What is the recommended management for a patient with chronic non-spinal back pain and a normal x-ray?

Management of Chronic Non-Spinal Back Pain with Normal X-Ray

Start with nonpharmacologic therapy as first-line treatment—specifically exercise, yoga, tai chi, or spinal manipulation—and avoid interventional spine procedures entirely, as they provide no mortality or quality-of-life benefit and carry serious risks. 1

First-Line: Nonpharmacologic Therapy (Mandatory Starting Point)

The American College of Physicians issues a strong recommendation that nonpharmacologic treatment must be the initial approach for chronic back pain lasting more than 12 weeks. 1, 2

Specific evidence-based options include:

• Exercise therapy: Provides moderate pain relief (approximately 10 points on a 100-point scale) with best outcomes using individualized, supervised programs incorporating stretching and strengthening. 1, 2

• Yoga: Viniyoga or Iyengar styles demonstrate moderate superiority over self-care, with sustained benefits at 26 weeks and decreased medication use. 1, 2

• Tai chi: Supported by moderate-quality evidence for chronic back pain management. 1, 2

• Spinal manipulation: Has low-quality evidence but remains guideline-recommended. 1, 2

• Motor control exercises: Supported by moderate-quality evidence. 1, 2

• Acupuncture: Recommended with moderate-quality evidence for chronic pain. 1

• Mindfulness-based stress reduction or cognitive-behavioral therapy: Particularly beneficial if psychological factors are present (fear-avoidance behaviors, catastrophizing, depression). 1, 2

Critical principle: Advise staying active and avoiding bed rest, as activity promotes recovery while rest leads to deconditioning and worsens symptoms. 1, 2

Second-Line: Pharmacologic Therapy (Only After Inadequate Response to Above)

If nonpharmacologic therapy fails after a reasonable trial (typically 3-6 months), proceed to medications in this specific order: 1, 2

First medication choice:

• NSAIDs (naproxen or ibuprofen): Most effective pharmacologic option with moderate-quality evidence, providing superior pain relief compared to other oral medications. 1, 2, 3

Second medication choice:

• Duloxetine (30-60 mg daily): Specifically recommended as second-line therapy, particularly beneficial if neuropathic pain component exists. 1, 2
• Tramadol: Alternative second-line option. 1, 2

Last resort only:

• Opioids: Consider only after documented failure of all above treatments, and only when benefits clearly outweigh risks after thorough discussion with the patient about addiction potential and limited long-term efficacy. 1, 2, 3

What NOT to Do (Critical to Avoid Harm)

The 2025 BMJ guideline issues strong recommendations AGAINST the following interventional procedures for chronic axial (non-radicular) spine pain: 1

• Epidural injections of local anesthetic, steroids, or their combination
• Joint radiofrequency ablation with or without joint-targeted injections
• Joint-targeted injections of local anesthetic, steroids, or their combination
• Intramuscular injections of local anesthetic with or without steroids
• Dorsal root ganglion radiofrequency procedures

These procedures do not improve morbidity, mortality, or quality of life and carry risks including deep infection, altered consciousness, paralysis, and death. 1

The 2020 NICE guideline similarly states: do not offer spinal injections for managing low back pain. 1

When to Refer

• Multidisciplinary pain management: If pain persists despite optimized nonpharmacologic and pharmacologic therapy over 3-6 months. 2

• Immediate specialist consultation: Only for red flags including progressive neurological deficits, cauda equina syndrome, suspected infection, or malignancy. 2, 3

Common Pitfalls to Avoid

• Do not routinely order imaging unless red flags are present (progressive neurological deficits, cauda equina symptoms, suspected infection/malignancy, or significant trauma). 2, 3

• Do not prescribe acetaminophen as first-line: While historically recommended, it is a weaker analgesic than NSAIDs (less than 10 points difference on 100-point scale) and should be reserved as an alternative when NSAIDs are contraindicated. 1, 3

• Do not use muscle relaxants or benzodiazepines for chronic pain: Evidence supports their use only for acute back pain, not chronic. 1, 3

• Do not refer for interventional procedures: This represents a major shift from older practices, as the most recent 2025 BMJ guideline strongly recommends against these procedures based on lack of benefit and potential for serious harm. 1