Spinal revival: The management of lower back pain

Spinal revival: The management of lower back pain


Lower back pain is a common complaint in the Western world, and pharmacological treatment should follow a systemic approach. Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) are always used for immediate relief, while the use of opioids, including tramadol, should be reserved for the management of chronic pain. Education in the management of the side-effects, and using proton pump inhibitors or other digestive protectants could enhance patient compliance. The use of mechanical intervention by physiotherapists, and education on correct ergonomics, such as posture whilst sitting and picking up heavy objects, could lessen the frequency of complaints.

Lower back pain

Non-specific lower back pain is defined as pain with no known aetiology (such as a visible or known trauma, tumor, or bruising), with complaints increasing in the Western world. While the reporting of lower back pain has not decreased dramatically, the cost of treatment has been steadily increasing. Acute lower back pain can be caused by several factors, inclusive of activities related to lifestyle, career, and sports. Generally, patients who have active jobs with high degrees of mechanical movement (such as laborer's, builders, and craftsmen) suffer from a greater frequency of lower back pain than those with more sedentary jobs (such as typists and office workers). However, studies suggest that more sedentary jobs, coupled with improper posture and seating, may also be a risk factor.

Pharmacological management of lower back pain

The World Health Organization (WHO) has classified pain management in several steps with increasing pharmacological intervention, known as the “pain ladder” or “pain pyramid”. This has dictated the use of several classes of medication and the rate at which dosages are increased or adjuvant therapies added. Pharmacological intervention for both acute and chronic lower back pain is typically the first-line treatment offered by most healthcare workers. These interventions normally include paracetamol (also known as acetaminophen), nonsteroidal anti-inflammatory drugs (NSAIDs), a weak opioid, and sometimes muscle relaxants as well. Many of these products are generally accessible as over-the-counter (OTC) medicines in the South African market. These products can be used to achieve goals associated with pain management, namely pain intensity reduction, enhancement of quality of life, lessened side-effects and shortened time to recovery.

Nonsteroidal anti-inflammatories

NSAIDs can be useful in the management of pain and the associated inflammation by inhibiting the enzymes cyclooxygenase-1 and -2 (COX-1 and COX-2) that produce pro-inflammatory and pyretic prostaglandins, thromboxane's and prostacyclin's. Pain management with analgesics and NSAIDs can be risky as many side-effects associated with these medicines could hamper a favorable outcome for the patient. Common side-effects associated with NSAIDs include nausea, gastrointestinal (GI) disturbances and risk of GI bleeding due to COX-1 inhibition, which disturbs GI mucosal lining production, as NSAIDs inhibit COX non-specifically. Paracetamol, a weak prostaglandin synthetase inhibitor, will normally be used in conjunction with NSAIDs such as ibuprofen, diclofenac, naproxen and mefenamic acid. Paracetamol is well tolerated with few side effects, as long as the dose is lower than 4 g per day. The COX-2-specific NSAIDs, such as etoricoxib (Arcoxia®, Extrib®), celecoxib (Celebrex®) and meloxicam (Coxflam®), are preferred as both are once-a-day formulations for short-term therapeutic use. These will, in turn, increase patient adherence to pharmacological intervention and provide a more tolerable side-effect profile compared to traditional three-times-a-day NSAID treatment. Additionally, this eliminates the need for concurrent meals during administration, which is beneficial for patients who observe religious fasting or patients who struggle with blood glucose.

Muscle relaxants

If the pain persists after the use of both NSAIDs and paracetamol/codeine, then skeletal muscle relaxants can be added to the regimen. Relaxants like orphenadrine (Norflex®, Besemax®) are used in combination with paracetamol, and are effective in the treatment of low back pain. Side-effects include dry mouth, drowsiness and constipation, and these side-effects are due to the blockade of acetylcholine receptors which help in the blockade of voltage-gated sodium channels. Diazepam (Pax®, Betapam®) can also be used in low doses as muscle relaxants, but these have a greater frequency of sedative effects that could reduce patient compliance. Diazepam works via the mimicry of gamma aminobutyric acid effects within the central nervous system, which causes an inhibitory effect.


While there are many avenues for pharmacological and non-pharmacological management of lower back pain, polypharmacy could lead to side-effect profiles that could make a patient lose adherence to the regimen. A systematic approach, working through possible aetiology, could be beneficial in pharmacological treatment. Single-line pharmacological intervention will increase patient compliance and adherence and ultimately lead to positive outcomes. Patient education in correct posture and daily movements could lessen the frequency of the incidence of lower back pain and thus improve quality of life.

Please note that we are not a medical practitioner and recommend you seek guidance from your medical doctor.

Kind Regards,

The SpineAlign Team