How should I manage a healthy 16‑year‑old male with chronic neck‑to‑low‑back pain and a small L4‑L5 disc protrusion (no canal or foraminal stenosis) who has not attended lumbar traction and did not respond to celecoxib?

Management of Adolescent Chronic Low Back Pain with L4-L5 Disc Protrusion

For this 16-year-old with chronic low back pain and a small L4-L5 disc protrusion who failed celecoxib and did not attend physical therapy, initiate a structured, supervised exercise program as the cornerstone of treatment, add a trial of duloxetine as second-line pharmacologic therapy, and consider spinal manipulation combined with home exercises. 1, 2

Immediate Next Steps

Prioritize Nonpharmacologic Treatment

• Restart physical therapy with emphasis on supervised, structured exercise focusing on core stabilization – this is the single most effective intervention for chronic low back pain with good evidence of moderate efficacy 2
• The patient's non-attendance at lumbar traction is actually beneficial, as traction is considered ineffective or potentially harmful for low back pain 3
• Supervised physical therapy programs demonstrate superior outcomes compared to home exercises alone, particularly for improving global patient assessment 1

Add Spinal Manipulation

• For adolescents with radicular symptoms extending from cervical to lumbar spine, spinal manipulation combined with home exercises and counseling produces greater improvement in both leg and back pain at 12 weeks compared to exercises alone 1
• Spinal manipulation shows moderate effectiveness with very rare serious adverse events (less than 1 per 1 million patient visits) 3
• This is particularly appropriate given the patient's pain distribution from cervical spine to lower back 3, 1

Pharmacologic Management

Second-Line Therapy: Duloxetine

• Since celecoxib (an NSAID) failed, proceed directly to duloxetine as second-line therapy rather than trying another NSAID 2
• Duloxetine is particularly beneficial if there is any neuropathic component to the pain, which is possible given the disc protrusion and radicular distribution 4
• This follows the American College of Physicians algorithm: NSAIDs first, then tramadol or duloxetine second 2

Consider Alternative NSAIDs (Optional)

• While celecoxib failed, you could trial a different NSAID as they remain first-line pharmacologic therapy 1, 2
• However, given the failure of one NSAID, moving to duloxetine is more logical 2

Critical Considerations for Adolescents

Avoid Opioids

• Do not prescribe opioids for this adolescent – they should only be considered after failure of all other treatments and only if benefits clearly outweigh risks 2
• In adolescents, the risks of opioids are particularly concerning and should be avoided 4

Address Psychological Factors

• Implement cognitive-behavioral therapy or mindfulness-based stress reduction as part of the treatment plan, showing moderate-quality evidence for improvements in pain and function 2
• Assess for anxiety, depression, catastrophizing, and fear-avoidance behaviors, which commonly co-occur with chronic pain 4

Understanding the Disc Findings

The MRI Results Are Reassuring

• Small disc protrusions without stenosis are commonly seen in asymptomatic individuals and may not be the primary pain generator 3, 5
• The absence of central canal stenosis, lateral recess stenosis, or foraminal stenosis means there is no significant nerve compression requiring intervention 3
• Disc degeneration in a 16-year-old is concerning but the small, shallow protrusion without stenosis suggests conservative management is appropriate 6, 5

Most Disc Herniations Improve with Time

• Lumbar disc herniations typically improve over time with or without medical treatment 6
• This supports an aggressive conservative approach before considering any interventional procedures 6

Treatment Algorithm

1. Week 1-2: Initiate duloxetine and refer to supervised physical therapy with specific instructions for core stabilization exercises 2, 4

2. Week 2-4: Add spinal manipulation (2-3 sessions per week) combined with home exercise program and patient education about pain neurophysiology 3, 1

3. Week 4-6: Add complementary approaches based on patient preference (yoga, mindfulness, tai chi) 2

4. Week 6-12: If inadequate response, consider referral for multidisciplinary rehabilitation combining physical, psychological, and educational interventions 2

5. After 12 weeks: If still inadequate response, consider low-dose tricyclic antidepressant (amitriptyline 10-25mg at bedtime) 2

Interventional Procedures: Not Yet Indicated

• Epidural steroid injections are not recommended for non-radicular low back pain and should not be used in this case 3
• Radiofrequency procedures require failed conservative treatment and are premature at this stage 3
• The patient has not yet had adequate conservative treatment (failed only one NSAID and did not attend PT) 3, 2

Common Pitfalls to Avoid

• Do not repeat MRI imaging – it provides no clinical benefit in uncomplicated chronic low back pain and can lead to increased healthcare utilization 3
• Do not prescribe bed rest – it is contraindicated and worsens outcomes 2
• Do not use TENS units – they show no difference compared to sham TENS for pain intensity or function 2
• Avoid systemic corticosteroids – they have not shown greater efficacy than placebo 2

Setting Realistic Expectations

• Pain benefits from nonpharmacologic therapies are typically small to moderate (5-20 points on a 100-point scale) and generally short-term 2
• Effects on function are generally smaller than effects on pain 2
• The goal is to restore function and improve quality of life, not necessarily eliminate all pain 3
• Most patients with this presentation improve with conservative management over 6-12 weeks 1, 6