What treatment options are available for a middle-aged adult patient with chronic back pain and neck stiffness, and a history of cervical degenerative changes and resolved leg neuropathy?

Treatment for Chronic Back Pain and Neck Stiffness

For chronic back pain and neck stiffness, begin with nonpharmacologic therapies as first-line treatment, including physical therapy with structured exercise programs, yoga, tai chi, or spinal manipulation, and only add NSAIDs if nonpharmacologic approaches fail. 1

Initial Nonpharmacologic Management (First-Line)

The American College of Physicians strongly recommends starting with nonpharmacologic interventions for chronic low back pain (>12 weeks duration) 1:

• Exercise-based therapies: Motor control exercise, progressive relaxation, or structured physical therapy programs 1
• Mind-body interventions: Mindfulness-based stress reduction, yoga, or tai chi 1
• Manual therapies: Spinal manipulation or massage 2, 3
• Behavioral approaches: Cognitive behavioral therapy or operant therapy 1

For neck stiffness specifically, physical therapy involving stretching and strengthening exercises has demonstrated benefit for both acute and chronic stable neck conditions 3. Early mobilization is preferred over prolonged rest for soft tissue injuries 3.

Pharmacologic Management (Second-Line)

Only consider medications after inadequate response to nonpharmacologic therapy 1:

First-Line Pharmacologic: NSAIDs

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are the first pharmacologic option for chronic low back pain 1
• Use at the lowest effective dose for the shortest duration necessary 4
• Critical warnings: NSAIDs increase risk of cardiovascular events (heart attack, stroke), gastrointestinal bleeding, and kidney problems 4
• Avoid in patients with history of ulcers, cardiovascular disease, kidney disease, or those taking anticoagulants 4

Second-Line Pharmacologic Options

If NSAIDs are ineffective or contraindicated 1:

• Tramadol (weak opioid)
• Duloxetine (SNRI antidepressant with pain-modifying properties)

Opioids: Last Resort Only

• Consider opioids only after failure of all above treatments 1
• Require explicit discussion of risks versus realistic benefits 1
• Must document that potential benefits outweigh risks for the individual patient 1

What NOT to Do

Strongly avoid these interventional procedures for chronic spine pain, as the 2025 BMJ guidelines issued strong recommendations against 1:

• Joint radiofrequency ablation with or without injections 1
• Epidural injections of local anesthetic, steroids, or combinations 1
• Facet joint injections 1
• Intramuscular trigger point injections 1
• Dorsal root ganglion radiofrequency procedures 1

These procedures lack evidence of benefit and carry risks of complications 1.

Neck-Specific Considerations

For cervical degenerative changes with neck stiffness 1, 3:

• Imaging is NOT indicated for chronic, unchanging neck pain with degenerative changes alone 1
• Degenerative findings on MRI correlate poorly with symptoms in patients over 30 years 1
• Conservative management with physical therapy is appropriate unless red flags present (fever, unexplained weight loss, neurologic deficits, trauma) 3, 5
• Most neck pain resolves within 2 months regardless of treatment type 6, 5

Critical Pitfalls to Avoid

1. Do not rush to imaging: Degenerative changes are common in asymptomatic individuals and do not require cross-sectional imaging unless symptoms change or red flags emerge 1

2. Do not start with medications: The evidence strongly supports nonpharmacologic approaches first, with medications only added for inadequate response 1

3. Avoid acetaminophen: While commonly used, acetaminophen is not specifically recommended in the ACP guidelines for chronic low back pain 1

4. Do not offer injections: Despite their popularity, epidural and facet injections have strong evidence against their use for chronic spine pain 1

5. Recognize that surgery is rarely indicated: For neck pain without myelopathy or progressive neurologic deficits, surgery shows no clear benefit over conservative care 7

Treatment Algorithm

Step 1: Initiate structured physical therapy with exercise (6+ weeks) plus one mind-body intervention (yoga, tai chi, or mindfulness) 1

Step 2: If inadequate response after 6-8 weeks, add NSAIDs at lowest effective dose 1

Step 3: If NSAIDs fail or contraindicated, trial tramadol or duloxetine 1

Step 4: If all above fail and pain remains disabling, consider opioid trial only after documented discussion of risks/benefits 1

Throughout: Continue nonpharmacologic therapies as they provide the foundation of chronic pain management 1