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While any management plan must be individualized, key elements of most conservative treatments for back pain include analgesia and education Analgesia can usually be provided with NSAIDs (see Table 5 3), but severe pain may require opioids (see Table 5 4) Rarely does the need for opioids extend beyond 1 2 weeks Diazepam, cyclobenzaprine, carisoprodol, and methocarbamol have prescribed as muscle relaxants, though their sedative effects may limit their use They should be reserved for patients who do not respond to NSAIDs and should also
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Table 20 7 AHRQ criteria for lumbar radiographs in patients with acute low back pain
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Possible fracture Major trauma Minor trauma in patients > 50 years Long-term corticosteroid use Osteoporosis > 70 years Possible tumor or infection > 50 years < 20 years History of cancer Constitutional symptoms Recent bacterial infection Injection drug use Immunosuppression Supine pain Nocturnal pain Agency for Healthcare Research and Quality, modified from Suarez-Almazor ME et al Use of lumbar radiographs for the early diagnosis of low back pain Proposed guidelines would increase utilization JAMA 1997 Jun 11;277(22): 1782 6
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If the history and physical examination do not suggest the presence of infection, cancer, inflammatory back disease, major neurologic deficits, or pain referred from abdominal or pelvic disease, further evaluation can be eliminated or deferred while conservative therapy is tried The great majority of patients will improve with conservative care over 1 4 weeks Regular radiographs of the lumbosacral spine give 20 times the radiation dose of a chest radiograph and provide limited, albeit important, information Oblique films double the radia-
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Preservation of pedal pulses helps exclude vascular claudication Diagnosis best confirmed by MRI
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be limited to courses of 1 2 weeks Their use should be avoided in older patients, who are at risk for falling All patients should be taught how to protect the back in daily activities ie, not to lift heavy objects, to use the legs rather than the back when lifting, to use a chair with arm rests, and to rise from bed by first rolling to one side and then using the arms to push to an upright position Back manipulation for benign, mechanical low back pain appears safe and as effective as therapies provided by physicians Rest and back exercises, once thought to be cornerstones of conservative therapy, are now known to be ineffective for acute back pain Advice to rest in bed is less effective than advice to remain active No bed rest with continuation of ordinary activities as tolerated is superior to 2 days of bed rest, 7 days of bedrest, and back mobilizing exercises Similarly, for acute back pain, exercise therapy is not effective The value of corsets or traction is dubious Epidural corticosteroid injections can provide short-term relief of sciatica but do not improve functional status or reduce the need for surgery In double-blind studies, repeated injections have been no more effective than a single injection For chronic low back pain, yoga is as effective as a back exercise program and more effective than a self-care book Corticosteroid injections into facet joints are ineffective for chronic low back pain Surgical consultation is needed urgently for any patient with a major or evolving neurologic deficit Surgery for disk disease is indicated when there is documentation of herniation by imaging, persistent pain, and a consistent neurologic deficit that has failed to respond to 4 6 weeks of conservative therapy Percutaneous lumbar discectomy, performed under local anesthesia, is a safe and effective (up to 75%) alternative to laminectomy The percutaneous procedure is contraindicated in the presence of tumor, infection, spondylolisthesis, foraminal stenosis, loose disk fragments, or severe facet joint arthritis Complaints without objective findings suggest a psychological role in symptom formation Treatment includes reassurance and nonopioid analgesics
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Weinstein JN et al Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial JAMA 2006 Nov 22;296(20): 2441-50 [PMID: 17119140] Weinstein JN et al Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort JAMA 2006 Nov 22;296 (20):2451 9 [PMID: 17119141]
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