What is the best management approach for an adult patient with no significant medical history presenting with acute back pain?

Management of Acute Back Pain in Adults

For an adult with acute back pain and no red flags, avoid imaging and initiate conservative management with NSAIDs or acetaminophen, heat therapy, and advice to maintain normal activity—most cases resolve within 4-6 weeks without intervention. 1, 2

Immediate Red Flag Assessment

Conduct a focused history and physical examination to identify conditions requiring urgent intervention 1:

• Cauda equina syndrome: Urinary retention, fecal incontinence, saddle anesthesia, bilateral leg weakness, or loss of anal sphincter tone—requires immediate MRI and neurosurgical consultation 1, 2
• Progressive neurologic deficits: Worsening weakness, numbness, or sensory loss—obtain urgent MRI 1, 3
• Cancer history: Prior malignancy with bone metastatic potential or unexplained weight loss—consider early imaging 4, 1
• Infection risk: Fever, recent bacterial infection, IV drug use, or immunosuppression—obtain urgent imaging and laboratory studies 1, 5
• Fracture risk: Age >65 years, chronic steroid use, significant trauma, or osteoporosis—consider plain radiography initially 4, 1
• Severe unrelenting pain: Pain that worsens at night or doesn't improve with rest—warrants further evaluation 2, 3

Imaging Guidelines

Do not obtain routine imaging for acute uncomplicated back pain without red flags—it provides no clinical benefit and increases healthcare costs, injections, surgeries, and disability claims without improving outcomes. 4, 1, 2

• Immediate MRI indicated: Red flags present, suspected cauda equina syndrome, progressive neurologic deficits, or suspected serious underlying condition (cancer, infection, fracture) 1, 2
• Delayed imaging (4-6 weeks): Consider plain radiography only if symptoms persist despite conservative management and patient remains a surgical or interventional candidate 1, 6
• MRI preferred over CT: Better visualization of soft tissue, vertebral marrow, and spinal canal without radiation exposure 1

First-Line Conservative Management

Nonpharmacologic Approaches (Cornerstone Treatment)

Nonpharmacologic therapies are the primary treatment for acute back pain and should be initiated before or alongside medications. 1, 2

• Maintain activity: Advise patients to stay active within pain limits—avoid bed rest as it increases disability and worsens outcomes 1, 2, 6
• Superficial heat therapy: Apply heating pads for symptomatic relief (moderate-quality evidence) 1, 6
• Spinal manipulation: May provide short-term benefit for acute pain 1, 2, 6
• Massage therapy: Low-quality evidence but reasonable option for acute/subacute pain 1
• Acupuncture: Low-quality evidence; conflicting data with higher-quality trials showing no benefit 1, 6

Pharmacologic Management

NSAIDs are first-line medication for acute back pain; acetaminophen is an alternative for mild-to-moderate pain. 1, 2

• NSAIDs: First choice for musculoskeletal pain (moderate-quality evidence); use with caution in patients with cardiovascular or gastrointestinal risk factors 1, 3, 6
• Acetaminophen: Up to 4g daily for mild-to-moderate pain if NSAIDs contraindicated 1, 3
• Skeletal muscle relaxants: Moderate-quality evidence for short-term use; cyclobenzaprine commonly used but causes drowsiness and dry mouth more frequently than other agents 1, 7
• Avoid opioids: No superior efficacy compared to NSAIDs, significant abuse potential, and not recommended for initial management 1, 2
• Avoid systemic corticosteroids: Not recommended for acute nonspecific back pain 1

Common Pitfalls to Avoid

• Ordering routine imaging: Exposes patients to unnecessary radiation without clinical benefit and increases downstream interventions 1, 2
• Prescribing prolonged bed rest: Worsens disability and delays recovery 1, 6
• Overreliance on opioids: Lacks superior efficacy and carries significant risks 1, 2
• Failing to assess psychosocial factors: Depression, catastrophizing, fear-avoidance behaviors, and job dissatisfaction predict progression to chronic pain and should be identified early 1, 2

Follow-Up and Reassessment

• Reevaluate at 4-6 weeks: If symptoms persist without improvement, consider imaging at this point if not previously performed 1, 2, 6
• Earlier reassessment indicated: Age >65 years, signs of radiculopathy or spinal stenosis, or worsening symptoms 1
• Consider referral at 3 months: If no response to standard noninvasive therapies after 3 months minimum, or if progressive neurologic deficits develop 1, 2
• Physical therapy referral: For persistent symptoms beyond 4-6 weeks or medium/high-risk patients identified by STarT Back tool 1

Risk Stratification for Chronic Pain

Use the STarT Back tool at 2 weeks to identify patients at risk for chronic disabling pain 1:

• Low-risk patients: Minimal psychosocial barriers—continue conservative management with reassurance 1
• Medium-risk patients: Refer to physiotherapy and develop patient-centered management plan 1
• High-risk patients: Refer for comprehensive biopsychosocial assessment; consider psychological interventions if anxiety, depression, catastrophizing, or fear-avoidance beliefs are prominent 1, 2