What are the recommended treatments for middle upper back pain in an older adult?

Middle Upper Back Pain in Older Adults: Treatment Recommendations

For middle upper back pain in older adults, begin with acetaminophen as first-line therapy (up to 4g/24 hours), followed by a structured assessment for specific underlying causes including compression fractures, spinal stenosis, and myofascial pain, while avoiding interventional procedures like epidural injections and radiofrequency ablation which have strong evidence against their use in chronic axial spine pain. 1

Initial Pharmacological Management

First-Line Therapy

• Acetaminophen is the recommended initial medication due to superior safety profile compared to NSAIDs in older adults, with maximum dose of 4g/24 hours from all sources 1
• Acetaminophen lacks the gastrointestinal bleeding, renal toxicity, and cardiovascular risks associated with NSAIDs 1
• Before escalating therapy, ensure the patient is taking adequate doses (sometimes increasing to 1000mg provides sufficient relief to avoid stronger medications) 1

Second-Line Considerations

• NSAIDs should be used with extreme caution in older adults due to multiple risks 1
• If NSAIDs are considered after acetaminophen failure, individualized risk assessment is mandatory including: cardiovascular disease, renal function, gastrointestinal bleeding history, and concomitant antiplatelet therapy 1
• Co-prescribe proton pump inhibitors with NSAIDs in patients at higher gastrointestinal risk 1
• Ibuprofen or naproxen preferred over diclofenac (which carries higher cardiovascular risk) 1

Opioid Therapy

• Consider opioid trials for moderate to severe persistent pain after acetaminophen failure, particularly when NSAIDs are contraindicated 1
• Requires careful assessment of: conventional practice for this pain type, alternative therapies with better therapeutic index, medical problems increasing opioid-related adverse effects, and patient's ability to manage therapy responsibly 1

Essential Diagnostic Evaluation

Red Flags Requiring Urgent Investigation

Older adults with middle upper back pain require heightened vigilance for serious pathology that occurs more frequently in this age group 2:

• Malignancy (more common presentation as back pain in elderly) 2
• Compression fractures from osteoporosis 2
• Spinal infection 3
• Aortic aneurysm 2
• Polymyalgia rheumatica 2

Physical Examination Priorities

Structured examination should assess 4:

• Myofascial pain (present in 96% of older adults with chronic back pain vs 10% without pain) 4
• Sacroiliac joint pain (84% with pain vs 5% without) 4
• Fibromyalgia tender points (19% vs 0%) 4
• Hip pathology by internal rotation (48% vs 0%) 4
• Scoliosis, kyphosis, and functional leg length discrepancy 4

Imaging Recommendations

• Do not routinely obtain imaging in nonspecific back pain 1
• Obtain MRI or CT when: severe/progressive neurologic deficits present, serious underlying conditions suspected (malignancy, infection, fracture), or patient is candidate for specific intervention 1
• Delay plain radiography for at least 1-2 months in nonspecific pain 5

Non-Pharmacological Interventions

Effective Therapies

For chronic or subacute middle/upper back pain, evidence supports 1:

• Exercise therapy (moderate evidence) 1
• Spinal manipulation (moderate evidence) 1
• Acupuncture (moderate evidence) 1
• Massage therapy (moderate evidence) 1
• Cognitive-behavioral therapy (moderate evidence) 1
• Intensive interdisciplinary rehabilitation for refractory cases (moderate evidence) 1

Patient Education

• Provide evidence-based information about expected course 1
• Advise patients to remain active (strong recommendation) 1
• Educate on effective self-care options 1

Interventional Procedures: Strong Recommendations AGAINST

The most recent high-quality guideline (2025) provides strong recommendations against commonly used interventional procedures for chronic axial spine pain 1:

Procedures NOT Recommended

• Joint radiofrequency ablation with or without targeted injection 1
• Epidural injection of local anesthetic, steroids, or combination 1
• Joint-targeted injection of local anesthetic, steroids, or combination 1
• Intramuscular injection of local anesthetic with or without steroids 1

These recommendations apply specifically to chronic spine pain (≥3 months duration) not associated with cancer or inflammatory arthropathy 1.

Adjuvant Analgesics for Neuropathic Components

If neuropathic pain is identified (burning, shooting, electric quality) 1:

• Gabapentinoids (gabapentin 900-3600mg/day or pregabalin 150-600mg/day in divided doses; effective doses may be lower in older adults) 1
• Duloxetine or tricyclic antidepressants for neuropathic pain 1
• Muscle relaxants (baclofen 5mg up to three times daily, maximum 30-40mg/day in older adults; or tizanidine 2mg up to three times daily) with careful monitoring for weakness, cognitive effects, and sedation 1

Special Considerations in Older Adults

Age-Related Factors Affecting Management 3

• Spinal degeneration and multiple comorbidities complicate treatment 3
• Age-related changes in central pain processing 3
• Polypharmacy risks requiring medication review at each visit 1
• Physical inactivity contributing to chronicity 3

Pain Assessment

• Screen for persistent pain at initial evaluation using targeted history and physical examination 1
• Many older adults are reluctant to report pain unprompted; use alternative terms like "aching" or "discomfort" 1
• Quantitative pain assessment tools should be employed 1

Critical Pitfalls to Avoid

1. Do not pursue interventional procedures (epidural injections, radiofrequency ablation) for chronic axial spine pain without radiculopathy 1
2. Do not ignore serious pathology - maintain high index of suspicion for malignancy, infection, and fractures in older adults 2
3. Do not prescribe NSAIDs without cardiovascular and gastrointestinal risk assessment 1
4. Do not overlook myofascial and sacroiliac joint pain as treatable contributors 4
5. Do not assume pain is "normal aging" - persistent pain warrants evaluation and treatment 1