What are the treatment options for lower back pain and nerve issues?

Treatment of Lower Back Pain and Nerve Issues

Start with Non-Pharmacologic Therapy First

For both acute and chronic lower back pain with or without nerve involvement, begin with non-pharmacologic interventions as your primary treatment strategy, specifically advising patients to remain active, avoid bed rest, and apply superficial heat. 1, 2, 3

Critical First Steps (All Patients)

• Advise patients to stay active and continue ordinary activities within pain limits—bed rest prolongs recovery and delays return to normal function. 1, 3, 4
• Apply superficial heat via heating pads or heated blankets for moderate short-term pain relief at 5 days and improved disability at 4 days. 5, 1, 2
• Provide reassurance that 90% of acute episodes resolve within 6 weeks regardless of treatment, though minor flare-ups may occur. 3, 4

Exercise Therapy (Cornerstone for Chronic Pain)

• Exercise therapy is the single most important non-pharmacologic intervention for chronic low back pain, producing small to moderate improvements in both pain (approximately 10 points on a 100-point scale) and function. 5, 2, 3
• Individualized, supervised programs incorporating stretching and strengthening produce the best outcomes. 2
• Motor control exercises specifically target spinal-supporting muscles and moderately decrease pain scores with sustained long-term benefits. 5, 2
• Consider McKenzie exercises specifically for pain radiating below the knee. 4

Additional Effective Non-Pharmacologic Options

• Spinal manipulation by appropriately trained providers provides small to moderate short-term benefits for both acute and chronic low back pain. 5, 1, 2, 3
• Yoga demonstrates moderate superiority over self-care education with sustained benefits at 26 weeks. 2, 3
• Tai chi shows moderate-quality evidence for pain improvement at 3 and 6 months. 2
• Massage therapy is moderately effective for chronic low back pain. 2, 3
• Cognitive-behavioral therapy or mindfulness-based stress reduction should be added, particularly if psychological factors or depression are present. 2, 3

Pharmacologic Treatment Algorithm

First-Line Medications (Acute and Chronic Pain)

NSAIDs are the preferred first-line pharmacologic option, providing small to moderate improvements in pain intensity superior to other oral medications. 5, 1, 2, 3, 6, 7

• Prescribe NSAIDs at the lowest effective doses for the shortest periods necessary. 1
• Assess cardiovascular and gastrointestinal risk factors before prescribing. 1
• Most head-to-head trials show no differences between different NSAIDs, so select based on cost and availability. 1
• Acetaminophen (up to 3000mg/day) can be used as an alternative first-line option due to favorable safety profile, though it shows no significant difference from placebo for pain intensity or function. 1, 3, 7
• Monitor for hepatotoxicity when using acetaminophen at maximum doses, especially in elderly patients or those with hepatic impairment. 1

Second-Line Medications (When First-Line Inadequate)

For acute pain (< 4 weeks):

• Skeletal muscle relaxants improve short-term pain relief at 2-4 and 5-7 days compared to placebo. 1, 7
• All skeletal muscle relaxants cause central nervous system adverse effects, primarily sedation. 1, 8
• Cyclobenzaprine should be used with caution in mild hepatic impairment starting with 5mg dose and titrating slowly; avoid in moderate to severe hepatic impairment. 8
• No compelling evidence exists that different skeletal muscle relaxants differ in efficacy or safety. 1

For chronic pain (> 12 weeks):

• Duloxetine is the preferred second-line agent when NSAIDs provide inadequate response, particularly if neuropathic pain components exist. 2
• Tramadol is an alternative second-line option. 2
• Tricyclic antidepressants can be considered as part of a multimodal strategy, though effects on pain appear small or uncertain. 2, 3, 7
• Gabapentin should be considered specifically for radicular symptoms (nerve pain radiating down the leg). 3

Opioid Considerations (Last Resort Only)

Opioids or tramadol may be considered only when severe, disabling pain is not controlled with acetaminophen and NSAIDs, and only after careful discussion of substantial risks including abuse potential and addiction. 5, 1

What NOT to Do: Critical Pitfalls

Treatments to Avoid

• Do NOT prescribe systemic corticosteroids—they have not been shown more effective than placebo for low back pain with or without sciatica. 5, 1, 3, 9
• Do NOT routinely order imaging (MRI/CT) for nonspecific low back pain—findings are often nonspecific and do not improve outcomes. 2, 3
• Do NOT prescribe bed rest or activity restriction—this provides no benefit and delays recovery. 1, 3, 4
• Do NOT use benzodiazepines except for time-limited courses due to risks for abuse, addiction, and tolerance. 1, 3
• Avoid epidural injections, facet joint injections, radiofrequency ablation, and intramuscular trigger point injections for axial spine pain—these do not improve morbidity, mortality, or quality of life. 2
• TENS shows no benefit compared to sham TENS. 2
• Lumbar supports have not shown clear benefits. 5, 2
• Insufficient evidence exists to recommend antidepressants or antiseizure medications for acute low back pain. 1

When to Obtain Imaging or Refer

Red Flags Requiring Immediate Action

• Progressive neurological deficits 2, 3
• Cauda equina syndrome (bowel/bladder dysfunction, saddle anesthesia) 3, 4
• Suspected infection or malignancy 3, 4
• Suspicion of spinal fracture or compression 4

Imaging Indications

• Only obtain MRI or CT when severe/progressive neurologic deficits are present, serious underlying conditions are suspected, or for persistent symptoms in surgical candidates. 3
• Consider plain lumbosacral spine x-ray if there is suspicion of spinal fracture or compression. 4
• Consider imaging if patients have no improvement after 6 weeks. 4
• A normal MRI is often a flag that something other than spinal problems may be the cause—consider urogenital irritation, piriformis syndrome, or other non-spinal causes. 10

Specialist Referral

• Refer to multidisciplinary pain management if pain persists despite optimized therapy over 3-6 months. 2
• Consider MRI and specialist referral if radicular symptoms persist beyond 4 weeks despite conservative management. 3
• Immediate specialist consultation required for any red flags listed above. 2

Special Considerations for Nerve Issues (Radiculopathy)

• Gabapentin specifically targets radicular symptoms and should be added when nerve pain radiating down the leg is present. 3
• Screen and treat depression appropriately as it commonly coexists with chronic back pain and nerve symptoms. 3, 7
• Avoid continuous or intermittent traction—it has not shown effectiveness for radicular symptoms. 3
• Conflicting evidence exists regarding epidural injection of corticosteroids, but one meta-analysis suggests they may provide small symptomatic improvement for patients with radiculopathy. 9

Treatment Duration Considerations

• Do NOT use extended courses of medications without clear evidence of continued benefits and absence of major adverse events. 1
• Muscle relaxants and narcotic analgesics should be prescribed for fixed periods only. 9, 7
• The magnitude of pain benefits from nonpharmacologic therapies is typically small to moderate and generally short-term, with effects on function smaller than effects on pain. 2, 3