What are the initial management and treatment options for lower back pain?

Initial Management of Lower Back Pain

For most patients with acute nonspecific low back pain, start with staying active, applying superficial heat, and taking NSAIDs or acetaminophen—avoid routine imaging and bed rest, as over 85% of cases improve without identifying a specific anatomical cause. 1, 2

Step 1: Categorize the Patient Through Focused Assessment

Conduct a targeted history and physical examination to place patients into one of three categories that determine your management pathway 1:

• Nonspecific low back pain (85% of cases): Pain localized to back/buttocks without clear anatomical source 1
• Radiculopathy or spinal stenosis (7% of cases): Radiating leg pain, positive straight leg raise, motor weakness, or pseudoclaudication 1, 2
• Specific serious spinal cause (<8% of cases): Cancer (0.7%), compression fracture (4%), infection (0.01%), cauda equina syndrome (0.04%) 1

Red Flags Requiring Immediate Imaging and Specialist Referral

Screen for these features that mandate urgent MRI or CT 1, 2:

• Progressive or severe neurologic deficits (motor weakness at multiple levels, saddle anesthesia) 1, 2
• Cauda equina syndrome (urinary retention, fecal incontinence, bilateral leg weakness) 1, 2
• History of cancer with new back pain 1, 2
• Fever with back pain or recent infection (vertebral osteomyelitis) 1, 2
• Significant trauma relative to age 2
• Unexplained weight loss 2

Psychosocial Risk Assessment

Identify factors predicting chronic disability: depression, anxiety, catastrophizing, fear-avoidance beliefs, job dissatisfaction 1, 2. Use the STarT Back tool at 2 weeks to risk-stratify patients and direct resources appropriately 2.

Step 2: Initial Management for Nonspecific Low Back Pain (No Red Flags)

Do NOT Order Routine Imaging

Avoid plain radiographs, CT, or MRI in patients without red flags—routine imaging does not improve outcomes and exposes patients to unnecessary radiation. 1 A single lumbar spine X-ray delivers gonadal radiation equivalent to daily chest X-rays for over one year 1.

Consider plain radiography only for 1:

• Suspected vertebral compression fracture (history of osteoporosis, steroid use, age >50 with midline tenderness) 1
• Persistent symptoms after 4-6 weeks of conservative therapy without improvement 1, 2

First-Line Nonpharmacologic Treatment

Prioritize nonpharmacologic interventions as first-line therapy 2:

• Maintain activity within pain limits—advise against bed rest, which worsens disability 2
• Superficial heat (heating pads): moderate-quality evidence for acute/subacute pain 2
• Spinal manipulation: low-quality evidence but recommended option 2
• Massage: low-quality evidence for acute pain 2
• Acupuncture: low-quality evidence for acute pain 2

Pharmacologic Treatment (If Nonpharmacologic Insufficient)

Add medications only if specifically desired after nonpharmacologic approaches 2:

First-line medications:

• NSAIDs (ibuprofen, naproxen): moderate-quality evidence 2, 3
• Acetaminophen (up to 4g daily): for mild-to-moderate pain 2, 3
• Skeletal muscle relaxants (cyclobenzaprine): moderate-quality evidence 2, 4

Avoid opioids for initial management—lack superior efficacy and carry abuse potential 2.

Common Pitfall: Cyclobenzaprine Dosing

When prescribing cyclobenzaprine, start with 5 mg three times daily, especially in elderly patients (≥65 years) where drug exposure is 1.7-fold higher 4. In elderly males, exposure increases 2.4-fold 4. Combination with naproxen increases drowsiness 4.

Step 3: Reassessment and Escalation

Timing of Reevaluation

• Standard patients: Reassess at 1 month if symptoms persist without improvement 1, 2
• Earlier reassessment for: older patients, severe pain/functional deficits, signs of radiculopathy or spinal stenosis 1

Management at 2-4 Weeks (If Not Improving)

Use STarT Back tool to stratify risk 2:

Low-risk patients (minimal psychosocial barriers):

• Continue self-management and activity 2

Medium-risk patients:

• Refer to physical therapy 2
• Consider additional nonpharmacologic treatments (massage, acupuncture, spinal manipulation) 2

High-risk patients (significant psychosocial factors):

• Refer for comprehensive biopsychosocial assessment by physical therapy 2
• Consider psychological interventions (cognitive behavioral therapy) 2

Management at 4-6 Weeks (Persistent Symptoms)

If no improvement with conservative therapy 2:

• Consider plain radiography as initial imaging option 1, 2
• Refer to physical therapy if not already done 2
• Continue nonpharmacologic approaches 2

Step 4: Chronic Low Back Pain (>12 Weeks)

Nonpharmacologic Treatments (First-Line)

Strong evidence supports these interventions for chronic pain 2, 3:

• Exercise therapy: moderate-quality evidence 2, 5
• Multidisciplinary rehabilitation: moderate-quality evidence 2
• Yoga: strong evidence for short-term and moderate evidence for long-term effectiveness 2, 6
• Cognitive behavioral therapy: low-quality evidence 2
• Mindfulness-based stress reduction: moderate-quality evidence 2
• Tai chi: low-quality evidence 2
• Acupuncture: moderate-quality evidence 2
• Spinal manipulation: low-quality evidence 2

Pharmacologic Escalation (If Inadequate Response)

Follow this stepwise approach 2, 3:

1. Continue NSAIDs or acetaminophen 2, 3
2. Second-line: Tramadol or duloxetine 2, 3
3. Last resort: Opioids with careful monitoring and documentation 2, 3

Note: Acetaminophen has little or no evidence of benefit for chronic low back pain 6. Skeletal muscle relaxants and lidocaine patches also lack evidence for chronic pain 6.

Step 5: When to Consider Specialist Referral

Refer for surgical evaluation only in select cases 2, 3:

• No response to standard noninvasive therapies after minimum 3 months 2
• Progressive neurologic deficits 2
• Persistent functional disabilities and pain despite comprehensive conservative therapy 2, 3

Most patients with chronic low back pain will not benefit from surgery 3.

Critical Pitfalls to Avoid

• Ordering routine imaging for uncomplicated acute low back pain—exposes patients to radiation without clinical benefit 1, 2
• Prescribing prolonged bed rest—worsens disability and delays recovery 2
• Starting with opioids—no superior efficacy compared to NSAIDs and carries significant abuse risk 2
• Failing to assess psychosocial factors—strongest predictors of progression to chronic disabling pain 1, 2
• Delaying physical therapy referral in medium/high-risk patients identified at 2 weeks 2
• Using passive treatments alone (rest, medications)—associated with worsening disability 5