Chapter 016. Back and Neck Pain (Part 12)

Algorithms for management of acute low back pain, age ≥18 years. A. Symptoms
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Chapter 016. Back and Neck Pain (Part 12) Chapter 016. Back and Neck Pain (Part 12) Algorithms for management of acute low back pain, age ≥18 years. A.Symptoms Clinical trials have shown no benefit of >2 days of bed rest foruncomplicated ALBP. There is evidence that bed rest is also ineffective forpatients with sciatica or for acute back pain with signs of nerve root injury.Similarly, traction is not effective for ALBP. Possible advantages of earlyambulation for ALBP include maintenance of cardiovascular conditioning,improved disk and cartilage nutrition, improved bone and muscle strength, andincreased endorphin levels. One trial of early vigorous exercise was negative, butthe value of less vigorous exercise or other exercise programs are unknown. Earlyresumption of normal physical activity (without heavy manual labor) is likely tobe beneficial. Proof is lacking to support the treatment of acute back and neck pain withacupuncture, transcutaneous electrical nerve stimulation, massage, ultrasound,diathermy, magnets, or electrical stimulation. Cervical collars can be modestly helpful by limiting spontaneous and reflexneck movements that exacerbate pain. Evidence regarding the efficacy of ice islacking; heat may provide a short-term reduction in pain and disability. These interventions are optional given the lack of negative evidence, lowcost, and low risk. Biofeedback has not been studied rigorously. Facet joint,trigger point, and ligament injections are not recommended for acute treatment. A role for modification of posture has not been validated by rigorousclinical studies. As a practical matter, temporary suspension of activity known toincrease mechanical stress on the spine (heavy lifting, prolonged sitting, bendingor twisting, straining at stool) may be helpful. Education is an important part of treatment. Satisfaction and the likelihoodof follow-up increase when patients are educated about prognosis, treatmentmethods, activity modifications, and strategies to prevent future exacerbations. Inone study, patients who felt they did not receive an adequate explanation for theirsymptoms wanted further diagnostic tests. Evidence for the efficacy of structured education programs (back school)is inconclusive; there is modest evidence for a short-term benefit, but evidence fora long-term benefit is lacking. Randomized studies of back school for primaryprevention of low back injury and pain have failed to demonstrate any benefit. NSAIDs and acetaminophen (see Table 12-1) are effective over-the-counteragents for ALBP. Muscle relaxants (cyclobenzaprine, 10 mg PO qhs as initialdose, up to 10 mg PO tid) provide short-term (4–7 days) benefit, particularly atnight if sleep is affected, but drowsiness limits daytime use. Opioid analgesics are no more effective than NSAIDs or acetaminophen forinitial treatment of ALBP, nor do they increase the likelihood of return to work.Short-term use of opioids may be necessary in patients unresponsive to orintolerant of acetaminophen or NSAIDs. There is no evidence to support the use oforal glucocorticoids or tricyclic antidepressants for ALBP. Epidural glucocorticoids may occasionally produce short-term pain relief inALBP with radiculopathy, but proof is lacking for pain relief beyond 1 month.Epidural glucocorticoids, anesthetics, or opioids are not indicated in the initialtreatment of ALBP without radiculopathy. Diagnostic nerve root blocks have been advocated to determine if painoriginates from a specific nerve root. However, improvement may result evenwhen the nerve root is not responsible for the pain; this may occur as a placeboeffect, from a pain-generating lesion located distally along the peripheral nerve, orfrom anesthesia of the sinuvertebral nerve. Therapeutic nerve root blocks with injection of glucocorticoids and a localanesthetic should be considered only after conservative measures fail, particularlywhen temporary relief of pain is necessary. A short course of lumbar spinal manipulation or physical therapy (PT) forsymptomatic relief of uncomplicated ALBP is a reasonable option. Prospective,randomized studies are difficult to perform in part because there is no consensusabout what constitutes an adequate placebo control. Specific PT or chiropracticprotocols that may provide benefit have not been fully defined.