What is the management for immediate back pain?

Management of Immediate Back Pain

For acute back pain without red flags, start with NSAIDs (ibuprofen 400 mg every 4-6 hours) or acetaminophen, combined with heat therapy and advice to remain active—imaging is not indicated initially. 1, 2

Initial Assessment: Rule Out Red Flags

Before initiating treatment, rapidly screen for serious pathology requiring urgent intervention 1:

Serious Red Flags (Require Immediate Action)

• Progressive motor or sensory deficits 1
• New-onset bowel/bladder incontinence or urinary retention 1, 3
• Saddle anesthesia or loss of anal sphincter tone 3
• Significant trauma (fall from height, motor vehicle crash, or minor trauma in elderly/osteoporotic patients) 1, 3
• History of cancer (especially metastatic to bone) 1, 3
• Suspected spinal infection 1, 3
• Cauda equina syndrome features 4

Less Urgent Red Flags (Consider Early Imaging/Referral)

• Age >65 years with risk factors for compression fracture 1
• Chronic steroid use 1
• Known osteoporosis 1

If any serious red flags are present, obtain immediate imaging (MRI preferred) and specialist consultation. 1 If no red flags exist, proceed with conservative management without imaging. 1, 2

First-Line Pharmacologic Treatment

NSAIDs (Preferred Initial Option)

• Ibuprofen 400 mg every 4-6 hours as needed 2, 5
• Maximum daily dose: 3200 mg, though doses above 400 mg show no additional benefit for acute pain 5
• Take with food or milk to minimize gastrointestinal effects 5
• NSAIDs provide superior pain relief compared to placebo and are more effective than opioids for musculoskeletal pain 1, 2

Acetaminophen (Alternative First-Line)

• Consider as first-line in elderly patients due to better safety profile 2
• Provides slightly less pain relief than NSAIDs but with fewer adverse effects 2
• Preferred over NSAIDs in patients with gastrointestinal, renal, or cardiovascular contraindications 2

Second-Line: Muscle Relaxants

• Add skeletal muscle relaxants if pain persists after 2-7 days of NSAID/acetaminophen therapy 2
• Provide short-term pain relief but use cautiously due to sedation risk 2

Avoid These Medications

• Systemic corticosteroids: No benefit over placebo 2
• Opioids: Reserve only for severe, disabling pain uncontrolled by NSAIDs/acetaminophen, and use for shortest duration possible 1, 2
• If opioids used around the clock for more than a few days, taper when discontinuing 1

First-Line Non-Pharmacologic Treatment

Heat Therapy

• Apply heating pads or heated blankets for short-term relief 1, 2
• Particularly effective for acute low back pain 1

Activity Modification

• Advise patients to remain active and continue ordinary activities within pain limits 1, 2
• Avoid bed rest—it worsens disability and outcomes 1, 6
• Early mobilization maintains function and prevents chronicity 1

Sleep Surface

• Recommend medium-firm mattresses over firm mattresses 2

Additional Non-Pharmacologic Options (If Initial Treatment Insufficient)

Evidence-Supported Modalities

• Spinal manipulation: Effective for acute low back pain, especially with radiculopathy 1
• Massage therapy: May provide benefit for acute pain 1
• Acupuncture or acupressure: Moderate evidence for acute musculoskeletal pain 1

Physical Therapy

• Consider if pain persists beyond initial management 1, 6
• Active exercise strategies decrease disability; passive approaches worsen outcomes 6

When to Image

Do NOT obtain imaging initially for uncomplicated acute back pain without red flags. 1, 2

Imaging IS Indicated When:

• Red flags present on history/examination 1
• Severe or progressive neurologic deficits 1
• No improvement after 6 weeks of conservative therapy 2, 7
• Considering epidural steroid injection or surgery 1

MRI is preferred over CT for neurologic or soft tissue abnormalities; plain radiography for suspected fracture. 4

Common Pitfalls to Avoid

• Do not routinely image acute uncomplicated back pain—imaging provides no clinical benefit and may lead to unnecessary interventions 1
• Do not prescribe opioids as first-line therapy—NSAIDs are more effective for musculoskeletal pain with better safety profile 1, 2
• Do not recommend bed rest—it increases disability and delays recovery 1, 6
• Do not use systemic corticosteroids—they are ineffective for non-specific back pain 2

When to Refer

• Immediate referral: Cauda equina syndrome, progressive neurologic deficit, suspected infection/malignancy 1, 3
• Urgent referral (within 2 weeks): Severe radicular pain with neurologic deficit 1
• Non-urgent specialist referral: Persistent pain beyond 6 weeks despite conservative management 7