Mechanical Back Pain Guidelines

Updated: Jan 24, 2017
  • Author: Debra G Perina, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Guidelines

Guidelines Summary

A summary of recommendations from the American College of Radiology (ACR) include the following [5] :

  • Uncomplicated acute low back pain and/or radiculopathy are benign, self-limited conditions that do not warrant any imaging studies.
  • MRI of the lumbar spine should be considered for those patients presenting with red flags raising suspicion for a serious underlying condition, such as cauda equina syndrome, malignancy, or infection.
  • In patients with a history of low-velocity trauma, osteoporosis, or chronic steroid use, initial evaluation with radiographs is recommended.
  • In the absence of red flags, first-line treatment for chronic low back pain remains conservative therapy with both pharmacologic and nonpharmacologic (eg, exercise, remaining active) therapy.
  • If there are persistent or progressive symptoms during or following 6 weeks of conservative management and the patient is a surgery or intervention candidate or diagnostic uncertainty remains, MRI of the lumbar spine has become the initial imaging modality of choice in evaluating complicated low back pain.
  • MRI is the imaging procedure of choice in patients suspected of cord compression or spinal cord injury.
  • Patients with recurrent low back pain and history of prior surgical intervention should be evaluated with contrast-enhanced MRI.

Practice guidelines for nonradicular pain include the following [34] :

  • 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 include the following [34] :

  • 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.