What are the treatment options for back pain?

Treatment Options for Back Pain

For back pain management, nonpharmacologic therapies should be tried first, followed by NSAIDs if needed, with opioids reserved only for cases where other treatments have failed and benefits outweigh risks. 1

Classification of Back Pain

• Back pain is typically classified by duration: acute (<4 weeks), subacute (4-12 weeks), and chronic (>12 weeks) 1
• Most acute back pain episodes are self-limited and resolve within one month, though up to one-third of patients report persistent pain after a year 1
• Back pain can be further categorized as nonspecific, potentially associated with radiculopathy/spinal stenosis, or potentially associated with another specific spinal cause 2

First-Line Treatment: Nonpharmacologic Approaches

For Acute Back Pain

• Remain active and avoid bed rest 1, 2
• Apply heat via heating pads or heated blankets for short-term relief 1, 3
• Use medium-firm mattresses rather than firm ones 1, 3

For Chronic Back Pain

• Exercise therapy and physical rehabilitation 1, 2
• Cognitive-behavioral therapy 1, 2
• Yoga, tai chi, mindfulness-based stress reduction 1, 2
• Spinal manipulation 1, 2
• Massage therapy and acupuncture 2

Pharmacologic Treatment Options

First-Line Medications

• Acetaminophen (up to 3000-4000mg/day) - though recent evidence suggests limited efficacy for acute low back pain 1, 3
• NSAIDs (e.g., ibuprofen, naproxen) - more effective than acetaminophen but with greater risk profile 1
  • Use lowest effective dose for shortest duration possible 1
  • Assess cardiovascular and gastrointestinal risk factors before prescribing 1, 3

Second-Line Medications

• Skeletal muscle relaxants (e.g., cyclobenzaprine) - effective for short-term pain relief in acute back pain but cause sedation 1, 4
  • Should only be used for short periods (up to 2-3 weeks) 4
  • Use with caution in patients with hepatic impairment 4
• Duloxetine (SNRI antidepressant) - effective for chronic low back pain 1, 2
• Tricyclic antidepressants - may be considered as part of multimodal strategy for chronic pain 1, 5

Third-Line Medications

• Tramadol or duloxetine as second-line therapy for chronic back pain when NSAIDs are ineffective 1
• Opioids should only be considered when other treatments have failed and only if potential benefits outweigh risks 1
  • Requires discussion of known risks and realistic benefits with patients 1, 3
  • Should be prescribed at lowest effective dose for shortest period necessary 3, 5

Ineffective or Limited Evidence Treatments

• Benzodiazepines - ineffective for radiculopathy 1
• Systemic corticosteroids - not effective for low back pain 1, 2
• Continuous or intermittent traction - not shown to be effective for radicular symptoms 2
• Antiseizure medications - insufficient evidence to determine effects 1

Special Considerations for Elderly Patients

• Acetaminophen is preferred first-line due to favorable safety profile 3
• NSAIDs should be used with extreme caution due to increased risks of gastrointestinal bleeding, renal dysfunction, and cardiovascular events 3
• Consider decreased renal function and altered hepatic metabolism which may prolong drug half-life 3
• Monitor for cognitive impairment, sedation, and falls risk with muscle relaxants and opioids 3, 2

Common Pitfalls to Avoid

• Overuse of imaging (MRI, CT) when not indicated - findings are often nonspecific and don't improve outcomes 2, 6
• Prolonged bed rest - can worsen outcomes and delay recovery 2, 7
• Overreliance on opioids for chronic pain management 3, 2
• Continuing ineffective treatments beyond recommended timeframes 4, 5