What are the treatment options for a pinched nerve in the back?

Treatment Options for a Pinched Nerve in the Back

For a pinched nerve in the back, conservative management should be pursued for at least 6 weeks before considering imaging or interventional procedures, including medications such as NSAIDs, physical therapy, and activity modification. 1

Initial Conservative Management (First 6 Weeks)

Medications

• First-line pharmacologic therapy:
  • NSAIDs (moderate-quality evidence) 2
    • Naproxen: 375-1100 mg/day
    • Diclofenac: 150 mg/day
    • Ibuprofen: 1800 mg/day 1
  • Acetaminophen
  • Muscle relaxants for acute pain (e.g., cyclobenzaprine) 3
    • Start with 5 mg dose in patients with mild hepatic impairment
    • Use with caution as drowsiness is a common side effect

Non-pharmacologic Interventions

• Heat and/or cold therapy 1
• Physical therapy focused on:
  • Postural education and correction
  • Gentle stretching exercises
  • Core strengthening 1
• Activity modification - avoid activities that exacerbate pain 1
• Exercise therapy (moderate-quality evidence) 2
• Consider complementary approaches with low-quality evidence:
  • Yoga
  • Tai chi
  • Progressive relaxation
  • Spinal manipulation 2

Persistent Symptoms (After 6 Weeks of Conservative Management)

Imaging

• MRI (preferred) or CT if symptoms persist after 6 weeks of optimal conservative management 1
• Avoid routine imaging for non-specific back pain without red flags 2, 1

Second-line Medications

• Duloxetine for chronic pain 2, 1
• Gabapentin for neuropathic pain with radiculopathy 1
• Tramadol as second-line therapy 2

Interventional Procedures

• Transforaminal Epidural Steroid Injection (TFESI) for patients with radicular symptoms consistent with imaging findings 1
• Imaging guidance (fluoroscopic or CT) is essential for accurate needle placement 1

Surgical Management

Consider surgery only when:

• Pain control is unsuccessful after adequate conservative management
• Motor deficit greater than grade 3 is present
• Radicular pain is associated with foraminal stenosis
• Cauda equina syndrome is present 1

Surgical options based on specific conditions:

• Lumbar discectomy for routine disc herniations
• Fusion only when herniation is associated with spinal instability or severe degenerative changes 1
• Decompression laminectomy for persistent neurogenic claudication 1

Important Considerations and Pitfalls

• Avoid rushing to imaging before completing an adequate trial of conservative management 1
• Avoid prolonged bed rest as it can worsen outcomes 2, 1
• Don't delay surgical consultation in cases with red flags or progressive neurological deficits 1
• Reassess patients with persistent symptoms after 4-6 weeks 1
• Consider psychosocial factors that may influence recovery 1
• Opioids should only be considered when other treatments have failed and only if potential benefits outweigh risks 2
• Monitor hepatic function when using medications like cyclobenzaprine in patients with liver impairment 3

The prognosis for pinched nerves in the back is generally favorable with conservative management, as disc resorption often occurs naturally over time 1. Always correlate clinical findings with imaging before proceeding with invasive treatments.