What is the treatment protocol for a patient with lumbar region pain and no specific demographic or medical history?

Treatment Protocol for Lumbar Region Pain

For acute lumbar pain (<4 weeks), advise patients to remain active, apply superficial heat, and use acetaminophen or NSAIDs as first-line medications; for chronic lumbar pain (≥3 months), prioritize nonpharmacologic therapies including exercise therapy, multidisciplinary rehabilitation, acupuncture, massage therapy, spinal manipulation, yoga, or cognitive-behavioral therapy before considering medications. 1

Initial Assessment and Classification

Conduct a focused history and physical examination to categorize patients into three groups: 1

• Nonspecific low back pain (85% of cases): No identifiable anatomical cause 1
• Back pain with radiculopathy or spinal stenosis: Radiating pain below the knee, positive straight leg raise test 1, 2
• Back pain with specific spinal cause: Red flags present (see below) 1

Red Flags Requiring Immediate Imaging and Specialist Referral

• Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction) 1, 3
• History of cancer, unexplained weight loss, or age >50 with night pain 4, 3
• Fever or recent infection suggesting spinal infection 3
• Significant trauma or history of osteoporosis suggesting compression fracture 3
• Progressive or severe neurologic deficits 1

Psychosocial Risk Assessment

Evaluate for factors predicting chronic disability: depression, catastrophizing, fear-avoidance beliefs, job dissatisfaction, and passive coping strategies. 1, 3 Use the STarT Back tool at 2 weeks to risk-stratify patients. 3

Diagnostic Imaging Guidelines

Do not routinely obtain imaging for nonspecific low back pain without red flags. 1 Imaging does not improve outcomes and identifies many incidental findings that correlate poorly with symptoms. 4

• Immediate MRI or CT: Only if red flags present (cauda equina, progressive neurologic deficits, suspected malignancy/infection) 1, 4
• Delayed imaging (after 4-6 weeks): Consider plain radiography if symptoms persist despite conservative therapy 3
• MRI preferred over CT: Superior soft tissue visualization without radiation exposure 4

Treatment Algorithm by Duration

Acute Low Back Pain (<4 weeks)

Nonpharmacologic interventions (first-line): 1, 3

• Advise to remain active: Avoid bed rest; maintaining activity reduces disability 1, 3
• Superficial heat: Apply heating pads for symptomatic relief 3
• Spinal manipulation: Small to moderate short-term benefits 1

Pharmacologic interventions (if nonpharmacologic insufficient): 1

• First-line: Acetaminophen (up to 4g daily) or NSAIDs 1, 3
• Second-line: Skeletal muscle relaxants (short-term use only; associated with sedation and dizziness) 1
• Avoid: Systemic corticosteroids (not more effective than placebo), opioids (abuse potential without superior efficacy) 1, 3

Do not recommend: Supervised exercise therapy (not effective for acute pain), routine imaging 1

Subacute Low Back Pain (4-12 weeks)

Nonpharmacologic interventions: 1, 3

• Intensive interdisciplinary rehabilitation: Moderately effective; includes physician consultation coordinated with psychological, physical therapy, social, or vocational intervention 1
• Functional restoration with cognitive-behavioral component: Reduces work absenteeism 1
• Continue activity modification and self-care strategies 3

Pharmacologic interventions: Same as acute phase if needed 1

Chronic Low Back Pain (≥3 months)

Nonpharmacologic interventions (first-line, all moderately effective): 1, 3

• Exercise therapy: Small to medium reduction in pain (MD -15.2 on 0-100 scale) and small improvement in function 1, 5
• Multidisciplinary rehabilitation: Medium reduction in pain (SMD -0.55) and small improvement in function 1, 5
• Acupuncture: Medium reduction in pain (MD -10.1 on 0-100 scale) and small improvement in function 1, 5
• Massage therapy: Moderately effective 1
• Spinal manipulation: Moderately effective 1
• Yoga (Viniyoga-style): Moderately effective 1
• Cognitive-behavioral therapy: Small reduction in pain, probably no difference in function 1, 5
• Progressive relaxation: Moderately effective 1

Pharmacologic interventions (if inadequate response to nonpharmacologic therapy): 1, 3

• First-line: Continue NSAIDs or acetaminophen 3
• Second-line: Tramadol or duloxetine 3
• Tricyclic antidepressants: Option for pain relief in chronic low back pain without contraindications 1
• Gabapentin: Small, short-term benefits for radiculopathy only 1
• Last resort: Opioids with careful monitoring (time-limited course, assess for continued benefits without major adverse events) 1, 3

Avoid: 1

• Systemic corticosteroids (not effective) 1
• Benzodiazepines (abuse potential; if used, time-limited course only) 1
• Selective serotonin reuptake inhibitors and trazodone (not effective for low back pain) 1

Interventional Procedures: Strong Recommendations Against

The 2025 BMJ guideline issued strong recommendations against the following for chronic spine pain (≥3 months): 1

• Joint radiofrequency ablation with or without joint injection 1
• Epidural injection of local anesthetic, steroids, or their combination 1
• Joint-targeted injection of local anesthetic, steroids, or their combination 1
• Intramuscular injection of local anesthetic with or without steroids 1
• Dorsal root ganglion radiofrequency for radicular pain 1

Important caveat: This represents the most recent (2025) high-quality guideline evidence contradicting older practices. These procedures have uncertain supporting evidence and inconsistent conclusions in the literature. 1

Follow-Up and Reassessment

• Reevaluate at 1 month if symptoms persist without improvement 3
• Earlier reassessment for patients >65 years, signs of radiculopathy/stenosis, or worsening symptoms 3
• Consider imaging at 4-6 weeks if not previously performed and symptoms persist despite conservative management 3
• Intensify nonpharmacologic therapies if Roland-Morris Disability Questionnaire score does not improve by at least 2 points after 4-6 weeks 3

Specialist Referral Indications

Immediate surgical referral: 4, 3

• Progressive motor deficits 4
• Suspected cauda equina syndrome 3
• Suspected cervical myelopathy (if upper back pain) 4

Elective referral (after 4-6 weeks of conservative therapy): 4, 3

• Persistent radicular symptoms in surgical candidates 4
• No response to standard noninvasive therapies after 3 months minimum 3
• Persistent functional disabilities and pain despite comprehensive conservative therapy 3

Common Pitfalls to Avoid

• Routine imaging for uncomplicated acute low back pain: Exposes patients to unnecessary radiation without clinical benefit 3
• Prescribing prolonged bed rest: Maintaining activity is more effective 1, 3
• Overreliance on opioid medications: Abuse potential without superior efficacy compared to other options 3
• Failing to assess psychosocial factors: Depression, catastrophizing, and fear-avoidance beliefs predict delayed recovery 1, 3
• Using interventional procedures for chronic pain: Strong evidence against epidural injections, radiofrequency ablation, and joint injections based on most recent (2025) guidelines 1
• Extended medication courses without reassessment: Reserve for patients clearly showing continued benefits without major adverse events 1