Back Pain: Causes, Symptoms, and Management (Simple Breakdown)
For acute back pain (less than 4 weeks), start with heat/ice, stay active, and use NSAIDs or muscle relaxants if needed; for chronic back pain (more than 12 weeks), prioritize exercise and physical therapy before considering medications. 1
Common Causes (What's Actually Wrong)
Mechanical low back pain means something in your spine, discs, or muscles is irritated—not from cancer, infection, or nerve damage 2. Think of it like:
- Muscle strain from lifting, twisting, or poor posture
- Disc problems where the cushions between your spine bones wear out or bulge
- Joint wear and tear from aging (degenerative changes)
- Ligament sprains from sudden movements
Most back pain (over 90%) is this "mechanical" type—annoying but not dangerous 2.
Red Flags (When to Worry)
You need urgent evaluation if you have:
- Loss of bladder/bowel control (new inability to pee or poop normally)
- Leg weakness that's getting worse
- History of cancer
- Recent spine surgery or injection
- Major trauma (car accident, bad fall—relative to your age)
- Fever with back pain (possible infection)
These suggest something serious like cauda equina syndrome, cancer, fracture, or infection 2. Otherwise, imaging (X-rays, MRIs) on your first visit is usually unnecessary and wastes money 2.
Symptoms (What You'll Feel)
Mechanical back pain:
- Pain in your lower back that worsens with movement or certain positions
- May radiate to buttocks or thighs (but not sharp shooting pain down the leg)
- Stiffness, especially in the morning
- Pain improves with rest (usually)
- No numbness, tingling, or weakness in legs 2, 3
If you have sciatica (nerve involvement):
- Sharp, shooting pain down one leg
- Numbness or tingling in leg/foot
- Weakness in leg muscles 2
Management Algorithm
Acute Back Pain (Less than 4 Weeks)
First-line (start here):
If you need medication:
- NSAIDs (ibuprofen, naproxen) are first choice 1, 4
- Muscle relaxants as alternative 1
- Avoid acetaminophen—weak evidence it helps 2
Other options with evidence:
Chronic Back Pain (More than 12 Weeks)
First-line (non-drug treatments are superior):
- Exercise programs—this is the foundation 1
- Physical therapy (especially McKenzie method) 2
- Yoga (strong evidence for long-term benefit) 2
- Tai chi 1
- Cognitive behavioral therapy (addresses pain psychology) 1
- Acupuncture 1
If non-drug treatments fail:
- NSAIDs first 1
- Tramadol or duloxetine second 1
- Opioids only as last resort after discussing risks—they're overprescribed and dangerous 1
Canadian ED Context
In Canadian emergency departments, the typical approach for non-urgent back pain includes 4:
- Most patients (93%) present with acute pain
- Pain assessment at triage (moderate intensity most common)
- Imaging used in only 30% of cases
- Medications given to 59%: ibuprofen (28%), hydromorphone (25%), acetaminophen (22%)
- Referral back to family doctor in 41% of cases
Common pitfall: Canadian EDs often use opioids (hydromorphone) too frequently 4, when guidelines recommend NSAIDs first 1.
What Doesn't Work (Save Your Money)
- Acetaminophen—little to no evidence for chronic back pain 2
- Most antidepressants (except duloxetine) 2
- TENS units (transcutaneous electrical nerve stimulation) 2
- Lidocaine patches 2
- Bed rest—actually delays recovery 1
Key Takeaways for OSCE
- Rule out red flags first—ask about bladder/bowel function, leg weakness, cancer history, trauma
- Most back pain is mechanical and self-limited—reassure patients
- Movement is medicine—staying active beats rest
- Medications are adjuncts, not solutions—NSAIDs for short-term relief only
- Chronic pain needs exercise and PT first—not pills 1
- Patient education matters—explain good prognosis, avoid catastrophizing 2
The evidence strongly favors a conservative, active approach over aggressive medication or imaging for most mechanical low back pain 1, 2.