What is the best course of treatment for a patient with lower back pain?

Treatment of Lower Back Pain

Start with NSAIDs and advise the patient to remain active—this combination provides the most effective initial management for low back pain, regardless of whether symptoms are acute or chronic. 1, 2

Initial Assessment

Before initiating treatment, quickly screen for red flags requiring immediate intervention:

• Serious red flags include cauda equina syndrome (new-onset bowel/bladder incontinence, urinary retention, saddle anesthesia, loss of anal sphincter tone), major or progressive motor/sensory deficits, history of cancer metastatic to bone, suspected spinal infection, or significant trauma 2, 3
• Fracture risk factors include age-related trauma (fall from height or motor vehicle crash in young patients, minor fall or heavy lifting in patients with osteoporosis) 3
• Assess for radicular symptoms (pain radiating below the knee) as this may guide additional treatment decisions 4, 2

First-Line Treatment: Acute Low Back Pain (<4 weeks)

Pharmacologic Management

NSAIDs are the preferred first-line medication, providing small to moderate pain relief superior to acetaminophen 1:

• Prescribe at the lowest effective dose for the shortest duration necessary 1, 5
• Assess cardiovascular and gastrointestinal risk factors before prescribing 1
• Ibuprofen dosing: 400 mg every 4-6 hours as needed (maximum 3200 mg/day), though doses above 400 mg show no additional benefit for pain relief 5
• Most head-to-head trials show no differences between different NSAIDs, so select based on cost and availability 1

Acetaminophen is an acceptable alternative for patients with NSAID contraindications 1:

• Maximum 4 grams daily with monitoring for hepatotoxicity in elderly or those with liver disease 2
• Shows no significant difference from placebo for pain intensity or function, but has a favorable safety profile 1

Non-Pharmacologic Measures (Essential)

• Advise patients to remain active and avoid bed rest—activity restriction prolongs recovery and delays return to normal activities 1, 2, 6
• Apply superficial heat via heating pads or heated blankets for short-term symptomatic relief 1
• Provide evidence-based self-care education materials 2
• Reassure patients that 90% of episodes resolve within 6 weeks regardless of treatment 6

Second-Line Treatment: When Initial Therapy Fails

For Acute Pain

Skeletal muscle relaxants improve short-term pain relief after 2-4 days 1:

• All agents cause central nervous system adverse effects, primarily sedation 1
• Prescribe time-limited courses only (≤1-2 weeks) 7, 2
• No compelling evidence exists that different muscle relaxants differ in efficacy or safety 1

Spinal manipulation by appropriately trained providers shows small to moderate short-term benefits for acute low back pain 4, 1, 2:

• Consider when patients do not improve with self-care options 4
• Evidence is insufficient to conclude that benefits vary by profession of manipulator 4

For Chronic or Subacute Pain (>4 weeks)

Multiple non-pharmacologic therapies have moderate effectiveness 4:

• Exercise therapy with individual tailoring, supervision, stretching, and strengthening shows the best outcomes 4
• Acupuncture provides moderate benefit 4
• Massage therapy is moderately effective 4
• Cognitive-behavioral therapy or progressive relaxation show moderate effectiveness 4
• Intensive interdisciplinary rehabilitation (physician consultation coordinated with psychological, physical therapy, social, or vocational intervention) is moderately effective 4
• Viniyoga-style yoga demonstrates moderate benefit 4

Pharmacologic options for chronic pain:

• Tricyclic antidepressants (e.g., amitriptyline) provide moderate pain relief 7
• Duloxetine shows small improvements in pain intensity and function, particularly useful if depression is present 7
• Gabapentin is effective specifically for radicular pain/sciatica at doses of 1200-3600 mg/day 7

Third-Line: Opioid Considerations

Opioid analgesics or tramadol may be considered only when severe, disabling pain is not controlled with acetaminophen and NSAIDs 1:

• Substantial risks include aberrant drug-related behaviors, abuse potential, and addiction 1
• Reserve for time-limited use with clear evidence of ongoing benefits 1, 2

Treatments NOT Recommended

• Systemic corticosteroids are not recommended for low back pain with or without sciatica—they show no superiority over placebo 4, 1, 7
• Benzodiazepines carry risks for abuse, addiction, and tolerance; if used, prescribe only time-limited courses 1
• Bed rest or activity restriction provides no benefit and delays recovery 1, 2
• Continuous or intermittent traction has not been proven effective 4
• Transcutaneous electrical nerve stimulation lacks evidence of effectiveness 4

Imaging and Advanced Evaluation

• Do not obtain routine imaging for nonspecific low back pain 2, 8
• Consider MRI only if the patient is a potential candidate for surgery or epidural steroid injection and symptoms persist beyond 4-6 weeks 2
• Prefer MRI over CT for superior soft-tissue contrast without radiation 2
• Plain lumbosacral spine x-ray should be delayed for at least 1-2 months in patients with nonspecific pain 9

Critical Pitfalls to Avoid

• Never prescribe bed rest—this provides no benefit and delays recovery 1, 2
• Do not use extended courses of medications without clear evidence of continued benefits and absence of major adverse events 4, 1
• Do not prescribe muscle relaxants for chronic low back pain—no evidence supports efficacy beyond 2 weeks 7
• Avoid skeletal muscle relaxants in elderly patients without careful consideration of fall risk and cognitive impairment from sedation 7
• Most patients improve within 4-6 weeks regardless of treatment, though up to one-third may have persistent moderate pain at one year 2