What is the treatment for lumbago?

Lumbago: Definition and Treatment

Lumbago is a general term for low back pain, which can be acute, subacute, or chronic, and requires a stepped approach to treatment starting with non-pharmacological interventions followed by appropriate medications only when necessary.

What is Lumbago?

Lumbago is simply another term for low back pain, which is one of the most common musculoskeletal complaints:

• It affects approximately 13% of U.S. adults in its chronic form (persisting ≥12 weeks) 1
• It is the leading cause of years lived with disability and the third ranking cause of disability-adjusted life-years in the United States 2
• It accounts for approximately 3% of emergency department visits 2

Evaluation of Lumbago

When evaluating lumbago, clinicians should assess for:

Red Flags (requiring immediate attention)

• Progressive motor or sensory loss
• New urinary retention or bowel/bladder incontinence
• Saddle anesthesia or loss of anal sphincter tone (cauda equina syndrome)
• History of cancer or suspected spinal infection
• Significant trauma relative to age (e.g., fall from height in young patients, minor fall in patients with osteoporosis)
• Fever or signs of infection 2, 1, 3

Imaging Considerations

• Imaging is not recommended initially unless red flags are present 2, 1
• When indicated, MRI without contrast is the preferred modality to assess neural compression 4
• Plain radiography is appropriate to assess for fracture and bony abnormality 3

Treatment of Lumbago

First-Line: Non-Pharmacological Approaches

1. Physical Activity

   • Avoid bed rest 1
   • Exercise therapy has shown benefit compared to usual care 4
   • Physical therapy with specific approaches like the McKenzie method may decrease recurrent pain 2, 3

2. Heat Therapy

   • Heat wrap therapy or heated blanket is moderately superior to placebo for short-term pain relief 2
   • Topical heat can be used as an adjunct to other treatments 4

3. Manual Therapies

   • Spinal manipulation may provide benefit, though evidence shows mixed results 2, 3
   • Massage therapy may be beneficial for chronic low back pain 2

Second-Line: Pharmacological Interventions

1. NSAIDs

   • First medication of choice for most patients 1
   • More effective than acetaminophen for acute low back pain 2
   • Should follow a stepped-care approach in patients with cardiovascular risk 4

2. Muscle Relaxants

   • Cyclobenzaprine is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 5
   • Should be used only for short periods (up to 2-3 weeks) 5
   • In elderly patients, start with 5 mg and titrate slowly upward 5

3. Other Medications

   • Duloxetine may be beneficial for chronic low back pain 1
   • Evidence is inconclusive for benzodiazepines, antidepressants (except duloxetine), corticosteroids, anticonvulsants, cannabis, and acetaminophen 1

Special Considerations

• Duration of Treatment

  • For acute lumbago: Most patients recover within a few weeks with minimal treatment 6
  • For chronic lumbago: Long-term management is often required with focus on improving function 7

• Medication Cautions

  • Opioids should be avoided as first-line therapy 4
  • Cyclobenzaprine should be used with caution in patients with hepatic impairment 5
  • NSAIDs should be used cautiously in patients with cardiovascular disease, renal impairment, or heart failure 4

• When to Consider Referral

  • Persistent symptoms beyond 4-6 weeks despite conservative treatment 4
  • Progressive neurological deficits 2
  • Intractable pain despite conservative management 4

Prevention of Recurrence

• Regular exercise and physical activity
• Proper body mechanics
• Spine stabilization exercises
• Risk stratification using tools like STarT Back to identify patients at risk of developing chronic pain 4

Treatment Algorithm

1. Start with non-pharmacological approaches (heat, exercise, physical therapy)
2. If inadequate relief, add pharmacological therapy:
   • First: NSAIDs (if no contraindications)
   • Second: Consider short-term muscle relaxants like cyclobenzaprine for acute muscle spasm
   • For chronic pain: Consider duloxetine if NSAIDs are ineffective
3. Reassess in 2-4 weeks; if no improvement, consider imaging and specialist referral

Remember that most cases of lumbago resolve with conservative treatment, and the goal for chronic cases is to improve pain and function rather than achieve complete resolution.