What is the appropriate management for a 22-year-old patient presenting with back pain?

Management of Back Pain in a 22-Year-Old

For a 22-year-old with back pain and no red flags, do NOT order imaging—start conservative management immediately with NSAIDs, activity modification, and reassurance about the favorable prognosis. 1, 2

Initial Assessment: Rule Out Red Flags

Your first priority is identifying red flags that would change management:

• Severe or progressive neurologic deficits (weakness, numbness, bowel/bladder dysfunction) require immediate MRI 1, 3
• Suspected cauda equina syndrome (saddle anesthesia, urinary retention, bilateral leg weakness) requires immediate MRI 1
• History of cancer with new back pain warrants urgent MRI due to high risk of spinal metastasis 1
• Unexplained weight loss, fever, or immunosuppression suggesting infection or malignancy necessitates immediate imaging 1
• Significant trauma relative to age should prompt evaluation for fracture 4

If none of these red flags are present, this is nonspecific mechanical low back pain and imaging is NOT indicated. 1, 2

Conservative Management (First-Line for Patients Without Red Flags)

Patient Education and Activity

• Inform the patient that most back pain improves substantially within the first month—this is obligatory counseling 2
• Advise remaining active rather than bed rest, as activity is more effective for acute/subacute low back pain 2, 4
• At age 22, the higher prevalence of back pain is attributed to youth sports intensity, obesity, and physical inactivity including increased sitting time 5

Pharmacologic Management

• Start with NSAIDs as first-line medication for short-term use after considering side effects 5, 2, 4
• Ibuprofen 400 mg every 4-6 hours as needed (do not exceed 3200 mg daily) 6
• Avoid opioids in this young patient with nonspecific back pain 2
• Acetaminophen has little or no evidence of benefit for chronic low back pain 4

Physical and Psychological Interventions

• Physical therapy may be used as part of multimodal strategy, particularly if symptoms persist beyond 2 weeks 5
• Yoga has strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness in chronic low back pain 4
• Cognitive behavioral therapy, biofeedback, and relaxation training provide relief for assessment periods ranging from 4 weeks to 2 years 5

When to Consider Imaging

Timing for MRI (Only If Specific Criteria Met)

MRI is NOT routinely indicated unless symptoms persist beyond 4-6 weeks AND the patient has radicular symptoms or is a potential candidate for surgical/interventional treatment. 1

• Radicular symptoms (leg pain radiating below the knee, numbness/tingling in dermatomal distribution) that persist despite conservative treatment may require MRI 1
• Positive straight leg raise test combined with persistent radicular pain supports the need for MRI 1
• Reevaluate after 1 month of conservative management if symptoms have not improved 1
• MRI should only be ordered after 6-8 weeks in patients with persistent pain and radiculopathy/stenosis signs who are potential surgical candidates 2

What NOT to Do

• Do NOT order MRI for acute nonspecific low back pain without radicular symptoms or red flags—this leads to overdiagnosis and potential harm from unnecessary interventions 1
• Do NOT rely solely on imaging findings without clinical correlation, as up to 20-28% of completely asymptomatic individuals have disc herniations on MRI 1
• Plain radiography is NOT recommended for initial evaluation of suspected spinal stenosis because it cannot visualize the spinal canal or nerve roots 3

Stratified Care Approach

Use the STarT Back tool at 2 weeks from onset to predict risk and guide management intensity: 5

• Low-risk patients: Continue supportive management in primary care with self-care education 5
• High-risk patients: Refer for biopsychosocial assessment performed in context of multidisciplinary team 5
• Identify psychosocial "yellow flags" (inadequate coping, job dissatisfaction, somatization) that predict chronicity 2

Documentation for Future Reference

If imaging becomes necessary later, ensure documentation includes: 1

• Specific radicular symptoms with dermatomal distribution
• Duration of symptoms (typically ≥6 weeks)
• Failed conservative treatments (NSAIDs, physical therapy)
• Neurological examination findings (motor weakness, sensory deficits, reflex changes)
• Rationale for considering surgical or interventional treatment