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Back Pain, Mechanical: Treatment & Medication

Author: Debra G Perina, MD, Associate Professor, Director of Prehospital Care Division, Department of Emergency Medicine, University of Virginia Health Sciences Center
Contributor Information and Disclosures

Updated: Jul 16, 2009

Treatment

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.

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.¹⁴ 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.¹⁵
  • 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.¹⁶
• 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.^17,18
• 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.¹⁹

• 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.

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.

Medication

The goal of pharmacotherapy is to reduce pain and inflammation.

Nonsteroidal anti-inflammatory agents (NSAIDs)

NSAIDs are most commonly used to relieve mild to moderate pain. Although the effectiveness of NSAIDs tends to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

DOC to treat mild to moderate pain if no contraindications exist.
Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Ketoprofen (Oruvail, Orudis, Actron)

For relief of mild to moderate pain and inflammation.
Small dosages initially are indicated in patients who are small or elderly and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.

Naproxen (Anaprox, Naprelan, and Naprosyn)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Muscle relaxants

These agents reduce tonic somatic motor activity of the muscle.

Carisoprodol (Soma)

Short-acting medication that may have depressant effects at spinal cord level.
Skeletal muscle relaxants have modest short-term benefit as adjunctive therapy for nociceptive pain associated with muscle strains and, used intermittently, for diffuse and certain regional chronic pain syndromes. Long-term improvement over placebo has not been established.

Cyclobenzaprine (Flexeril)

Skeletal muscle relaxant that acts centrally and reduces motor activity of tonic somatic origins influencing both alpha and gamma motor neurons.
Structurally related to tricyclic antidepressants and thus carries some of the same liabilities.

Analgesics

Pain control is essential to ensure patient comfort, to promote pulmonary toilet, and to aid physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained injuries.

Acetaminophen (Tylenol, Panadol, Aspirin Free Anacin)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, in those with upper GI disease, or in those who are taking oral anticoagulants.

Acetaminophen and codeine (Tylenol #3)

A drug combination indicated for the treatment of mild to moderate pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

A drug combination indicated for the relief of moderate to severe pain.

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