What are the possible causes and treatments for sharp left lateral mid back pain?

Sharp Left Lateral Mid Back Pain: Causes and Treatment

For sharp left lateral mid back pain, begin with acetaminophen or NSAIDs combined with advice to remain active, while screening for red flags that would require urgent imaging. 1

Initial Diagnostic Approach

Red Flag Assessment

Immediately evaluate for serious conditions requiring urgent intervention:

• Cauda equina syndrome: urinary retention, fecal incontinence, saddle anesthesia, motor deficits at multiple levels 2, 3
• Malignancy: history of cancer (increases probability from 0.7% to 9%), unexplained weight loss, age >50 years, failure to improve after 1 month 2, 3
• Spinal infection: fever, recent infection, IV drug use, immunocompromised status 2, 3
• Vertebral fracture: older age, osteoporosis history, steroid use 2
• Progressive neurologic deficits: rapidly worsening motor or sensory loss 1

Pain Characterization

Document specific features to guide management:

• Location and radiation: determine if pain is purely axial (midline) or has radicular features extending into the leg 2
• Duration: acute (<4 weeks), subacute (4-8 weeks), or chronic (≥3 months) 1
• Neurological symptoms: assess knee/ankle reflexes, foot dorsiflexion strength, sensory distribution if radicular symptoms present 2

Psychosocial Factors

These predict outcomes more strongly than physical findings:

• Screen for depression, job dissatisfaction, passive coping strategies, disputed compensation claims 2
• These factors are stronger predictors of disability than pain severity or duration 2

Imaging Decisions

Do not routinely obtain imaging for nonspecific back pain without red flags. 1

When to Image Immediately

• Red flags present: obtain urgent MRI with and without contrast for suspected infection or malignancy 3
• Cauda equina syndrome suspected: immediate MRI required 3
• Severe or progressive neurologic deficits: prompt MRI or CT 1

When to Delay Imaging

• Nonspecific pain without red flags: avoid imaging initially, as it does not improve outcomes and incidental findings are common 1, 2
• Persistent radicular symptoms: consider MRI only after 4 weeks if patient is a candidate for surgery or epidural injection 1

Treatment Algorithm

First-Line: Pharmacologic + Activity

Start with NSAIDs or acetaminophen combined with education to remain active. 1

• NSAIDs: first-line medication with moderate evidence for short-term benefit 1, 4
• Acetaminophen: alternative first-line option 1
• Avoid bed rest: advise patients to remain active, which is more effective than rest 1, 5
• Educate on prognosis: inform patients of the generally favorable natural history, with high likelihood of substantial improvement within the first month 1

Important caveat: Extended medication courses should be reserved only for patients showing continued benefits without major adverse events. 1

Second-Line: Nonpharmacologic Therapies

For acute pain (<4 weeks):

• Spinal manipulation: small to moderate short-term benefits 1
• Avoid exercise therapy: not effective in acute phase 1

For subacute (4-8 weeks) or chronic pain (≥3 months): Multiple options with moderate evidence:

• Exercise therapy: individualized programs with supervision, stretching, and strengthening show best outcomes 1
• Acupuncture: moderately effective for chronic pain 1
• Massage therapy: moderate evidence for chronic pain 1
• Yoga: moderate evidence for chronic pain 1
• Cognitive-behavioral therapy: moderate evidence 1
• Intensive interdisciplinary rehabilitation: includes coordinated physician, psychological, physical therapy, and vocational interventions 1

What NOT to Do

The 2025 BMJ guideline strongly recommends AGAINST these interventions for chronic spine pain:

• Joint radiofrequency ablation 1
• Epidural injections of local anesthetic or steroids 1
• Joint-targeted injections 1
• Intramuscular injections 1
• Dorsal root ganglion radiofrequency 1

This represents a significant shift from older practices, as these interventional procedures increased 271% between 1994-2001 despite uncertain supporting evidence. 1

Also avoid:

• Opioids as first-line: reserve as second-line only, with limited evidence for chronic pain and significant risks 1, 4
• Prolonged bed rest: worsens disability 5, 6
• Routine imaging without red flags: does not improve outcomes 1, 2

Common Pitfalls

• Delaying imaging when red flags are present: immediate MRI is indicated, not the usual 4-6 week wait recommended for nonspecific pain 3
• Overuse of interventional procedures: despite rapid growth in use, strong evidence now recommends against epidural injections and radiofrequency ablation for chronic pain 1
• Ignoring psychosocial factors: these predict outcomes more strongly than physical findings and must be addressed 2
• Prescribing extended opioid courses: modest efficacy with high attrition rates due to side effects; prescription opioid overdoses quadrupled between 1999-2015 1