What are the treatment options for back pain?

Treatment Options for Back Pain

For acute back pain, treatment should begin with conservative approaches including maintaining physical activity, applying local heat, and using acetaminophen or NSAIDs, while avoiding prolonged bed rest. 1

Diagnosis and Classification

• Back pain can be categorized into three main types:

  • Nonspecific low back pain (most common, ~85% of cases)
  • Back pain with radiculopathy/spinal stenosis
  • Back pain with specific spinal cause 1

• Assessment should include screening for red flags requiring urgent evaluation:

  • Progressive neurological deficits
  • Cauda equina syndrome (bowel/bladder dysfunction, saddle anesthesia)
  • Fever or signs of infection
  • History of cancer
  • Significant trauma 1

Treatment Algorithm

First-Line Approaches (0-4 weeks)

1. Non-Pharmacological Treatments:

   • Maintain tolerable physical activity (avoid bed rest)
   • Apply local heat for moderate pain relief
   • Education on self-care and body mechanics
   • Massage therapy for short-term relief 1

2. Pharmacological Management:

   • First choice: Acetaminophen (up to 3000mg/day) due to favorable safety profile
   • Alternative first-line: NSAIDs if acetaminophen is insufficient
     • Use with caution in elderly patients due to increased risk of adverse effects 1

Second-Line Approaches (if inadequate response after 2-3 weeks)

1. Additional Non-Pharmacological Options:

   • Physical therapy with focus on core strengthening
   • Spinal manipulation (especially if history of good response)
   • Mind-body approaches (mindfulness, tai chi, yoga)
   • Acupuncture for moderate benefit 1

2. Additional Pharmacological Options:

   • Muscle relaxants: Cyclobenzaprine for short periods only (2-3 weeks maximum)
     • Effective for acute muscle spasm but causes drowsiness 1, 2
   • For neuropathic pain: Consider gabapentin or pregabalin 1
   • Avoid opioids as first-line treatment due to risks outweighing benefits 1

Persistent Pain Management (beyond 4-6 weeks)

1. Diagnostic Considerations:

   • MRI of lumbar spine (without contrast) is preferred for radiating pain
   • Consider upright radiographs with flexion/extension views to assess segmental motion 1

2. Interventional Options:

   • Diagnostic medial branch blocks for suspected facet-mediated pain
   • Consider referral to pain specialist for interventional procedures 1

3. Multidisciplinary Rehabilitation:

   • Combined exercise, physical therapy, and cognitive-behavioral therapy
   • Addresses fear of movement and improves functionality 1, 3

4. Surgical Consultation:

   • Only if persistent disabling symptoms despite conservative treatment
   • Progressive neurological deficits
   • Cauda equina syndrome 1

Special Considerations

• Elderly patients:

  • Higher risk of medication side effects
  • Need slower progression of exercise intensity
  • More frequent follow-up 1

• Patients with connective tissue disorders:

  • May require gentler physical therapy
  • Benefit from multidisciplinary approach 1

• Hepatic impairment:

  • If using cyclobenzaprine, start with 5mg dose and titrate slowly upward
  • Avoid in moderate to severe hepatic impairment 2

Treatment Efficacy Evidence

• Cyclobenzaprine has demonstrated significantly greater improvement compared to placebo in controlled studies for muscle spasm, with effectiveness similar to diazepam but with different side effect profiles (more dry mouth, less dizziness) 2

• NSAIDs have good evidence supporting efficacy for acute low back pain, while evidence for corticosteroids remains conflicting 3, 4

• Recent evidence indicates that nonpharmacologic treatments should be first-line for chronic low back pain, with NSAIDs as the initial medication of choice when pharmacologic intervention is needed 3

Common Pitfalls to Avoid

• Prescribing prolonged bed rest, which can worsen outcomes
• Using muscle relaxants beyond 2-3 weeks
• Initiating opioids as first-line treatment
• Ordering routine imaging without clinical indications
• Failing to reassess treatment effectiveness and adjust accordingly 1, 2