Nonsurgical Management
Nonsurgical management of axial low back pain is initially a brief period of rest and avoidance of pain-provoking activities. In an interesting study from Berlin, 24 medically and psychologically healthy males were placed on strict bed rest for 60 days with 61 of head tilt down (i.e., Trendelenburg position). Baseline MRIs found degenerative changes in the lumbar spine. After 60 days of bed rest, there was some radiographic recovery of disc height and hydration. However, after 2 years of follow-up, these findings were not sustained and did not continue to reconstitute to radiographically normal parameters.
Since low back pain stems from multiple etiologies, there are multiple modalities for coping. Medications including nonsteroidal antiinflammatory medications, acetaminophen, narcotics, muscle relaxants, and antidepressants are all commonly used. Exercise programs, aerobic conditioning, and yoga are widely accepted forms of core strengthening. Acupuncture and spinal manipulation therapy (SMT) also are part of the spectrum of nonsurgical treatment modalities. A recent update of the Cochrane Review found SMT to be no more effective for acute low back pain than inert interventions, sham SMT, or as adjunct therapy.
Unfortunately, axial low back pain can become a chronic issue. Focal and epidural injections also have been described with variable effectiveness for those patients who have failed noninvasive modalities. Injections are minimally invasive, but in general they are not intended as definitive treatment for the problem. For chronic axial back pain, surgery is the last alternative for treatment.