What is the most likely diagnosis and appropriate management for a 31‑year‑old male taxi driver with diffuse lumbar, thoracic and trapezius pain, no swelling, fever, trauma or heavy lifting, currently taking only paracetamol?

Mechanical Low Back Pain from Prolonged Sitting

This is nonspecific mechanical low back pain caused by prolonged static posture from taxi driving, and should be treated with NSAIDs, activity modification, superficial heat, and reassurance about the favorable prognosis.

Most Likely Diagnosis

Nonspecific mechanical low back pain arising from occupational postural stress. 1, 2

• Prolonged sitting in taxi drivers creates static loading of soft tissues, accelerates disc degeneration, and causes musculoskeletal pain in the back, neck, and trapezius regions. 3
• Fixed postures lead to accumulation of metabolites and tissue discomfort, particularly affecting the lumbar spine, thoracic spine, and trapezius muscles. 3
• The absence of trauma, fever, swelling, or neurologic symptoms makes serious pathology (infection, fracture, malignancy, cauda equina syndrome) highly unlikely. 1, 2
• Mechanical low back pain accounts for 97% of back pain cases and arises intrinsically from spinal structures including bone, ligaments, discs, joints, and soft tissues. 2, 4

Red Flags Assessment (All Should Be Absent)

Check specifically for these warning signs that would change management: 1, 5, 6

• Cauda equina syndrome: urinary retention, fecal incontinence, saddle anesthesia 1, 7, 5
• Cancer: history of cancer, unexplained weight loss, age >50 years, failure to improve after 1 month 7, 5
• Infection: fever, IV drug use, recent infection 7, 5
• Fracture: significant trauma, osteoporosis history, steroid use 7, 5
• Progressive neurologic deficits: progressive motor weakness, sensory loss 7, 2

Since none of these red flags are present, imaging is NOT indicated at this stage. 1, 5, 6

Immediate Management Plan

First-Line Pharmacologic Treatment

NSAIDs are the primary medication with the strongest evidence for moderate pain relief in mechanical back pain. 7, 2

• Paracetamol (acetaminophen) alone has only fair evidence for efficacy and is insufficient as monotherapy. 7
• Consider adding a skeletal muscle relaxant for short-term use (days to 1-2 weeks), which has good evidence for acute low back pain. 7
• Avoid opioids as first-line therapy; reserve for cases where NSAIDs are contraindicated or insufficient, using the lowest dose for the shortest time. 7

Non-Pharmacologic Interventions

Advise the patient to remain active rather than rest, as activity is more effective than bed rest for acute low back pain. 7, 6

• Apply superficial heat (heating pad, warm compress), which has good evidence for moderate benefits in acute presentations. 7, 6
• Consider spinal manipulation, which has fair evidence for small to moderate benefits in acute mechanical back pain. 7

Occupational Modifications

Address the root cause by modifying driving posture and habits: 3

• Use a seat with good lumbar support to reduce static loading on the lumbar spine. 3
• Avoid fixed postures by taking regular breaks every 30-60 minutes to stand, stretch, and walk. 3
• Adjust seat position to maintain neutral spine alignment and reduce flexion stress. 3

What NOT to Do

Do not order imaging (X-ray, MRI, CT) at this initial presentation, as routine imaging provides no clinical benefit, does not improve outcomes, and incurs unnecessary expense when red flags are absent. 1, 7, 5, 6

Do not offer epidural steroid injections, as recent high-quality guidelines strongly recommend against epidural injections for non-radicular mechanical low back pain. 7

Patient Education and Prognosis

Reassure the patient that most acute low back pain improves substantially within the first 4 weeks with conservative management. 1, 7

• Explain that the pain arises from postural stress and soft tissue loading, not from serious structural damage. 3, 2
• Emphasize that remaining active and avoiding prolonged bed rest accelerates recovery. 7, 6
• Inform the patient that early imaging cannot identify a precise cause in most cases and does not change treatment. 7

Follow-Up Timing

Reevaluate after 1 month if symptoms persist or worsen. 5

• If pain persists beyond 4-6 weeks despite conservative treatment, consider imaging (MRI preferred over CT) and specialist referral. 7, 5, 4
• Earlier reevaluation is warranted if new red flag symptoms develop (neurologic deficits, bowel/bladder dysfunction, fever). 5, 2
• Consider specialist referral within 3 months for persistent symptoms that do not respond to standard noninvasive therapies. 1, 7

Common Pitfalls to Avoid

• Do not over-rely on paracetamol alone, as it has limited efficacy compared to NSAIDs for mechanical back pain. 7, 2
• Do not order unnecessary imaging in the absence of red flags, as this leads to increased healthcare utilization without improved outcomes. 6, 2
• Do not prescribe prolonged bed rest, as this worsens outcomes compared to maintaining activity. 7, 6
• Do not ignore occupational factors—failure to address prolonged sitting posture will lead to recurrent symptoms. 3