Treatment for Teenage Spine Pain
For teenagers with spine pain and no red flags, avoid imaging and interventional procedures—instead, advise staying active, provide reassurance about the favorable prognosis, and use NSAIDs or acetaminophen for symptom relief as needed. 1, 2
Initial Assessment and Red Flag Screening
The first priority is determining whether clinical red flags are present, as most pediatric back pain is self-limiting and does not require imaging or aggressive intervention. 1
Red flags requiring urgent evaluation include: 1
- Severe or progressive neurologic deficits (motor weakness, sensory loss, bowel/bladder dysfunction)
- Fever, night sweats, or unexplained weight loss (suggesting infection or malignancy)
- History of significant trauma
- History of cancer
- Age-related concerns (very young children with back pain warrant more concern)
If red flags are present: Obtain MRI (preferred over CT) promptly, as delayed diagnosis of serious conditions like vertebral infection, cauda equina syndrome, or cancer with spinal cord compression leads to worse outcomes. 1
If no red flags are present: Do NOT order imaging (radiographs, CT, or MRI), as diagnostic imaging in children with transient back pain, normal physical examination, and no neurologic deficit is unlikely to be beneficial and does not improve outcomes. 1, 2
First-Line Conservative Management
Education and Activity Modification
Provide evidence-based reassurance: Most acute back pain in adolescents improves substantially within the first month, with 90% of episodes resolving within 6 weeks regardless of treatment. 2, 3
Advise the teenager to remain active: Continuation of ordinary activities within pain limits leads to faster recovery than bed rest or complete activity restriction. 2, 1 Prolonged bed rest causes rapid muscle atrophy, deconditioning, and worse outcomes. 2, 4
Avoid strong analgesics except for sleep: They mask pain and may allow overvigorous activity that worsens the underlying injury. 4
Pharmacologic Management
NSAIDs are the preferred first-line medication: Ibuprofen 400 mg every 4-6 hours (maximum 3200 mg daily) provides superior pain relief compared to acetaminophen—approximately 10 points better on a 100-point pain scale. 2, 5
Acetaminophen is an acceptable alternative: Use up to 3000 mg/day if NSAIDs are contraindicated due to gastrointestinal, renal, or cardiovascular concerns. 2
Non-Pharmacologic Measures
Apply superficial heat: Use heating pads or heated blankets for 20-30 minutes, 3-4 times daily, which provides moderate pain relief and is superior to acetaminophen or ibuprofen after 1-2 days. 2
Recommend ice for acute injuries: Apply to painful areas during the first 48-72 hours after injury. 3
Sport-Specific Considerations
Adolescent athletes have unique risk factors including growth spurts, abrupt increases in training intensity, improper technique, unsuitable equipment, and leg-length inequality. 4
Common athletic injuries include: 4
- Sprains and strains (most common cause)
- Spondylolysis or spondylolisthesis (in sports with repeated hyperextension like gymnastics, diving, football)
- Lumbar facet syndrome
- Sacroiliac joint irritation
For athletes with spondylolysis or facet irritation: Initially limit to flexion exercises only (Williams flexion exercises). 4
For athletes with disc-related pain: Perform extension exercises initially (McKenzie exercises), which are particularly helpful for pain radiating below the knee. 4, 3
Management of Persistent Pain (>4 Weeks)
If pain persists beyond 4 weeks despite conservative management, escalate treatment while continuing to avoid imaging unless red flags develop. 2
Implement supervised exercise therapy: Individualized programs incorporating stretching and strengthening become essential once pain transitions to subacute phase, with moderate evidence supporting 10-point improvements on a 100-point pain scale. 2, 5
Consider additional interventions: 2
- Spinal manipulation by appropriately trained providers (small to moderate short-term benefits)
- Massage therapy
- Acupuncture
- Yoga
- Cognitive-behavioral therapy if psychosocial factors are present
Assess for psychosocial risk factors ("yellow flags"): Depression, fear-avoidance beliefs, and barriers to treatment predict chronic disabling back pain and should be addressed. 2
When to Consider Imaging and Specialist Referral
Obtain MRI if: 1
- Pain persists beyond 6 weeks without improvement despite conservative therapy
- Radicular symptoms (leg pain, numbness, tingling) develop and persist
- Patient becomes a potential candidate for epidural steroid injection or surgery
- New red flags emerge during follow-up
Refer to specialist within 2 weeks if: 1
- Severe radicular pain that is disabling and prevents normal activities
- Neurological deficit develops (sensory or motor changes)
Refer to specialist within 3 months if: 1
- Less severe radicular pain persists despite conservative management
Critical Pitfalls to Avoid
Do NOT order routine imaging without red flags: It does not improve outcomes, leads to unnecessary interventions, and identifies incidental findings that poorly correlate with symptoms. 1, 2
Do NOT recommend prolonged bed rest: It causes deconditioning and worse outcomes. 2, 5
Do NOT use interventional procedures: Strong recommendations exist AGAINST epidural injections, facet joint injections, radiofrequency ablation, and trigger point injections for chronic spine pain, as these procedures lack evidence for effectiveness and carry risks. 1 These recommendations apply to chronic pain (≥3 months) and should not be offered outside clinical trials. 1
Do NOT prescribe systemic corticosteroids: They are no more effective than placebo for low back pain. 5
Prognosis and Follow-Up
The rate of recurrence is high in adolescents, so ongoing education about staying active and appropriate lifestyle modification is essential for preventing chronicity. 2 Up to one-third may report persistent pain of at least moderate intensity at 1 year, though most show substantial improvement within the first month. 2