Since many types of back pain resolve within 6 weeks without invasive measures, the first approach to treating lower back pain is often non-operative in nature. Relative rest may be recommended or, in some cases, total bed rest not to exceed 2 days. Various combinations of the following options may also be used:

• Anti-inflammatory medications: Acetaminophen and other non-steroidal anti-inflammatory drugs (NSAIDs) provide short-term benefit as analgesics and anti-inflammatories. A COX-2 selective NSAID may be recommended for patients with gastritis or ulcer history.
• Opioids: Opioids are more effective than naproxen or placebo, but they don’t improve psychological or functional status. Muscle relaxants (cyclobenzaprine for example) and opioids should be avoided by patients with chronic pain.
• Antidepressants: These drugs can provide partial relief. In clinical trials they have proved more effective than placebo, but side effects may be limiting. They are particularly useful if back pain is accompanied by a mood disorder.
• Exercise and physical therapy: Broadly speaking, these may include stretching, strengthening exercises and “back school" types of patient education. These interventions may be better than medical care alone, especially when they are medically supervised. Manipulative therapy is also somewhat effective.
• Massage therapy: Massage therapy decreases symptoms and improves function, especially when combined with exercise and education.
• Patient education: A back school program to teach neutral spine posture, proper body mechanics and proper positioning during basic movements can be helpful.
• Spinal injections: Corticosteroids and anesthetics can be injected into the epidural space and used as an adjuvant treatment to facilitate rehabilitation, but they are not recommended for short-term relief.
• Smoking cessation: Quitting smoking is highly recommended since smokers have a higher incidence of low back pain and disc herniations, and a higher incidence of persistent back pain after treatment.

The following measures have also been advocated, but there is no evidence that they have any real effect on lower back pain:

• Orthoses (braces and splints to restrict movement)
• Transcutaneous electrical nerve stimulation (TENS) electromyograph
• Traction
• Acupuncture
• Magnet therapy
• Injections into trigger points
• Hydrotherapy

When non-operative therapy fails, a patient’s next recourse may be minimally invasive treatment.