What is the initial management for a patient presenting with acute low back pain?

Initial Management of Acute Low Back Pain

For a patient presenting with acute low back pain, advise them to stay active within pain limits (avoid bed rest), and offer acetaminophen or NSAIDs as first-line medication if pharmacologic treatment is desired. 1, 2

Immediate Assessment for Red Flags

Screen for serious underlying conditions that require urgent imaging or specialist referral: 1, 2

• Cauda equina syndrome (saddle anesthesia, new bowel/bladder incontinence or urinary retention, loss of anal sphincter tone) 1, 3
• History of cancer with metastatic potential to bone 1, 2
• Suspected spinal infection (fever, recent infection, unexplained weight loss) 1, 2
• Significant trauma relative to age (high-impact injury in young patients, or minor fall/heavy lifting in patients with osteoporosis) 1, 3
• Progressive or severe neurologic deficits (major motor or sensory loss) 2, 3

If red flags are present, obtain immediate MRI (preferred over CT due to superior soft tissue visualization and no radiation exposure) and arrange urgent specialist consultation. 2

Activity Modification and Self-Care

Maintaining activity is superior to bed rest and reduces disability. 1, 2, 4

• Advise patients to continue ordinary activities within pain limits—90% of episodes resolve within 6 weeks regardless of treatment 4, 5
• Avoid bed rest entirely if possible, as it worsens outcomes 1, 3
• Apply superficial heat using heating pads for symptomatic relief 1, 2
• Encourage early return to work, which is associated with less long-term disability 4

First-Line Pharmacologic Management

NSAIDs are the most effective first-line medication option, providing moderate short-term pain relief with stronger evidence than acetaminophen. 6, 2

• NSAIDs provide approximately 10 points greater pain relief on a 100-point visual analogue scale compared to acetaminophen 6
• Acetaminophen (up to 4g daily) is a reasonable alternative with a more favorable safety profile and lower cost, though slightly less effective 6, 2
• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs; use the lowest effective dose for the shortest duration necessary 6
• Consider co-administration with a proton-pump inhibitor in higher-risk patients 6

Skeletal muscle relaxants can be added for short-term relief if NSAIDs/acetaminophen are insufficient, but all cause central nervous system sedation. 6, 2

Medications to Avoid

• Systemic corticosteroids are not recommended—they show no benefit over placebo 1, 2
• Avoid opioids for initial management due to substantial risks of abuse, addiction, and lack of superior efficacy 1, 2
• Opioids or tramadol should only be considered judiciously for severe, disabling pain uncontrolled by acetaminophen and NSAIDs, with time-limited courses 6

Diagnostic Imaging: When NOT to Order

Routine imaging is not recommended for uncomplicated acute low back pain in the first 4-6 weeks. 1, 2, 7

• Unnecessary imaging leads to increased healthcare utilization without clinical benefit—a study of 145,320 patients showed 27.2% received inappropriate radiography within 4 weeks 7
• Abnormal findings are common in asymptomatic individuals (degenerative disc changes in 29% of asymptomatic 20-year-olds) 7
• Most disc herniations show spontaneous regression at 8 weeks 7

Reserve imaging for: 1, 2, 7

• Presence of red flags suggesting serious pathology
• Symptoms persisting or worsening after 4-6 weeks of conservative management
• Patients who are candidates for surgery or intervention

Nonpharmacologic Therapies

Consider adding nonpharmacologic treatments, particularly if patients prefer to avoid medications: 2

• Spinal manipulation (low-quality evidence) 2
• Massage (low-quality evidence) 2
• Acupuncture (low-quality evidence) 2
• McKenzie exercises if pain radiates below the knee 4

Follow-Up and Reassessment

Reevaluate patients with persistent, unimproved symptoms after 1 month. 1, 2

• Consider earlier reassessment for patients over 65 years, those with signs of radiculopathy or spinal stenosis, or worsening symptoms 1, 2
• Reassess for missed red flags if symptoms persist 1
• Consider referral for physical therapy or more intensive rehabilitation if no improvement 1
• Consider imaging at this point if not previously performed and symptoms have not improved with conservative therapy 1, 2

Psychosocial Risk Factors

Assess for psychosocial factors that predict progression to chronic pain and poorer outcomes: 1, 2

• Depression, passive coping strategies, catastrophizing thoughts about pain 1
• Job dissatisfaction, disputed compensation claims, higher baseline disability 1
• These factors should be addressed early to prevent chronicity 1, 2

Common Pitfalls to Avoid

• Ordering routine imaging for uncomplicated cases—this is the most common error, occurring in over 27% of cases despite clear guideline recommendations against it 7
• Prescribing prolonged bed rest—this worsens outcomes and increases disability 1, 2
• Failing to address psychosocial factors that contribute to delayed recovery 1, 2
• Overreliance on opioid medications for initial pain management 2