What are the appropriate management and treatment options for left-sided back pain?

Management of Left-Sided Back Pain

For left-sided back pain without red flag symptoms, advise the patient to remain active, start acetaminophen or NSAIDs (ibuprofen 400mg every 4-6 hours), and avoid routine imaging—most cases improve substantially within the first month. 1

Initial Red Flag Assessment

First, determine if urgent evaluation is needed by screening for serious underlying conditions:

• Immediate red flags requiring prompt imaging (MRI preferred): Progressive neurologic deficits, suspected cauda equina syndrome (urinary retention/incontinence, bilateral leg weakness, saddle anesthesia), suspected vertebral infection, or cancer with impending spinal cord compression 1
• Cancer risk factors: History of cancer (strongest predictor), age >50 years, unexplained weight loss, failure to improve after 1 month of treatment 1
• Infection indicators: Fever, IV drug use, recent infection, immunosuppression 2
• Fracture risk: Significant trauma, prolonged corticosteroid use, osteoporosis 3

If any red flags are present, obtain MRI immediately—delayed diagnosis worsens outcomes. 1 If the patient is >50 years without other cancer risk factors, you can delay imaging for 1 month while treating conservatively. 1

Classification and Imaging Strategy

Do not obtain routine imaging for nonspecific low back pain—it does not improve outcomes and incurs unnecessary expense. 1, 4

Only image if:

• Red flags present (see above) 1
• Persistent radicular symptoms beyond 4 weeks AND patient is a surgical candidate 1
• Severe or progressive neurologic deficits 1

When imaging is indicated, MRI is preferred over CT because it avoids ionizing radiation and provides superior visualization of soft tissue, vertebral marrow, and spinal canal. 1

Acute Management (< 4 weeks)

Patient Education and Activity

• Inform the patient of excellent prognosis: High likelihood of substantial improvement within the first month 1, 4
• Advise to remain active and avoid bed rest—staying active is more effective than bed rest 1, 4
• Provide evidence-based self-care education materials 1, 4

First-Line Pharmacologic Treatment

Start with acetaminophen (up to 3000mg/day) or NSAIDs as first-line therapy: 1, 4

• Ibuprofen 400mg every 4-6 hours as needed (maximum 3200mg/day, though doses >400mg show no additional benefit for pain relief) 5
• Take with meals or milk if GI complaints occur 5
• Avoid systemic corticosteroids—they are no more effective than placebo 1, 4

Nonpharmacologic Options for Acute Pain

If medication alone is insufficient, add: 4

• Superficial heat application (good evidence for moderate benefit) 4
• Spinal manipulation (fair evidence for small-to-moderate benefit) 1, 4
• Acupuncture may be considered (limited evidence) 4

Subacute/Chronic Management (> 4 weeks)

When to Escalate Treatment

If pain persists beyond 4 weeks despite initial management:

For radicular symptoms (leg pain, numbness, weakness):

• Consider MRI only if patient is a surgical candidate or candidate for epidural steroid injection 1
• Most lumbar disc herniations with radiculopathy improve within 4 weeks with conservative management 1
• Avoid continuous or intermittent traction—it has not been proven effective 1, 4

Chronic Pain Pharmacologic Options (> 12 weeks)

• Continue NSAIDs or acetaminophen if effective 4
• Add duloxetina 30mg/day, increasing to 60-120mg/day for neuropathic/radicular component (moderate evidence for benefit) 6, 7
• Consider tricyclic antidepressants (amitriptyline) as alternative 4
• Gabapentin for radicular symptoms 4

Nonpharmacologic Therapies for Chronic Pain

Exercise therapy is a cornerstone of chronic pain management (good evidence, moderate efficacy): 4

• Programs incorporating individual tailoring, supervision, stretching, and strengthening show best outcomes 1

Other evidence-based options: 1, 4

• Cognitive-behavioral therapy (good evidence)
• Spinal manipulation (moderate effectiveness)
• Acupuncture
• Massage therapy
• Yoga
• Intensive interdisciplinary rehabilitation

Common Pitfalls to Avoid

• Do not over-image: MRI/CT findings like bulging discs are often nonspecific and don't correlate with symptoms 1, 4
• Avoid benzodiazepines: No solid evidence for low back pain and risk of dependence 6
• Do not prescribe opioids long-term: Insufficient evidence for chronic use 7
• Screen for depression: It commonly coexists with chronic back pain and requires appropriate treatment 4
• Monitor NSAIDs in high-risk patients: Check for GI bleeding, renal function, cardiovascular risk 5

Specialist Referral Indications

Consider referral when: 1

• No response to 3+ months of conservative therapy
• Progressive neurologic deficits
• Persistent functional disability despite multimodal treatment
• Surgical evaluation needed (minimum 1 year of symptoms for nonspecific low back pain) 1