What is the recommended pain management for a 15-year-old with lower back pain?

Pain Management for a 15-Year-Old with Lower Back Pain

Start with NSAIDs (ibuprofen 400 mg every 4-6 hours) as first-line pharmacologic treatment, combined with education to remain active and avoid bed rest. 1

Initial Assessment Priorities

Before initiating treatment, determine if this is nonspecific low back pain versus pain with radiculopathy or a serious underlying condition requiring urgent evaluation. 1

Red flags requiring immediate imaging and specialist referral include: 1

• Progressive motor or sensory deficits
• New urinary retention or incontinence (cauda equina syndrome)
• History of cancer or recent spinal procedure
• Significant trauma
• Fever or constitutional symptoms suggesting infection

If no red flags are present, imaging is NOT indicated initially and does not improve outcomes. 1, 2

First-Line Treatment Algorithm

Patient Education and Activity Modification

Advise the patient to remain active rather than resting in bed—this is more effective than bed rest for managing back pain. 1, 2 Provide evidence-based information about the generally favorable prognosis, with high likelihood of substantial improvement within the first month. 1

Pharmacologic Management

Step 1: NSAIDs as Initial Therapy

• Ibuprofen 400 mg every 4-6 hours is the recommended starting dose 3
• NSAIDs are more effective for pain relief than acetaminophen (approximately 10 points better on a 100-point pain scale) 1
• Use the lowest effective dose for the shortest duration necessary 1, 3
• Maximum daily dose should not exceed 3200 mg 3
• In adolescents, cardiovascular risks are minimal, but assess for gastrointestinal risk factors and consider taking with food or milk 1, 3

Step 2: If NSAIDs Alone Are Insufficient

• Add a skeletal muscle relaxant for short-term use (≤1-2 weeks) if severe pain persists 1, 4
• Cyclobenzaprine has the strongest evidence among muscle relaxants for acute low back pain 4
• Warning: All muscle relaxants cause sedation and should be used cautiously in adolescents, particularly regarding activities requiring alertness 1

Medications to AVOID:

• Systemic corticosteroids are NOT recommended—they are no more effective than placebo 1, 2
• Opioids should be avoided in adolescents except in rare circumstances of severe, disabling pain unresponsive to other treatments 1
• Acetaminophen is less effective than NSAIDs and offers minimal additional benefit 1

Second-Line Treatment for Persistent Pain (>4 Weeks)

Non-Pharmacologic Therapies

If pain persists beyond 4 weeks despite first-line treatment, add non-pharmacologic interventions: 1, 2

Most Effective Options:

• Spinal manipulation by appropriately trained providers (small to moderate short-term benefits for acute pain) 1, 2
• Exercise therapy with individual tailoring, supervision, stretching, and strengthening (most effective for subacute/chronic pain) 1, 2
• Physical therapy using methods like the McKenzie technique (may decrease recurrence) 5

Additional Options with Moderate Evidence:

• Massage therapy 1, 2
• Acupuncture 1, 2
• Cognitive-behavioral therapy if psychosocial factors are present 1

When to Consider Imaging

Only obtain MRI or CT if: 1, 2

• Pain persists beyond 4-6 weeks with radicular symptoms (leg pain below the knee)
• Patient is a potential candidate for epidural steroid injection or surgery
• Progressive neurologic deficits develop

Special Considerations for Radicular Pain (Sciatica)

If the 15-year-old has leg pain radiating below the knee suggesting nerve root involvement: 2

Pharmacologic additions:

• Gabapentin provides small to moderate short-term benefits for radiculopathy 1, 2, 4
• Start at low doses and titrate based on response and tolerability 4

Interventional option if conservative treatment fails:

• Epidural steroid injections may be considered for persistent radicular symptoms 1, 2

Critical Pitfalls to Avoid

1. Do NOT prescribe prolonged bed rest—this leads to deconditioning and worse outcomes 1, 2
2. Do NOT order routine imaging without red flags—it does not improve outcomes and may lead to unnecessary interventions 1, 2
3. Do NOT use muscle relaxants beyond 1-2 weeks—no evidence supports longer duration and risks increase 1, 4
4. Do NOT prescribe systemic corticosteroids—they are ineffective 1, 2
5. Do NOT extend medication courses indefinitely—reserve extended use only for patients showing clear continued benefits without adverse events 1

Monitoring and Follow-Up

Reassess at 2-4 weeks: 1

• Evaluate pain improvement and functional status
• Screen for yellow flags (psychological factors, fear-avoidance behaviors) that predict chronicity
• If no improvement, consider imaging and specialist referral
• If improving, continue activity encouragement and taper medications to lowest effective dose