What is the best approach to managing back pain in a patient, considering factors such as age, occupation, lifestyle, and medical history, which may include conditions like osteoporosis or a history of sports injuries?

Managing Back Pain: A Structured Approach

Begin with diagnostic triage to classify the patient into one of three categories: nonspecific low back pain (85% of cases), back pain with radiculopathy/spinal stenosis, or back pain with a specific underlying cause requiring targeted treatment. 1

Initial Assessment and Red Flag Screening

Immediately evaluate for serious conditions requiring urgent intervention:

• Cauda equina syndrome: Check for urinary retention (90% sensitivity), saddle anesthesia, fecal incontinence, or motor deficits at multiple levels 1, 2
• Cancer risk factors: History of cancer (increases probability from 0.7% to 9%), unexplained weight loss, failure to improve after 1 month, or age >50 years 1
• Infection: Fever (present in only 45% of vertebral osteomyelitis), IV drug use, recent infection, or spinal percussion tenderness 1, 2
• Fracture risk: Older age, osteoporosis history, or corticosteroid use 1
• Inflammatory spondyloarthropathy: Younger age, morning stiffness improving with exercise, alternating buttock pain, or awakening during the second part of the night 1, 3

Critical pitfall: Vertebral osteomyelitis takes 2-4 months on average to diagnose due to insidious presentation; maintain high suspicion even without fever 2

Risk Stratification Using STarT Back Tool

At 2 weeks from pain onset, use the STarT Back tool to predict risk for chronic disability and guide resource allocation: 1

• Low-risk patients: Encourage self-management with education materials 1
• Medium-risk patients: Refer to physiotherapy with patient-centered management plan 1
• High-risk patients: Refer for comprehensive biopsychosocial assessment and multidisciplinary team evaluation 1

First-Line Treatment for Nonspecific Low Back Pain

Advise patients to remain active and avoid bed rest—this is more effective than resting for acute or subacute low back pain: 1, 4

Provide evidence-based self-care education using materials like The Back Book, which are as effective as costlier interventions like supervised exercise, acupuncture, or massage 1

Initiate medication with proven short-term benefits:

• First-line: NSAIDs (ibuprofen 400mg every 4-6 hours, maximum 3200mg daily) or acetaminophen 1, 5, 6, 7
• NSAIDs provide approximately 10 points greater pain relief on a 100-point scale compared to acetaminophen 1
• Adjunct: Skeletal muscle relaxants for short-term use 4
• Heat therapy: Apply heating pads or heated blankets for short-term relief 1

Common pitfall: Avoid prescribing extended bed rest—if patients require brief rest for severe symptoms, encourage return to normal activities as soon as possible 1

When to Image and Refer

Delay imaging for at least 4-6 weeks unless red flags are present 1, 4

Review patients within 2 weeks of pain onset: 1

• If improving: Continue current conservative management 1
• If no improvement or deterioration: Apply STarT Back tool and escalate care accordingly 1

Review high-risk patients no later than 12 weeks: 1

• If no improvement: Consider referral to specialist pain center or spinal center 1
• If improving: Continue supportive management in primary care 1

Special Populations

For workers with back pain: Consider age, general health, and physical job demands when advising about activity limitations 1

For patients with osteoporosis: Maintain heightened suspicion for vertebral compression fracture, especially with history of minor trauma or steroid use 1

For patients with radiculopathy/sciatica: Perform straight-leg-raise test (91% sensitivity, 26% specificity for herniated disc) and neurologic examination assessing L4, L5, and S1 nerve root function 1

What NOT to Do

Avoid interventional spine procedures (epidural injections, facet injections, radiofrequency ablation) for chronic axial spine pain—these do not improve morbidity or quality of life 5

Do not routinely order imaging or laboratory tests in the absence of red flags—they do not improve outcomes and increase costs 1, 4