1

  • Cyclobenzaprine: Start with 5mg dose and titrate slowly in patients with mild hepatic impairment; not recommended for moderate to severe hepatic impairment 3
  • Be aware that muscle relaxants may cause drowsiness; advise patients about driving and operating machinery 1

Second-line options:

• Acetaminophen: Better safety profile than NSAIDs for older adults despite being slightly less effective 1

  • Note: Evidence shows no difference in pain intensity or function compared with placebo for acute low back pain (low-quality evidence) 1

• Gabapentin: Has small, short-term benefits specifically for patients with radiculopathy 1

• Duloxetine (SNRI): Moderate-quality evidence for chronic low back pain 1

• Tricyclic antidepressants: Effective for chronic low back pain 1

Third-line options (for severe, refractory pain):

• Opioids: Only consider when other options have failed for severe, disabling pain
  • Use judiciously due to substantial risks and insufficient evidence for effectiveness in acute back pain 1

Non-pharmacological Interventions

• Activity: Advise patients to continue normal daily activities as much as pain allows rather than bed rest 1
• Heat application: Moderate benefits in acute pain and may help in chronic cases 1
• Exercise therapy: Moderate efficacy in reducing chronic low back pain 1
• Cognitive-behavioral therapy: Particularly helpful for addressing psychological factors 1
• Spinal manipulation: Small to moderate benefits for chronic low back pain 1

Interventional Procedures

• Epidural steroid injections: Consider for persistent radicular symptoms despite conservative therapy 2, 4

  • More than 50% of cases of lumbar radicular pain settle with simple analgesics, but significant and lasting pain relief can be achieved with transforaminal epidural steroid injection 4

• Surgery: Consider for:

  • Progressive neurological deficits
  • Severe radicular pain refractory to conservative measures 4
  • Persistent symptoms associated with spinal stenosis 2

Monitoring and Follow-up

• Assess response to treatment within 1-2 weeks 1
• Monitor for sedation and other central nervous system side effects with muscle relaxants 1
• Reevaluate patients with persistent symptoms after 1 month 1
• Consider earlier reevaluation for patients with:
  • Severe pain
  • Functional deficits
  • Advanced age
  • Signs of radiculopathy 1

Common Pitfalls and Caveats

• Findings on MRI or CT (such as bulging disc without nerve root impingement) are often nonspecific 2
• NSAIDs have limited evidence for radiculopathy specifically, with small and inconsistent effects on pain 2
• Avoid routine imaging for non-specific back pain as it doesn't improve outcomes and increases costs 2, 1
• The STarT Back tool should be used at 2 weeks after pain onset to predict the risk of developing persistent disabling pain 1
• Psychosocial factors are stronger predictors of outcomes than physical examination findings 1