What are the treatment options for left lower back pain?

Treatment of Left Lower Back Pain

For left lower back pain without red flags, start with patient education emphasizing the favorable prognosis, advise remaining active, and initiate acetaminophen or NSAIDs as first-line pharmacotherapy. 1

Initial Assessment and Red Flag Screening

Conduct a focused history and physical examination to categorize the pain into one of three groups: nonspecific low back pain, pain with radiculopathy/spinal stenosis, or pain from another specific spinal cause. 1

Critical red flags requiring immediate imaging and specialist referral include: 1, 2

• Progressive or severe motor/sensory deficits
• New bowel/bladder incontinence or urinary retention
• Saddle anesthesia or loss of anal sphincter tone
• History of cancer metastatic to bone
• Suspected spinal infection (vertebral osteomyelitis)
• Cauda equina syndrome
• Significant trauma relative to age (major trauma in young patients, minor fall in elderly with osteoporosis)

Do not routinely obtain imaging for nonspecific low back pain without red flags, as it does not improve outcomes and increases costs. 1

Assess psychosocial risk factors (yellow flags) that predict chronic disability, including depression, catastrophizing, fear-avoidance behaviors, and job dissatisfaction. 1

Treatment Algorithm by Pain Duration

Acute Low Back Pain (<4 weeks)

Patient Education and Activity Modification:

• Inform patients that 90% of acute episodes resolve within 6 weeks regardless of treatment, with substantial improvement typically occurring within the first month. 1, 3, 2
• Advise patients to remain active and continue ordinary activities within pain limits—bed rest should be avoided as it worsens disability. 1, 3
• Provide evidence-based self-care information emphasizing the favorable natural history. 1

Pharmacologic Management:

• First-line: Acetaminophen (up to 3000-4000 mg/day) or NSAIDs (ibuprofen, naproxen). 1, 4
• Acetaminophen has a more favorable safety profile but is slightly less effective than NSAIDs (approximately 10 points less on a 100-point pain scale). 1
• Before prescribing NSAIDs, assess cardiovascular and gastrointestinal risk factors; use the lowest effective dose for the shortest duration. 1
• Consider co-administration with proton-pump inhibitors in high-risk patients. 1
• Skeletal muscle relaxants (cyclobenzaprine, methocarbamol) can provide short-term pain relief but cause sedation and other CNS side effects. 1, 5
• Avoid systemic corticosteroids—they are not more effective than placebo. 1, 4

Nonpharmacologic Interventions:

• Spinal manipulation is associated with small to moderate short-term benefits for acute low back pain. 1, 4
• Superficial heat application provides moderate benefits. 4
• Do not initiate supervised exercise therapy or home exercise programs during the acute phase, as they are not effective for acute pain. 1

Subacute Low Back Pain (4-12 weeks)

If symptoms persist beyond 4 weeks:

• Continue first-line pharmacologic approaches if providing benefit. 4
• Add intensive interdisciplinary rehabilitation (coordinated physician consultation with psychological, physical therapy, social, or vocational interventions) or functional restoration with cognitive-behavioral components. 1, 4
• Consider imaging (MRI preferred over CT) only if the patient is a potential candidate for surgery or epidural steroid injection. 1

Chronic Low Back Pain (>12 weeks)

Pharmacologic Management:

• Continue acetaminophen or NSAIDs if effective. 4, 6
• Tricyclic antidepressants (amitriptyline, nortriptyline) are an option for pain relief in chronic low back pain without contraindications. 1
• Selective serotonin reuptake inhibitors have not been shown effective for low back pain. 1
• Gabapentin is associated with small, short-term benefits specifically for radiculopathy. 1, 4
• Opioid analgesics or tramadol should be used judiciously only for severe, disabling pain not controlled by acetaminophen and NSAIDs, with careful assessment of abuse risk. 1
• Failure to respond to time-limited opioid courses should prompt reassessment and consideration of alternative therapies. 1

Nonpharmacologic Interventions (all have moderate evidence): 1, 4

• Exercise therapy (aerobic fitness, endurance training, spine stabilization exercises)
• Cognitive-behavioral therapy
• Spinal manipulation
• Acupuncture
• Massage therapy
• Yoga
• Progressive relaxation
• Intensive interdisciplinary rehabilitation programs

The magnitude of benefit from these therapies is typically small to moderate and short-term, with effects on function generally smaller than effects on pain. 4

Special Considerations for Radiculopathy

For persistent radicular symptoms (pain radiating below the knee):

• Consider McKenzie exercises, which are helpful for radicular pain. 3
• Epidural steroid injections are a treatment option for persistent radicular symptoms despite noninvasive therapy, though study results are mixed. 1, 6
• MRI is indicated only if the patient is a surgical candidate or candidate for epidural steroid injection. 1
• The natural history of lumbar disc herniation with radiculopathy shows improvement within the first 4 weeks with noninvasive management in most patients. 1

Common Pitfalls to Avoid

Imaging Overuse:

• MRI and CT findings (such as bulging disc without nerve root impingement) are often nonspecific and do not correlate with symptoms. 1, 4
• Routine imaging does not affect treatment decisions or improve outcomes in nonspecific low back pain. 1

Medication Misuse:

• Avoid benzodiazepines except for time-limited courses, as they carry risks for abuse, addiction, and tolerance. 1
• Do not prescribe carisoprodol without considering its metabolism to meprobamate (associated with abuse and overdose risk). 1
• Acetaminophen at 4 g/day can cause asymptomatic aminotransferase elevations even in healthy adults. 1

Activity Restrictions:

• Bed rest worsens disability and should be avoided. 1, 7, 3
• Passive treatment strategies (rest, medications alone) are associated with worsening disability. 8

Depression Screening:

• Depression is common in chronic low back pain and should be assessed and treated appropriately, as it affects outcomes. 1, 4

Reassessment Timing:

• If no improvement occurs after 1-2 weeks of conservative management, consider adding goal-directed manual physical therapy (not modalities like heat, traction, ultrasound, or TENS). 3
• Reevaluate within 1 month for patients over 50 years without other cancer risk factors before pursuing imaging. 1