Nonsurgical options for back pain

Why a spine surgeon talks about nonsurgical care

It may seem odd for a surgeon to write about avoiding surgery. But part of good spine care is knowing who does not need an operation. Many people who see a spine surgeon leave with a plan that involves no surgery at all. Those who do need surgery often do better if they are stronger and more active going in.

Doctors tend to use these options in roughly the order listed. Not every option fits every person, and some work better for certain kinds of pain.

Stay active, within reason

For a new episode of back pain, staying active is one of the most helpful things you can do. Bed rest for more than a day or two tends to slow recovery. Gentle walking, normal daily tasks and changing positions often help the back loosen up. You may need to cut back on heavy lifting or long drives for a while, but try to keep moving.

Heat can ease muscle spasm in the first weeks. Some people prefer ice. Either is fine if it helps.

Physical therapy and exercise

For pain that lasts more than a few weeks, a structured exercise program is one of the best-supported treatments. A physical therapist can teach you exercises for core strength, hip strength and flexibility, and safer ways to lift, bend and sit. The goal is to make the spine better supported and less sensitive over time.

Guidelines from the American College of Physicians also list tai chi, yoga and motor control exercise as reasonable options for long-lasting back pain. The exercise that helps most is often the one you will keep doing. Results usually build over six to twelve weeks, not days.

Medicines

• Anti-inflammatory medicines such as ibuprofen or naproxen are often the first choice for short-term pain. They can upset the stomach and affect the kidneys and blood pressure, so check with your doctor if you have those conditions or take blood thinners.
• Acetaminophen is gentler on the stomach, though studies suggest it does less for back pain than many people expect.
• Muscle relaxants may help for a short time with spasms, but they can cause drowsiness.
• Nerve pain medicines, such as gabapentin or duloxetine, are sometimes used for leg pain from a pinched nerve or for long-lasting pain.
• Opioids have a limited role in back pain. They carry real risks and are generally used only for short periods, if at all.

Hands-on and other therapies

Massage, spinal manipulation (such as chiropractic care), acupuncture and heat have modest evidence for short-term relief. They tend to work better as part of a plan that also includes exercise. Mindfulness-based stress reduction and cognitive behavioral therapy can also help people with long-lasting pain. This is not because the pain is "in your head," but because stress, sleep and mood change how strongly the nervous system signals pain.

Spinal injections

Injections are often done by a pain management or physical medicine doctor, using X-ray guidance to place the needle. The main types are:

• Epidural steroid injections, which place anti-inflammatory medicine near an irritated nerve root. They are used mostly for leg pain from a herniated disc or spinal stenosis. Relief can last weeks to months and may give a window to make progress in therapy. They tend to help leg pain more than back pain.
• Facet joint injections or medial branch blocks, which target the small joints at the back of the spine. If a block helps, a procedure called radiofrequency ablation can quiet the small nerves to those joints for a longer period.
• Sacroiliac joint injections, for pain that comes from the joint where the spine meets the pelvis.

Injections do not fix the underlying structure, and doctors usually limit how many steroid injections you receive in a year.

Everyday habits that help the back

• Quit smoking. Nicotine reduces blood flow to the discs and is linked to more back pain and slower healing.
• Work toward a healthy weight. Less load on the spine can mean less pain, especially with arthritis and stenosis.
• Sleep well. Poor sleep makes pain feel worse.
• Set up your work. For long drives, desk jobs or farm and warehouse work, small changes to seating, lifting and breaks can reduce strain.

Do you need an MRI first?

For most new back pain without warning signs, imaging in the first several weeks does not change treatment. Many MRI findings, such as disc bulges and worn discs, are common in people without pain. An MRI becomes more useful when pain lasts, when there is weakness or numbness, or when an injection or surgery is being considered. Our guide to MRI report terms explains the common findings.

When nonsurgical care is not enough

Surgery may be worth discussing when:

• Leg pain from a pinched nerve stays severe after six to twelve weeks of good nonsurgical care
• There is weakness in a leg or foot, or it is getting worse
• Walking distance keeps shrinking because of leg pain or heaviness from stenosis
• A spinal curve or slip is getting worse, or it is causing you to lean and tire quickly

Even then, surgery is a choice, not a requirement, in most cases. When it does make sense, smaller operations such as endoscopic spine surgery may be an option for some people with a herniated disc or narrowing. Our article on minimally invasive spine surgery explains the approaches.

Common questions

Sources

• Qaseem A, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017.
• Low Back Pain, National Institute of Neurological Disorders and Stroke (NIH)
• Low Back Pain, AAOS OrthoInfo
• Back Pain, MedlinePlus (NIH)