What is the best course of treatment for a patient with lower back pain, considering conservative management and potential underlying conditions such as herniated disc or spinal stenosis?

Lower Back Pain Management

For patients with lower back pain, begin with conservative management including staying active, NSAIDs or acetaminophen for pain control, and physical therapy, reserving imaging only for red flags or failure to improve after 4-6 weeks of treatment. 1, 2

Initial Classification and Red Flag Assessment

Classify patients into three categories through focused history and physical examination 1:

• Nonspecific low back pain (most common)
• Back pain with radiculopathy or spinal stenosis
• Back pain with specific spinal pathology requiring urgent intervention

Red flags requiring immediate imaging or specialist referral 1, 3:

• Progressive neurologic deficits or motor weakness at multiple levels
• Bladder or bowel dysfunction, urinary retention, or loss of anal sphincter tone
• Saddle anesthesia
• History of cancer (positive likelihood ratio of 14.7)
• Suspected spinal infection
• Significant trauma relative to age
• Major or progressive motor/sensory deficits

Yellow flags predicting chronic disabling pain should be assessed, including depression, job dissatisfaction, disputed compensation claims, or somatization 1.

Imaging Strategy

Avoid routine imaging for nonspecific low back pain, as it does not improve outcomes and identifies abnormalities poorly correlated with symptoms 1, 2, 4.

Obtain MRI or CT only when 1, 5:

• Severe or progressive neurologic deficits are present
• Red flags suggest serious underlying conditions (cancer, infection, fracture)
• No improvement after 6 weeks of conservative management 6
• Considering surgical intervention

Plain radiography may be considered if spinal fracture or compression is suspected, particularly in patients with osteoporosis or steroid use 1, 6.

First-Line Conservative Management

Activity Modification

Patients should remain active and avoid bed rest, as staying active is more effective for managing pain and reduces disability 2, 6, 4. Advise patients to continue ordinary activities within pain limits and return to work early 6.

Pharmacological Management

First-line medications 1, 2, 4, 7:

• NSAIDs: More effective for pain relief than acetaminophen but carry gastrointestinal and cardiovascular risks that must be assessed before prescribing 2
• Acetaminophen: First-line option with favorable safety profile, though provides slightly less pain relief than NSAIDs 2, 7
• Use the lowest effective NSAID dose for the shortest period necessary 2

Second-line pharmacological options 1, 2:

• Muscle relaxants (cyclobenzaprine, tizanidine, metaxalone): Short-term use when muscle spasm contributes to pain 2
• Tricyclic antidepressants: May provide pain relief for chronic discogenic pain 1
• Gabapentin: Small, short-term benefits for radiculopathy associated with spinal stenosis 2
• Duloxetine: May be beneficial for chronic low back pain 4

Opioids should only be used judiciously for severe, disabling pain uncontrolled with acetaminophen and NSAIDs, due to substantial risks and dependence potential 2, 7.

Non-Pharmacological Therapies

Effective therapies with strong evidence 1, 2, 4:

• Exercise therapy: Moderately effective for chronic low back pain, with programs incorporating individual tailoring, supervision, stretching, and strengthening showing best outcomes 2
• Intensive interdisciplinary rehabilitation with cognitive-behavioral component 1
• Spinal manipulation: May provide small to moderate short-term benefits for acute low back pain 2, 3
• Massage therapy: Moderate effectiveness for chronic low back pain 2
• Acupuncture: Can be considered for chronic low back pain 1, 2
• Cognitive-behavioral therapy: Recommended for chronic discogenic pain 1

Supportive measures 2, 6:

• Heat application using heating pads for short-term relief 2
• Medium-firm mattresses preferred over firm mattresses 2
• McKenzie exercises helpful for pain radiating below the knee 6

Management Based on Specific Conditions

Radiculopathy

• Epidural steroid injections may provide short-term relief for radiculopathy 1
• Consider physical therapy and goal-directed manual therapy if no improvement in 1-2 weeks 6
• Surgical evaluation after 4-6 weeks of failed conservative therapy in appropriate candidates 1

Spinal Stenosis

• Surgery should be considered for persistent symptoms after failed conservative management 2
• The 2025 BMJ guideline strongly recommends against epidural injections of local anesthetic, steroids, or their combination for chronic axial spine pain 2
• Conventional or cooled lumbar radiofrequency ablation is strongly recommended by the 2025 BMJ guideline 2

Discogenic Pain

Comprehensive conservative management must continue for at least 3-6 months before considering surgical intervention 1.

The BMJ guideline strongly recommends against 1:

• Epidural injection of local anesthetic, steroids, or their combination for chronic axial discogenic pain without radiculopathy
• Joint radiofrequency ablation for chronic axial discogenic pain
• Joint-targeted injection for chronic axial discogenic pain

Surgical Considerations

Fusion is recommended only when ALL of the following are present 1:

• Documented structural instability
• Failed comprehensive conservative management (minimum 3-6 months)
• Significant functional impairment
• Pain correlated with degenerative changes on imaging

Fusion is NOT indicated for 1:

• Isolated disc herniation or radiculopathy without instability
• Chronic low back pain without documented instability or spondylolisthesis
• Inadequate conservative management trial

Immediate surgical referral indicated for 1:

• Progressive motor deficits
• Suspected myelopathy
• Severe radicular pain unresponsive to conservative measures

Common Pitfalls

• Avoid prolonged bed rest, as it leads to deconditioning and worsens symptoms 2, 6
• Do not routinely image nonspecific low back pain, as MRI findings like bulging discs are often nonspecific and poorly correlated with symptoms 1, 2
• Use NSAIDs cautiously in older patients and those with cardiovascular, renal, or gastrointestinal risk factors 2
• Avoid premature surgical referral without adequate conservative management trial of 3-6 months 1
• Reassure patients that 90% of acute episodes resolve within 6 weeks regardless of treatment, though minor flare-ups may occur 6