Nonspecific pain Patients with uncomplicated back pain should be encouraged to remain active and return to normal activities. The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible, to restore the individual's ability to function in everyday activities, to help the patient cope with residual pain, to assess for side-effects of therapy, and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain to a manageable level to progress with rehabilitation, which then can lead to long-term pain relief. Also, for some people the goal is to use non-surgical therapies to manage the pain and avoid major surgery, while for others surgery may be the quickest way to feel better. Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority of people with back pain (most estimates are 1–10%) require surgery. Non medical Back pain is generally treated with non-pharmacological therapy first, as it typically resolves without the use of medication. Superficial heat and massage, acupuncture, and spinal manipulation therapy may be recommended. * Heat therapy is useful for back spasms or other conditions. A review concluded that heat therapy can reduce<unk> s of acute and sub-acute low-back pain. * Regular activity and gentle stretching exercises is encouraged in uncomplicated back pain, and is associated with better long-term outcomes. Physical therapy to strengthen the muscles in the abdomen and around the spine may also be recommended. These exercises are associated with better patient satisfaction, although it has not been shown to provide functional improvement. However, one review found that exercise is effective for chronic back pain, but not for acute pain. If used, they should be performed under supervision of a licensed health professional. * Massage therapy may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower pack pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage. * Acupuncture may provide some relief for back pain. However, further research with stronger evidence needs to be done. * Spinal manipulation appears similar to other recommended treatments. * "Back school" is an intervention that consists of both education and physical exercises. There is no strong evidence supporting the use of Back School for treating acute, sub-acute, or chronic non-specific back pain. * Insoles appear to be an ineffective treatment intervention. * While traction for back pain is often used in combination with other approaches there appears to be little or no impact on pain intensity, functional status, global improvement and return to work. Medication If non-pharmacological measures are not effective, medications may be tried. * Non-steroidal anti-inflammatory drugs (NSAIDs) are typically tried first. NSAIDs have been shown to be more effective than placebo, and are usually more effective than paracetamol (acetaminophen). * Long-term use of opioids has not been tested in order to determine if it is effective or safe for treating chronic lower back pain. For severe back pain not relieved by NSAIDs or acetaminophen, opioids may be used. Opioids may not be better than NSAIDs or antidepressants for chronic back pain with regards to pain relief and gain of function. * Skeletal muscle relaxers may also be used. Their short term use has been shown to be effective in the relief of acute back pain. However, the evidence of this effect has been disputed, and these medications do have negative side-effects. * In people with nerve root pain and acute radiculopathy, there is evidence that a single dose of steroids, such as dexamethasone, may provide pain relief. * Epidural corticosteroid injection (ESI) is a procedure in which steroid medications are injected into the epidural space. The steroid medications reduce inflammation and thus decrease pain and improve function. ESI has long been used to both diagnose and treat back pain, although recent studies have shown a lack of efficacy in treating low back pain. Surgery Surgery for back pain is typically used as a last resort, when serious neurological deficit is evident. A 2009 systematic review of back surgery studies found that, for certain diagnoses, surgery is moderately better than other common treatments, but the benefits of surgery often decline in the long term. Surgery may sometimes be appropriate for people with severe myelopathy or cauda equina syndrome. Causes of neurological deficits can include spinal disc herniation, spinal stenosis, degenerative disc disease, tumor, infection, and spinal hematomas, all of which can impinge on the nerve roots around the spinal cord. There are multiple surgical options to treat back pain, and these options vary depending on the cause of the pain. When a herniated disc is compressing the nerve roots, hemi- or partial- laminectomy or discectomy may be performed, in which the material compressing on the nerve is removed. A mutli-level laminectomy can be done to widen the spinal canal in the case of spinal stenosis. A foraminotomy or foraminectomy may also be necessary, if the vertebrae are causing significant nerve root compression. A discectomy is performed when the intervertebral disc has herniated or torn. It involves removing the protruding disc, either a portion of it or all of it, that is placing pressure on the nerve root. Total disc replacement can also be performed, in which the source of the pain (the damaged disc) is removed and replaced, while maintaining spinal mobility. When an entire disc is removed (as in discectomy), or when the vertebrae are unstable, spinal fusion surgery may be performed. Spinal fusion is a procedure in which bone grafts and metal hardware is used to fix together two or more vertebrae, thus preventing the bones of the spinal column from compressing on the spinal cord or nerve roots. If infection, such as a spinal epidural abscess, is the source of the back pain, surgery may be indicated when a trial of antibiotics is ineffective. Surgical evacuation of spinal hematoma can also be attempted, if the blood products fail to break down on their own.
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