What is the recommended approach for evaluating and managing back pain?

Evaluation and Management of Back Pain

Begin with a focused history and physical examination to categorize patients into nonspecific low back pain, back pain with radiculopathy/spinal stenosis, or back pain with a specific spinal cause—this triage determines all subsequent management decisions. 1

Initial Clinical Assessment

History Components

• Inquire about pain location, frequency, duration, and intensity using a 0-10 numerical rating scale 1, 2
• Screen for red flags requiring immediate imaging: cauda equina syndrome symptoms (urinary retention, saddle anesthesia), history of cancer, unexplained weight loss, fever, significant trauma, age >50 with new onset pain, prolonged corticosteroid use, or osteoporosis 2, 3
• Assess for radiculopathy symptoms: leg pain radiating below the knee, numbness, tingling, or weakness 4
• Evaluate yellow flags (psychosocial risk factors): depression, passive coping strategies, job dissatisfaction, somatization, disputed compensation claims—these predict outcomes more strongly than physical findings 2, 1

Physical Examination

• Perform neurological examination including straight leg raise test for radiculopathy 3
• Assess for severe or progressive neurologic deficits that require urgent imaging 2, 1
• Evaluate spinal alignment, range of motion, and palpable muscle spasm 5

Diagnostic Imaging Strategy

When NOT to Image

Do not order routine imaging for nonspecific low back pain—this exposes patients to unnecessary radiation and leads to unnecessary interventions without improving outcomes. 2, 1

• Plain radiography and advanced imaging (MRI/CT) are not associated with improved patient outcomes in nonspecific low back pain 2
• Radiographic abnormalities correlate poorly with symptoms and may lead to harmful interventions 2

When to Image Immediately

• Severe or progressive neurologic deficits present 2, 3
• Suspected cauda equina syndrome 2, 3
• Suspected vertebral infection or cancer with impending spinal cord compression 2
• Use MRI as first choice (preferred over CT) for better soft tissue visualization without ionizing radiation 2, 3

Delayed Imaging Considerations

• Plain radiography for suspected vertebral compression fracture in high-risk patients (osteoporosis, steroid use, age >50) 2, 3
• Consider imaging after 4-6 weeks if symptoms persist despite conservative therapy and no red flags are present 2, 1
• For persistent symptoms with radiculopathy or spinal stenosis, obtain MRI only if patient is a potential surgical candidate 2

Management Approach for Nonspecific Low Back Pain

Patient Education and Activity

• Provide reassurance about favorable prognosis—90% of episodes resolve within 6 weeks regardless of treatment 1, 6
• Advise patients to stay active and continue ordinary activities within pain limits—avoid bed rest as it leads to deconditioning and worse outcomes 2, 1, 3
• Apply heat using heating pads for short-term symptom relief 1, 3

First-Line Pharmacological Management

• Start with acetaminophen or NSAIDs as first-line medications 2, 1, 3
• Acetaminophen has a more favorable safety profile but provides slightly less pain relief than NSAIDs 3, 7
• NSAIDs are more effective for pain relief but carry gastrointestinal and cardiovascular risks—use lowest effective dose for shortest duration 3, 7
• COX-2 inhibitors have not been shown more effective than traditional NSAIDs for acute low back pain 6

Muscle Relaxants

• Consider cyclobenzaprine, tizanidine, or metaxalone for short-term use when muscle spasm contributes to pain 7, 5
• Cyclobenzaprine produces clinical improvement whether or not sedation occurs 5
• Muscle relaxants have fair evidence for acute low back pain but should be prescribed for fixed periods 6, 8

Opioid Analgesics

• Reserve opioids or tramadol only for severe, disabling pain not controlled with acetaminophen and NSAIDs 3, 7
• Prescribe for fixed periods due to substantial risks of adverse effects and potential for dependence 7
• Avoid overreliance on opioids for chronic pain management—this is a common pitfall 1, 3

Non-Pharmacological Therapies

For Acute/Subacute Pain

• McKenzie exercises are helpful for pain radiating below the knee 6
• Ice application for painful areas and stretching exercises 6
• Spinal manipulation may provide small to moderate short-term benefits 3, 7

For Chronic Pain (>6 weeks)

• Refer to adjunct conservative management if no improvement after 6 weeks: exercise therapy, cognitive behavioral therapy, or pain management programs 2, 1, 3
• Exercise therapy is moderately effective for chronic low back pain—programs with individual tailoring, supervision, stretching, and strengthening show best outcomes 7
• Massage therapy has moderate effectiveness for chronic low back pain 7
• Acupuncture can be considered for chronic low back pain 7
• Intensive interdisciplinary rehabilitation, yoga, or progressive relaxation may be beneficial 3

Management of Radiculopathy and Spinal Stenosis

Conservative Management

• Same activity advice and first-line medications as nonspecific low back pain 1, 3
• Gabapentin may provide small, short-term benefits in radiculopathy 7

Interventional Procedures

• Evidence is conflicting on epidural steroid injections—they may provide small, short-term symptomatic improvement for radiculopathy 2, 8
• The 2025 BMJ guideline strongly recommends against epidural injections for chronic axial spine pain, while ASIPP supports fluoroscopically guided epidural injections 7
• Radiofrequency ablation recommendations are contradictory between guidelines 7

Surgical Referral

• Consider surgery only for persistent symptoms with radiculopathy or spinal stenosis after failed conservative management 7
• Most patients with chronic low back pain will not benefit from surgery 4

Follow-Up Strategy

• Reevaluate patients with persistent, unimproved symptoms after 1 month 2, 1, 3
• Consider earlier reassessment (1-2 weeks) for severe pain, functional deficits, older patients, or signs of radiculopathy/spinal stenosis 2, 1
• Minor flare-ups may occur in the subsequent year after initial resolution 6

Common Pitfalls to Avoid

• Ordering unnecessary imaging for nonspecific back pain without red flags 2, 1, 3
• Providing inappropriate advice regarding rest—bed rest worsens outcomes 2, 1, 3
• Over-prescribing opioid medications without considering risks 2, 1, 3
• Failing to assess psychosocial factors that delay recovery 2, 1
• Assuming MRI findings (bulging discs) are clinically significant—they correlate poorly with symptoms 2, 7
• Referring for surgery in absence of red flags or failed conservative management 6, 4