Mechanical Back Pain Treatment & Management

  • Author: Debra G Perina, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Nov 3, 2011
 

Prehospital Care

If the patient's back pain is from a traumatic injury, full spinal precautions using a long backboard for spinal immobilization should be used.

If no history of trauma is present, spinal precautions is not necessary, as the patient may experience significant exacerbation of pain by lying on a rigid board. If the patient is brought into the emergency department on a rigid board, they should be removed from the board at the first opportunity.

If a rigid board is necessary, the patient may be made more comfortable by supporting the lower extremities with a pillow or blanket.

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Emergency Department Care

If new neurologic deficits are noted accompanied by bowel or bladder dysfunction one should suspect cauda equina syndrome. This is a true emergency, and emergency imaging is mandated. MRI is the preferred imaging modality in this situation. If cauda equina syndrome is strongly suspected, the practitioner should consider giving dexamethasone without delay to prevent further loss of neurologic function while pursuing confirmatory testing.

Conservative therapy is the mainstay of treatment, as even those with true sciatica generally respond.[17] Ultimately, only 2% of patients with sciatica and 4-6% of patients with true disc herniation require surgery. Conservative therapy traditionally includes the following:

  • Bed rest, once the cornerstone of treatment, is no longer widely recommended.
    • A growing body of evidence suggests that even brief bed rest is not necessary except in patients with true sciatica. In this case, the supine position decreases pressure on the spinal cord itself, and is useful for the first 2-3 days.
    • Early mobilization with gentle range of motion and strengthening exercises are recommended for patients with nonsciatic back pain.[18]
    • Early return to work on light duty or restricted activity lead to better long-term outcomes.
  • Pharmacologic therapy involves both anti-inflammatory medication and muscle relaxants.
    • Narcotics may be used initially to gain relief, but their long-term use is associated with increased functional impairment.
    • Steroids, while highly recommended by some practitioners, lack prospective confirmation of their value. Some physicians may prescribe a single burst or short course of oral steroids, which can be beneficial, particularly in those with a significant degree of inflammation.
    • Epidural steroid injection may also bring significant short-term relief, but this treatment is not without adverse effects and has not been shown to provide lasting benefit.[19]
  • Unless the patient is allergic to the medicine or it is otherwise contraindicated, severe low back pain can be improved significantly with a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants.
  • Use of hot or cold compresses has never been proven scientifically to speed symptom resolution, but some patients may experience brief relief.
  • Gentle flexion/extension exercises are helpful.[20, 21]
  • Spinal traction is ineffective.

Evidence-based clinical practice guidelines from the American Pain Society (APS) for patients with chronic low back pain describe the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation.[22]

  • Practice guidelines for nonradicular pain
    • Interdisciplinary rehabilitation emphasizing cognitive-behavioral approaches should be considered for patients who do not respond to usual interventions.
    • Provocative discography (injecting material into a disc nucleus in an attempt to reproduce the patient's typical pain) is not recommended.
    • Facet joint corticosteroid injection, prolotherapy (repeated injections of irritant material to stimulate an inflammatory response), and intradiscal corticosteroid injection are not recommended.
    • Persistent disabling symptoms and degenerative spinal changes should prompt discussion and shared decision-making regarding surgery or interdisciplinary rehabilitation (evidence is insufficient to weigh the risks and benefits of vertebral disc replacement in these patients).
  • Practice guidelines for persistent radiculopathy
    • For patients with herniated discs, the use of epidural steroid injection should be discussed.
    • For patients with herniated discs and disabling leg pain from spinal stenosis, surgical options should be discussed.
    • For patients with persistent pain after surgery, the risks and benefits of spinal cord stimulation should be discussed.
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Consultations

  • ED consultation with a specialist is necessary for patients who present with acute cauda equina syndrome, demonstrate intractable pain, have evidence of a serious etiology (eg, epidural abscess, tumor), or where a social situation makes hospitalization necessary.
  • Whether orthopedic or neurosurgical consultation is chosen depends on local custom and resources.
  • Other medical consultation may be needed if the cause of back pain is not mechanical.
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Contributor Information and Disclosures
Author

Debra G Perina, MD  Associate Professor, Director of Prehospital Care Division, Department of Emergency Medicine, University of Virginia Health Sciences Center

Debra G Perina, MD is a member of the following medical societies: Air Medical Physician Association, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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