From the Guidelines
If conservative management for back pain doesn't work, the next step typically involves more advanced interventions, such as considering the use of medications with proven benefits, nonpharmacologic therapy with proven benefits, or interventional procedures like epidural steroid injections, as recommended by the American College of Physicians and the American Pain Society 1.
Key Considerations
- The choice of next steps depends on the specific diagnosis, pain severity, and how the body responds to previous interventions.
- Medications such as prescription-strength NSAIDs, muscle relaxants, or short-term opioids may be considered for pain management, with evidence suggesting that NSAIDs and skeletal muscle relaxants have good evidence of short-term effectiveness for low back pain 1.
- Nonpharmacologic therapies, including spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation, may be considered for patients who do not improve with self-care options, with moderate-quality evidence supporting their use 1.
- Interventional procedures like epidural steroid injections can provide targeted relief, usually administered as a series of 1-3 injections spaced 2-4 weeks apart.
- For persistent pain, imaging studies such as an MRI may be suggested to identify specific structural issues, and surgical options might be considered, ranging from minimally invasive procedures to more extensive surgeries depending on the underlying cause.
Important Evidence
- A systematic review published in 2017 found that several systemic pharmacologic therapies for low back pain are associated with small to moderate, primarily short-term effects on pain, with effects on function generally smaller than effects on pain 1.
- The evidence base has limitations, including sparse data for several medications, methodological flaws, and underrepresentation of older adults, highlighting the need for more research to determine effective treatments for radicular low back pain and to understand the optimal selection of medications, combinations, and sequencing of treatments 1.
From the FDA Drug Label
The efficacy of pregabalin for the management of neuropathic pain associated with spinal cord injury was established in two double-blind, placebo-controlled, multicenter studies Treatment with pregabalin 150–600 mg/day statistically significantly improved the endpoint weekly mean pain score, and increased the proportion of patients with at least a 30% and 50% reduction in pain score from baseline.
The next step for back pain management if conservative management doesn't work is not directly addressed in the provided drug label. However, pregabalin is shown to be effective in managing neuropathic pain associated with spinal cord injury.
- Key points:
- Pregabalin improved weekly mean pain score
- Increased proportion of patients with at least 30% and 50% reduction in pain score from baseline
- Effective dose range: 150-600 mg/day The provided information does not directly answer the question about the next step for back pain management if conservative management doesn't work, as it focuses on neuropathic pain associated with spinal cord injury, not back pain in general 2.
From the Research
Next Steps for Back Pain Management
If conservative management for back pain does not work, the next steps may include:
- Re-evaluation of the diagnosis to ensure that the correct treatment approach is being used 3
- Consideration of alternative conservative treatments, such as manipulation, massage, and acupuncture, although their effectiveness is not well supported by evidence 3
- Multidisciplinary biopsychosocial rehabilitation programs, which have shown positive outcomes, including improved mobility, strength, and higher return-to-work rates 3, 4
- Pharmacological treatments, such as baclofen, duloxetine, NSAIDs, and opiates, which have been shown to improve pain and disability levels in patients with chronic low back pain 5
- Epidural steroid injections (ESIs), which have been shown to increase patients' quality of life, relieve lumbosacral radicular pain, and reduce or delay more invasive interventions, such as spinal surgery 6
Considerations for Treatment
When considering the next steps for back pain management, it is essential to:
- Take a stepwise approach to treatment, starting with conservative management and progressing to more invasive interventions as needed 3
- Involve the patient in the decision-making process and consider their individual needs and preferences 4
- Monitor the patient's progress and adjust the treatment plan as needed to ensure optimal outcomes 4, 7