What are the treatment options for low back pain?

Treatment of Low Back Pain

Conservative management should be the first-line approach for low back pain, including NSAIDs, physical therapy, and patient education for 4-6 weeks before considering surgical intervention. 1

Initial Assessment and Risk Stratification

• Use the STarT Back tool to categorize patients into risk levels:

  • Low risk: Encourage self-management
  • Medium risk: Refer to physiotherapy with patient-centered plan
  • High risk: Refer for comprehensive biopsychosocial assessment 1

• Watch for red flags requiring immediate attention:

  • Cauda equina syndrome
  • Progressive neurological deficits
  • Significant motor deficits
  • Persistent radicular symptoms despite conservative treatment 1

First-Line Pharmacological Treatment

1. NSAIDs:

   • Recommended for limited periods (up to one week)
   • Monitor for gastrointestinal, renal, and cardiovascular side effects
   • Consider gastroprotective agents in high-risk patients 1

2. Acetaminophen:

   • Can be used for pain control
   • Less effective than NSAIDs for low back pain 2

3. Muscle Relaxants:

   • Cyclobenzaprine can be effective for acute musculoskeletal conditions
   • Start with 5mg dose in elderly patients or those with hepatic impairment
   • Drowsiness and dry mouth are common side effects 3
   • Short-term use only for muscle spasm 1

Non-Pharmacological Approaches

1. Physical Therapy:

   • Strongly recommended over no treatment
   • Focus on active interventions (supervised exercise) rather than passive interventions
   • McKenzie method may decrease recurrence of low back pain 1, 4

2. Patient Education:

   • Formal self-management programs (group or individual)
   • Advice to stay active and maintain normal activities 1, 5

3. Evidence-based complementary approaches:

   • Yoga shows strong evidence for short-term and moderate evidence for long-term effectiveness 4
   • Acupuncture, massage, and spinal manipulation may benefit certain patients 2

Second-Line and Adjunctive Treatments

1. Neuropathic pain medications:

   • Gabapentin or pregabalin for neuropathic component 1

2. Epidural steroid injections:

   • May benefit patients with radicular symptoms
   • Evidence shows mixed results 2

3. Multidisciplinary rehabilitation programs:

   • For chronic low back pain not responding to first-line treatments
   • Incorporate behavioral therapy and physical conditioning 5

Surgical Considerations

• Surgery is not recommended for:

  • Isolated stenosis without deformity or instability
  • Following primary disc excision for lumbar disc herniation with radiculopathy (without instability or deformity) 1

• Surgery should be considered for:

  • Cauda equina syndrome
  • Progressive neurological deficits
  • Significant motor deficits
  • Persistent radicular symptoms despite 6-12 weeks of conservative treatment 1

Common Pitfalls to Avoid

1. Overreliance on imaging:

   • Disc abnormalities are common in asymptomatic patients
   • Lumbar spine radiography should be delayed for at least 1-2 months in patients with nonspecific pain 1, 2

2. Premature surgical intervention:

   • Most patients with chronic low back pain will not benefit from surgery
   • Lumbar fusion is not recommended for isolated stenosis 1, 2

3. Prolonged opioid use:

   • Prescribe only as a last resort and for very limited duration
   • Evaluate risk of abuse, misuse, or diversion
   • Plan for tapering if taken regularly for more than a few days 1

4. Failure to address psychosocial factors:

   • Low back pain is often associated with other pain manifestations
   • Widespread pain is associated with worse prognosis compared to localized low back pain 5

By following this evidence-based approach to low back pain management, clinicians can effectively address pain while minimizing unnecessary interventions and improving patient outcomes.