What is the recommended treatment for a 53-year-old female with left-sided lumbar pain without tingling or numbness?

Treatment for Left-Sided Lumbar Pain Without Radiculopathy

This patient should begin conservative management immediately with NSAIDs and remain active, avoiding routine imaging, as this presentation represents uncomplicated mechanical low back pain that is self-limiting in most cases. 1

Initial Management Strategy

Do NOT Order Imaging

• Routine imaging provides no clinical benefit and leads to increased healthcare utilization in patients with uncomplicated low back pain without red flags. 1
• Imaging is only indicated if red flags are present (fever, trauma, cancer history, progressive neurologic deficits, bowel/bladder dysfunction) or if symptoms persist beyond 6 weeks of optimal conservative management. 1
• The absence of tingling or numbness indicates no radiculopathy, making imaging even less justified at this stage. 1

First-Line Pharmacologic Treatment

• Start with NSAIDs (ibuprofen 400 mg every 4-6 hours as needed, not exceeding 3200 mg daily) as the first-line medication. 1, 2
• Acetaminophen is an alternative if NSAIDs are contraindicated, though evidence for efficacy is weaker. 1
• Avoid long-term opioids and benzodiazepines due to risks of abuse, addiction, and lack of long-term efficacy data. 1

Essential Patient Education

• Advise the patient to remain active and avoid bed rest, as activity promotes faster recovery. 1
• Provide evidence-based information that most low back pain improves within 4-6 weeks with conservative management. 1
• Emphasize self-care options and functional restoration rather than complete pain elimination. 3

If No Improvement After 2-4 Weeks

Add Nonpharmacologic Therapies

• Consider spinal manipulation therapy, which has small to moderate short-term benefits for acute low back pain. 1
• Other effective options include massage therapy, acupuncture, or yoga for symptom relief. 1
• A short course of muscle relaxants (cyclobenzaprine 5 mg three times daily) may provide additional benefit if muscle spasm is prominent, though drowsiness is common. 1, 4

If Symptoms Persist Beyond 6 Weeks

Reassess and Consider Advanced Conservative Management

• At 6 weeks, if the patient remains a candidate for intervention and symptoms persist, MRI lumbar spine without contrast becomes appropriate. 1
• Implement structured physical therapy focused on core strengthening and flexibility for at least 3 months. 3
• Consider multidisciplinary rehabilitation incorporating cognitive-behavioral therapy if pain becomes chronic. 1, 3

Potential Interventions for Refractory Cases

• If imaging reveals facet joint pathology correlating with symptoms, diagnostic medial branch blocks followed by radiofrequency ablation may be considered. 5
• Epidural steroid injections are NOT recommended for axial back pain without radiculopathy. 6

Critical Pitfalls to Avoid

• Do not proceed to imaging in the first 6 weeks unless red flags develop—this is a strong recommendation based on moderate-quality evidence. 1
• Do not assume imaging findings correlate with symptoms; degenerative changes are common in asymptomatic individuals. 1, 3
• Avoid prescribing systemic corticosteroids, as they are not more effective than placebo for low back pain. 1
• Screen for psychosocial yellow flags (depression, catastrophizing, fear-avoidance behaviors) that predict progression to chronic disabling pain. 1, 6

Expected Outcomes

• Most patients experience significant improvement within the first month with conservative management alone. 1
• Up to one-third may report persistent moderate pain at 1 year, but functional improvement typically occurs earlier. 1
• Conservative management is as effective as surgical interventions for chronic low back pain without stenosis or instability at 2-year follow-up. 3, 7