What is the recommended treatment for a 30-year-old female with low back pain and incidental finding of lumbar scoliosis?

Treatment of Low Back Pain with Incidental Lumbar Scoliosis in a 30-Year-Old Female

For a 30-year-old woman with low back pain and incidental lumbar scoliosis, treat the low back pain itself with first-line NSAIDs and activity modification while ignoring the scoliosis finding, as the scoliosis is likely an incidental radiographic finding that does not require specific treatment and does not change the management approach for nonspecific low back pain. 1

Initial Assessment and Classification

The first priority is determining whether this represents nonspecific low back pain versus pain with radiculopathy or another specific spinal cause. 1

• Conduct a focused history looking specifically for: duration of pain (acute <4 weeks, subacute 4-12 weeks, chronic >3 months), presence of leg pain or sciatica, neurologic symptoms (numbness, weakness, bowel/bladder dysfunction), and red flags (fever, unexplained weight loss, history of cancer, trauma, or progressive neurologic deficit). 1

• Physical examination should assess for: straight leg raise test, neurologic examination of lower extremities (motor strength, sensation, reflexes), and presence of radicular symptoms versus isolated axial back pain. 1

• The incidental scoliosis finding should not alter your treatment approach unless the patient has severe deformity with rotatory olisthesis, as most adult scoliosis is asymptomatic and the correlation between radiographic findings and symptoms is poor. 1, 2, 3

Treatment Algorithm Based on Pain Duration

If Acute Low Back Pain (<4 weeks):

First-line treatment:

• NSAIDs are the preferred initial medication: ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily, prescribed at the lowest effective dose for the shortest period necessary. 4
• Advise remaining active and avoiding bed rest, as activity restriction prolongs recovery and delays return to normal function. 1, 4
• Assess cardiovascular and GI risk before prescribing NSAIDs, evaluating for cardiovascular disease, GI bleeding history, renal impairment, and hypertension. 4

Second-line if severe pain persists after 2-4 days:

• Add skeletal muscle relaxant for short-term use (≤1-2 weeks): cyclobenzaprine 5-10 mg three times daily. 4

Avoid these interventions:

• Do not order imaging (X-rays, MRI, CT) without red flags, as they are unnecessary and often show degenerative changes that correlate poorly with symptoms. 1, 4
• Do not prescribe systemic corticosteroids, as they are not effective for acute low back pain. 4
• Do not recommend supervised exercise therapy for acute low back pain, as it is not effective during the acute phase. 4

If Chronic or Subacute Low Back Pain (≥4 weeks):

First-line nonpharmacologic therapy (choose based on patient preference and availability):

• Exercise therapy with supervised stretching and strengthening programs provides moderate pain relief and should be individualized. 1, 5
• Spinal manipulation has moderate evidence for effectiveness in chronic low back pain. 1
• Yoga (Viniyoga or Iyengar styles) demonstrates sustained benefits at 26 weeks with decreased medication use. 5

Pharmacologic therapy:

• NSAIDs remain the most effective pharmacologic option with moderate-quality evidence. 5
• Consider duloxetine as second-line therapy if a neuropathic pain component exists. 5
• Skeletal muscle relaxants may be added for short-term use if severe pain persists, but should not be used beyond 1-2 weeks. 5

Strongly avoid these interventions:

• Do not offer interventional procedures (epidural injections, joint radiofrequency ablation, joint-targeted injections, or intramuscular injections) for chronic axial spine pain, as recent high-quality evidence shows they do not improve morbidity, mortality, or quality of life. 1
• Do not use transcutaneous electrical nerve stimulation (TENS) or traction, as they have not been proven effective. 1

Special Considerations for the Scoliosis Finding

The incidental scoliosis does not require specific treatment in most cases. 2, 3

• Scoliosis-specific intervention is only indicated if: the patient has severe deformity with documented progression, rotatory olisthesis on imaging, or symptoms of spinal stenosis/claudication. 2, 3

• Pain severity in scoliotic patients correlates with: Cobb angle magnitude, vertebral rotation, and presence of rotatory olisthesis—but these factors should only influence treatment if causing specific mechanical symptoms beyond typical nonspecific low back pain. 3

• If the patient has inguinal pain or cruralgia (anterior thigh pain), this may be more specifically related to the scoliosis and warrants consideration of the deformity as a pain generator. 3

When to Consider Specialist Referral

Refer to spine specialist if:

• Pain persists despite 3 months of appropriate conservative treatment with NSAIDs and nonpharmacologic therapy. 1
• Progressive neurologic deficits develop (motor weakness, sensory changes, bowel/bladder dysfunction). 1, 5
• Red flags emerge suggesting serious underlying pathology (fever, unexplained weight loss, history of cancer). 1, 5
• Symptoms of spinal stenosis or severe radiculopathy develop. 1

Do not refer for surgical evaluation of scoliosis unless the patient has failed at least 3 months of conservative treatment and has documented mechanical symptoms specifically attributable to the deformity. 1, 2

Critical Pitfalls to Avoid

• Do not attribute all back pain to the scoliosis finding, as approximately 85% of low back pain is nonspecific and incidental imaging findings are extremely common in asymptomatic individuals. 1

• Do not order advanced imaging (MRI) without red flags or failure of conservative treatment, as this leads to overdiagnosis of incidental findings that do not correlate with symptoms. 1, 5

• Do not pursue interventional procedures based solely on imaging findings of scoliosis, as strong 2025 evidence demonstrates these procedures are ineffective for chronic axial spine pain. 1

• Do not prescribe prolonged bed rest, as it leads to deconditioning and worse outcomes. 5, 4

• Do not use muscle relaxants chronically beyond 2 weeks, as there is no evidence for efficacy with longer duration and risks increase. 5, 4