What is the recommended management for a patient with sudden onset back pain?

Management of Sudden Onset Back Pain

For sudden onset back pain, reassure the patient that 90% of cases resolve within 6 weeks, advise them to stay active and avoid bed rest, and start acetaminophen or NSAIDs if medication is needed—imaging is not indicated unless red flags are present. 1, 2

Immediate Assessment: Rule Out Red Flags

Perform a focused history and physical examination specifically looking for:

• Severe or progressive neurologic deficits (leg weakness, foot drop, numbness in saddle distribution, loss of bowel/bladder control) suggesting cauda equina syndrome or severe nerve root compression 1
• Suspicion of serious underlying conditions: fever with back pain (infection), age >50 with new onset pain (malignancy), history of cancer, unexplained weight loss, immunosuppression, or significant trauma (fracture) 1, 3
• Age >65 years with history of osteoporosis or steroid use increases risk for compression fracture 1

If any red flags are present: Obtain immediate imaging (MRI preferred for neurologic deficits, plain radiographs for suspected fracture) and consider urgent specialist referral 1. For suspected cauda equina syndrome, immediate surgical consultation is required 4.

If no red flags are present: This is nonspecific low back pain—proceed with conservative management below. Do not obtain imaging. 1

First-Line Management: Activity and Self-Care

• Advise patients to remain active and continue normal activities within pain limits—this is more effective than bed rest and prevents deconditioning 1, 2
• Explicitly tell patients to avoid bed rest, as it worsens outcomes and increases disability 5, 6
• Apply superficial heat using heating pads or heated blankets for short-term pain relief 1, 2
• Provide evidence-based reassurance: Explain that most acute low back pain improves substantially within the first month, with 90% resolving by 6 weeks regardless of treatment 2, 5, 6
• Explain that imaging is not helpful at this stage—it does not identify a precise cause, does not improve outcomes, and often shows nonspecific findings that can lead to unnecessary interventions 1

Pharmacologic Management (If Needed)

First-line medications:

• Acetaminophen (up to 3000 mg/day) has a favorable safety profile and is reasonable for mild-to-moderate pain 1, 2, 5
• NSAIDs (ibuprofen or naproxen) are more effective than acetaminophen for pain relief (approximately 10 points better on a 100-point scale) and are the preferred first-line option for most patients 1, 2, 7

Avoid:

• Systemic corticosteroids—they have not shown greater efficacy than placebo 2, 5
• Routine use of muscle relaxants or benzodiazepines for acute nonspecific back pain 8
• Opioids should not be used for acute nonspecific low back pain 7

Nonpharmacologic Therapies (Consider if Not Improving After 1-2 Weeks)

• Spinal manipulation has fair evidence for small-to-moderate benefits in acute low back pain 1, 2
• McKenzie exercises are specifically helpful if pain radiates below the knee 6
• Goal-directed manual physical therapy (not passive modalities like ultrasound or TENS) may be considered if no improvement in 1-2 weeks 6

Reassessment and Follow-Up

• Reevaluate patients with persistent, unimproved symptoms after 1 month 1
• If symptoms persist beyond 4-6 weeks despite conservative management, consider plain radiographs as initial imaging and reassess for missed red flags 1, 6, 9
• Assess psychosocial risk factors (depression, job dissatisfaction, fear-avoidance behaviors, catastrophizing) as these predict progression to chronic pain more strongly than physical findings 1, 5

Common Pitfalls to Avoid

• Do not order routine imaging (X-ray, MRI, CT) for nonspecific low back pain without red flags—this exposes patients to unnecessary radiation, identifies nonspecific abnormalities poorly correlated with symptoms, and does not improve outcomes 1, 5
• Do not prescribe bed rest—it increases disability and delays recovery 5, 6
• Do not refer for surgery in the absence of red flags or progressive neurologic deficits 6
• Do not use passive physical therapy modalities (heat, traction, ultrasound, TENS) as primary treatment—active approaches are superior 6