What is the initial management for neck and back pain in a primary care setting?

Primary Care Management of Neck and Back Pain

Initial Assessment and Red Flag Screening

Start with a focused history and physical examination to identify red flags requiring urgent intervention—do not routinely order imaging for uncomplicated cases. 1

Critical red flags requiring immediate action include:

• Cauda equina syndrome (urinary retention, fecal incontinence, saddle anesthesia, bilateral leg weakness)—obtain immediate MRI and urgent neurosurgical consultation 1, 2
• History of cancer with new back pain—positive likelihood ratio of 14.7 for malignancy 2
• Unexplained weight loss, fever, or age >50 with failure to improve—consider vertebral malignancy or infection 3, 2
• Significant trauma or osteoporosis/steroid use with midline tenderness—suspect vertebral compression fracture 1, 2
• Progressive neurologic deficits—obtain urgent imaging 1

For radiculopathy assessment, perform straight-leg raise test (sensitivity 91%, specificity 26% for herniated disc) and assess motor strength at L5 (foot dorsiflexion) and S1 (plantarflexion) nerve roots 3

Risk Stratification at 2 Weeks

Use the STarT Back tool at 2 weeks from pain onset to stratify patients into low, medium, or high risk for developing chronic disabling pain. 3, 1

• Low-risk patients: Encourage self-management with reassurance and activity 3, 1
• Medium-risk patients: Refer to physiotherapy and develop patient-centered management plan 1
• High-risk patients: Refer for comprehensive biopsychosocial assessment by physiotherapy, review no later than 12 weeks 3, 1

Psychosocial factors predicting poor outcomes include depression, passive coping strategies, job dissatisfaction, and higher disability levels 3, 1

Acute and Subacute Pain (<12 weeks)

First-Line: Nonpharmacologic Treatment

For acute or subacute low back pain, prescribe nonpharmacologic treatments first: superficial heat, massage, acupuncture, or spinal manipulation. 3, 1

• Superficial heat (heating pads)—moderate-quality evidence 3, 1
• Massage therapy—low-quality evidence 3
• Acupuncture—low-quality evidence 3
• Spinal manipulation—low-quality evidence 3
• Advise staying active and avoiding bed rest—maintaining activity reduces disability 1

Pharmacologic Treatment (Only if Specifically Desired)

Add NSAIDs or skeletal muscle relaxants only if nonpharmacologic treatment is insufficient or patient specifically requests medication. 3, 1

For back pain:

• NSAIDs (moderate-quality evidence)—first-line pharmacologic option 3
• Skeletal muscle relaxants (moderate-quality evidence)—effective for acute low back pain 3
• Avoid acetaminophen for back pain—insufficient evidence 3
• Avoid systemic corticosteroids—good evidence of ineffectiveness 3
• Avoid opioids for initial management—abuse potential without superior efficacy 1

For neck pain (differs from back pain):

• Acetaminophen (up to 4g daily) for mild-to-moderate pain 1, 4
• NSAIDs or topical medications if acetaminophen insufficient 4, 5
• Muscle relaxants—effective for acute neck pain 5

Chronic Pain (>12 weeks)

First-Line: Nonpharmacologic Treatment

For chronic low back pain, prescribe exercise therapy, multidisciplinary rehabilitation, or cognitive behavioral therapy as first-line treatment. 3, 1

Moderately effective options include:

• Exercise therapy (moderate-quality evidence)—programs with individual tailoring, supervision, stretching, and strengthening show best outcomes 3
• Multidisciplinary rehabilitation (moderate-quality evidence) 3
• Acupuncture (moderate-quality evidence) 3
• Mindfulness-based stress reduction (moderate-quality evidence) 3
• Cognitive behavioral therapy (low-quality evidence) 3
• Yoga or tai chi (low-quality evidence) 3
• Spinal manipulation (low-quality evidence) 3
• Massage therapy 3

Avoid transcutaneous electrical nerve stimulation (TENS) and traction—not proven effective. 3

Pharmacologic Escalation (If Inadequate Response)

If nonpharmacologic therapy fails, escalate pharmacologically: first NSAIDs, then tramadol or duloxetine, and only use opioids as last resort with careful monitoring. 3, 1

• NSAIDs—continue if tolerated 3, 1
• Tricyclic antidepressants—small to moderate benefit for chronic low back pain 3
• Tramadol or duloxetine—second-line options 3, 1
• Gabapentin—fair evidence for radiculopathy 3
• Opioids—last resort only, with careful monitoring for abuse 3, 1

Imaging Strategy

Do not routinely order imaging for nonspecific low back pain without red flags—it does not improve outcomes and may lead to unnecessary interventions. 3, 1, 2

• Plain radiography: Consider only after 4-6 weeks of failed conservative therapy or if vertebral compression fracture suspected 3, 1
• MRI or CT: Order immediately only if cauda equina syndrome, severe/progressive neurologic deficits, or serious underlying condition suspected 3, 1
• MRI preferred over CT—better soft tissue visualization, avoids radiation 1, 2

A single lumbar spine x-ray delivers gonadal radiation equivalent to daily chest x-ray for >1 year 3, 2

Follow-Up and Referral

Reevaluate patients with persistent, unimproved symptoms after 1 month; consider earlier reassessment for older patients, severe pain, or signs of radiculopathy. 3, 1

Refer to specialist when no response to standard noninvasive therapies after minimum 3 months, or if progressive neurologic deficits develop. 3, 1

Consider specialist referral for:

• Persistent symptoms after 3 months of comprehensive conservative therapy 3, 1
• Progressive neurologic deficits 1
• Consideration of surgery (only after minimum 1 year of symptoms based on surgical trial inclusion criteria) 3

Critical Pitfalls to Avoid

• Ordering routine imaging for uncomplicated acute pain—exposes patients to unnecessary radiation without benefit 3, 1, 2
• Prescribing prolonged bed rest—worsens outcomes compared to staying active 1
• Overreliance on opioids—use only as last resort with monitoring 3, 1
• Missing cauda equina syndrome—leads to permanent neurologic disability from delayed surgery 2
• Failing to assess psychosocial factors—strongest predictors of outcomes, more important than physical findings 3, 1
• Overlooking cancer history—posttest probability jumps from 0.7% to 9% in patients with prior malignancy 2