What is the treatment for pinched nerves on the back?

Treatment for Pinched Nerves in the Back

For pinched nerves in the back, treatment should begin with nonpharmacologic approaches including exercise, superficial heat, and physical therapy, with pharmacologic options like NSAIDs reserved as second-line therapy. 1

Initial Management Approach

Nonpharmacologic First-Line Treatments

• Exercise therapy: Moderate-quality evidence shows exercise results in small improvements in pain relief and function compared to no exercise 1
• Superficial heat: Moderate-quality evidence demonstrates heat wraps moderately improve pain relief and disability compared to placebo 1
• Motor control exercises: Focus on restoring coordination, control, and strength of muscles that support the spine 1
• Spinal manipulation: Can provide short-term functional improvement, especially when combined with exercise 1

Physical Therapy Options

• Neural gliding exercises: Help restore nerve mobility and reduce compression symptoms 2
• Stretching techniques: Target tight muscles that may be compressing nerves
• Postural education: Correct positions that may exacerbate nerve compression

Pharmacologic Options (Second-Line)

• NSAIDs: First medication choice for pain management 1, 3
• Muscle relaxants: May be considered for acute muscle spasm, though evidence is limited 3
• Duloxetine: Can be beneficial as a second-line option for chronic pain 3

Treatment Algorithm Based on Duration

Acute Pinched Nerve (<4 weeks)

1. Avoid bed rest (not recommended) 3
2. Apply heat therapy (moderate evidence of effectiveness) 1
3. Begin gentle exercises as tolerated
4. Consider NSAIDs for pain relief
5. Add low-level laser therapy with NSAIDs for enhanced pain relief (low-quality evidence) 1

Chronic Pinched Nerve (>12 weeks)

1. Structured exercise program (strong recommendation) 1
2. Consider specialized exercise approaches:
   • Motor control exercise
   • Tai chi (moderate evidence for pain improvement) 1
   • Yoga (low-quality evidence for pain reduction) 1
3. Add NSAIDs if nonpharmacologic approaches are insufficient 1
4. Consider duloxetine or tramadol as second-line pharmacologic options 1

When to Consider Advanced Interventions

• Diagnostic nerve blocks: Consider when pain persists despite conservative management 4
• Surgical evaluation: Appropriate for patients with:
  • Progressive neurological deficits
  • Cauda equina syndrome
  • Persistent symptoms after 6-12 weeks of conservative treatment 5
  • Intractable pain despite conservative management 5

Important Caveats

• Imaging is not routinely recommended for nonspecific back pain within the first 6 weeks unless red flags are present 5
• Opioids should be avoided as first-line therapy and only considered when other treatments have failed 1, 3
• Most patients improve without surgery: 90% of episodes resolve within 6 weeks regardless of treatment 5
• Lumbar supports show no significant benefit over educational programs alone 1
• Neural tension tests can help diagnose specific compression neuropathies 2

Red Flags Requiring Immediate Attention

• Cauda equina syndrome (urinary retention, saddle anesthesia)
• Progressive neurological deficits
• Severe or worsening pain unresponsive to conservative measures

By following this structured approach to treating pinched nerves in the back, most patients will experience significant improvement in pain and function without requiring invasive interventions.