What are the recommended management strategies for severe lower back pain?

Management Strategies for Severe Lower Back Pain

The recommended first-line management for severe lower back pain includes maintaining activity within pain limits, using acetaminophen or NSAIDs as initial medication options, and avoiding routine imaging unless specific red flags are present. 1, 2

Initial Assessment

• Perform diagnostic triage to rule out specific spinal pathology or radicular syndrome through focused history and physical examination 2
• Assess for red flags requiring immediate imaging or specialist referral: cauda equina syndrome, history of cancer, unexplained weight loss, fever, significant trauma, or osteoporosis 1, 2
• Evaluate for neurological deficits through examination including straight leg raise test for radiculopathy 1
• Assess yellow flags (psychosocial risk factors) to tailor education, reassurance, and advice 2

Diagnostic Testing

• Avoid routine imaging for non-specific low back pain, even with midline tenderness, if no red flags are present 1, 2
• Order MRI or CT immediately if severe or progressive neurologic deficits are present, cauda equina syndrome is suspected, or serious underlying condition is suspected 1, 2
• Consider plain radiography only for patients with risk factors for vertebral compression fracture or persistent symptoms after 4-6 weeks of conservative management 1

Non-Pharmacological Management

• Advise patients to stay active and avoid bed rest 2
• Provide education about good prognosis and self-care strategies 2
• For chronic or subacute low back pain that doesn't improve with self-care, consider adding evidence-based non-pharmacological therapies 2:
  • Intensive interdisciplinary rehabilitation 2
  • Exercise therapy 2, 3
  • Spinal manipulation 2, 4
  • Acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation 2

Pharmacological Management

• First-line medication options: acetaminophen or NSAIDs 2
  • Acetaminophen has a more favorable safety profile but is slightly weaker than NSAIDs 2
  • NSAIDs are more effective for pain relief but carry gastrointestinal and cardiovascular risks 2
• Consider opioid analgesics or tramadol only for severe, disabling pain not controlled with acetaminophen and NSAIDs 2
  • Use judiciously due to substantial risks including potential for abuse or addiction 2
  • Reassess if no response to time-limited course 2
• Skeletal muscle relaxants are an option for short-term relief of acute low back pain but are associated with central nervous system adverse effects (primarily sedation) 2

Follow-up and Referral

• If patients have not improved after 6 weeks, refer to adjunct conservative management (exercise therapy, cognitive behavior therapy, pain management programs) 2
• Patients with persistent, unimproved symptoms after 1 month should be reevaluated 1
• Consider earlier reassessment for older patients, patients with signs of radiculopathy or spinal stenosis, or worsening symptoms 1

Common Pitfalls to Avoid

• Ordering unnecessary imaging for non-specific low back pain 1, 2
• Prescribing prolonged bed rest 1, 3
• Overreliance on opioid medications for pain management 1, 2
• Failing to assess for psychosocial factors that may contribute to delayed recovery 1, 2
• Providing inappropriate advice regarding rest and activity 2
• Over-prescribing opioid medicines 2

Emerging Treatments

• Platelet-rich plasma (PRP) injections are considered investigational with insufficient evidence to support routine use over established treatments 5
• Current guidelines classify PRP as a "novel agent" still in the investigational stage 5