Management of 7-Day Right-Sided Low Back Pain
Do not order imaging and treat conservatively with NSAIDs, activity as tolerated, and reassurance about the favorable natural history—acute uncomplicated low back pain is self-limiting in most patients and imaging provides no clinical benefit while increasing healthcare costs. 1
Initial Clinical Assessment
First, screen for red flags that would change management:
- Cauda equina syndrome: urinary retention/incontinence, bilateral leg weakness, saddle anesthesia 2, 3
- Progressive motor deficits: new or worsening weakness in legs 4, 2
- Suspected malignancy: history of cancer, unexplained weight loss, age >50 with new onset pain 3, 5
- Infection: fever, IV drug use, recent spinal procedure 3, 6
- Fracture: significant trauma relative to age, prolonged steroid use, osteoporosis 3, 5
If any red flags are present, obtain immediate MRI and specialist referral. 4, 2 If no red flags are present (which is the case for most patients), proceed with conservative management without imaging.
Why No Imaging at 7 Days
The American College of Radiology explicitly states that acute low back pain (<4 weeks duration) without red flags is self-limiting and responsive to medical management in most patients. 1 Key evidence against early imaging:
- Routine imaging provides no clinical benefit and leads to increased healthcare utilization without improving outcomes 1
- Disc abnormalities are common in asymptomatic people: 29% of asymptomatic 20-year-olds and 43% of asymptomatic 80-year-olds have disc protrusions on imaging 1, 2
- Most disc herniations regress spontaneously by 8 weeks after symptom onset 1, 4
- Early imaging increases unnecessary interventions: patients who get early imaging are more likely to receive epidural injections, surgery, and disability compensation without better outcomes 1
Conservative Management Protocol
Pharmacologic Treatment
- First-line: NSAIDs (ibuprofen, naproxen) with moderate evidence for effectiveness 2, 7, 3
- Alternative: Acetaminophen if NSAIDs contraindicated, though evidence is weaker 7, 6
- Consider adding: Muscle relaxant (cyclobenzaprine 5-10 mg) for muscle spasm, particularly at night 4, 8
- Avoid opioids as initial therapy—reserve as last resort only if other treatments fail 2, 7
Non-Pharmacologic Treatment
- Remain active: Continue ordinary activities within pain limits—this is more effective than bed rest 4, 2, 7
- Avoid bed rest: Bed rest is inferior to activity maintenance and should be avoided if possible 4, 2, 3
- Apply superficial heat to painful areas for symptomatic relief 4, 2
- Patient education: Reassure that 90% of episodes resolve within 6 weeks regardless of treatment 7, 9
Physical Therapy Considerations
Physiotherapy can begin immediately as part of first-line conservative management. 4 For severe or disabling pain, refer to physical therapy within 2 weeks of presentation. 4 Consider McKenzie exercises if pain radiates below the knee. 7, 6
Follow-Up Timeline
- Reassess at 4-6 weeks if symptoms persist without improvement 2, 7
- Earlier reassessment warranted for severe pain, functional deficits, or worsening neurologic symptoms 2
- At 6-week mark: If no improvement despite conservative therapy, consider MRI lumbar spine without contrast for surgical candidates or those considering epidural steroid injection 1, 4
Common Pitfalls to Avoid
- Ordering imaging before 6 weeks without red flags increases costs without improving outcomes and may lead to unnecessary interventions 1, 2
- Prescribing bed rest is counterproductive—patients should remain active 4, 2, 7
- Starting opioids initially should be avoided—use NSAIDs first 2, 7
- Failing to screen for psychosocial factors: Depression, anxiety, fear-avoidance beliefs, and job dissatisfaction predict poor outcomes more strongly than physical findings 2, 6
- Delaying specialist referral beyond 3 months for persistent symptoms can lead to prolonged disability 4
When to Escalate Care
Refer to specialist services if: