What is the best course of treatment for a patient with unilateral back pain and stiffness throughout the entire back?

Treatment of Unilateral Back Pain with Diffuse Stiffness

Start with NSAIDs and advise the patient to remain active—this combination provides the most effective initial management for nonspecific low back pain with stiffness. 1, 2

Initial Assessment and Red Flags

Before initiating treatment, quickly assess for serious underlying conditions that would change management:

• Rule out cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction, bilateral leg weakness) requiring immediate intervention 3, 4
• Check for progressive neurological deficits (worsening weakness, numbness) that warrant urgent imaging 1
• Screen for infection or malignancy (fever, unexplained weight loss, history of cancer, immunosuppression, IV drug use) 1, 5
• Assess for fracture risk (significant trauma, osteoporosis, prolonged corticosteroid use) 1, 6

If no red flags are present, imaging is not indicated and will not improve outcomes. 1

First-Line Treatment (Start Immediately)

Pharmacologic Management

NSAIDs are the preferred first-line medication, providing small to moderate pain relief superior to acetaminophen: 1, 2

• Prescribe at the lowest effective dose for the shortest duration 2
• Assess cardiovascular and gastrointestinal risk factors before prescribing 3, 2
• No specific NSAID is superior to another—choose based on cost and availability 2

Acetaminophen is an acceptable alternative for patients with NSAID contraindications, though it shows no significant difference from placebo in acute low back pain: 2

• Maximum 4g/day with monitoring for hepatotoxicity in elderly or those with liver disease 3, 2

Non-Pharmacologic Essentials

Advise the patient to remain active and avoid bed rest—this is critical as activity restriction prolongs recovery: 1, 3, 4, 2

• Even if brief bed rest is needed for severe symptoms, return to normal activities as soon as possible 3, 4
• Provide evidence-based self-care education materials 3, 4

Apply superficial heat using heating pads or heated blankets for short-term symptomatic relief: 3, 4, 2

Second-Line Treatment (If No Improvement After 1-2 Weeks)

Additional Pharmacologic Options

Consider skeletal muscle relaxants (cyclobenzaprine, tizanidine, or metaxalone) for short-term relief when muscle spasm contributes to pain: 1, 3, 2

• All cause sedation as a central nervous system adverse effect 2
• Prescribe time-limited courses only 2

Non-Pharmacologic Therapies

Spinal manipulation by appropriately trained providers shows small to moderate short-term benefits for acute pain: 1, 3, 4

For chronic or subacute pain (>4 weeks), expand options to include: 1

• Exercise therapy with individual tailoring, supervision, stretching, and strengthening 1, 3, 4
• Acupuncture 1, 3, 4
• Massage therapy 1, 3, 4
• Cognitive-behavioral therapy 1, 3, 4
• Intensive interdisciplinary rehabilitation 1, 3, 4

When to Consider Advanced Evaluation

Obtain MRI only if the patient is a potential candidate for surgery or epidural steroid injection and symptoms persist beyond 4-6 weeks: 1, 3

• MRI is preferred over CT for superior soft-tissue contrast without radiation 4
• Imaging without red flags does not improve outcomes and may lead to unnecessary interventions 3

Critical Pitfalls to Avoid

Never prescribe prolonged bed rest—it causes deconditioning and worsens outcomes: 3, 2

Do not use systemic corticosteroids—they are not more effective than placebo for low back pain with or without sciatica: 3, 2

Reserve opioids only for severe, disabling pain uncontrolled by NSAIDs, given substantial risks of abuse and addiction: 2

Extended medication courses should only continue if the patient shows clear ongoing benefits without major adverse events: 1, 3

Most patients improve within 4-6 weeks regardless of treatment, though up to one-third may have persistent moderate pain at one year: 1, 5