How should I manage a patient with uncomplicated low back pain (no red‑flag features)?

Management of Uncomplicated Low Back Pain Without Red Flags

For adults with acute uncomplicated low back pain and no red‑flag features, prescribe oral NSAIDs (ibuprofen 400–800 mg three times daily, naproxen 500 mg twice daily, or diclofenac 50 mg twice daily) combined with advice to remain active and avoid bed rest; do not order imaging. 1, 2

Immediate Assessment: Screen for Red Flags

Before initiating conservative management, rapidly screen for the following red‑flag symptoms that mandate urgent imaging and specialist referral:

• Cauda equina syndrome: urinary retention or incontinence, saddle anesthesia, bilateral lower‑extremity weakness—these require emergent MRI and surgical consultation. 1, 2
• Progressive motor deficits: new foot drop or worsening weakness necessitates prompt imaging to prevent permanent neurologic injury. 1
• Malignancy indicators: history of cancer with bone metastatic potential, unexplained weight loss, or age >50 years with new‑onset pain. 3, 2
• Infection risk: fever, recent bacterial infection, IV drug use, or immunosuppression. 3, 2
• Fracture risk: significant trauma (relative to age), osteoporosis, or prolonged corticosteroid use. 3, 2

Critical caveat: Red flags have limited predictive value—64% of patients with spinal malignancy had no associated red flags in one large study, and the absence of red flags does not meaningfully decrease the likelihood of serious pathology. 4 However, their presence does increase probability of underlying disease and warrants further evaluation. 4

First‑Line Pharmacologic Management

• Oral NSAIDs are the medication of choice, providing moderate short‑term pain relief with good evidence of efficacy. 1, 2, 5
• Acetaminophen may be used if NSAIDs are contraindicated, though evidence shows limited benefit over placebo. 2
• Monitor for adverse effects: gastrointestinal bleeding, cardiovascular events, and renal toxicity, especially with prolonged NSAID use. 1
• Skeletal muscle relaxants can be added for short‑term relief when NSAIDs are insufficient, though evidence is low quality. 1
• Avoid systemic corticosteroids—high‑quality evidence demonstrates no superiority over placebo for low back pain. 1
• Limit extended analgesic courses to patients demonstrating clear ongoing benefit without major adverse events. 1

First‑Line Non‑Pharmacologic Management

• Advise patients to remain active as tolerated and continue ordinary activities within pain limits—this yields small improvements in pain and function compared with bed rest. 1, 2
• Avoid bed rest entirely, as it delays recovery and worsens outcomes. 1, 2
• Spinal manipulation (by a trained practitioner) is the only non‑pharmacologic intervention with proven short‑term benefit for acute low back pain <4 weeks, providing small‑to‑moderate improvements. 1
• Do not prescribe supervised or home exercise programs in the acute phase (<4 weeks), as they have not demonstrated effectiveness for acute low back pain. 1
• Reassure patients about the favorable natural history—most acute low back pain resolves spontaneously. 2

Imaging: The Critical "Do Not Order" Rule

Do not order any imaging (plain radiographs, CT, or MRI) during the initial evaluation of uncomplicated acute low back pain without red flags. 1, 2

• Routine imaging provides no clinical benefit and increases unnecessary healthcare utilization, including higher rates of injections, surgical interventions, and disability claims. 1, 2
• The majority of disc herniations undergo spontaneous reabsorption by approximately 8 weeks after symptom onset, rendering early imaging unhelpful. 1
• Imaging abnormalities (disc protrusions, bulges) are present in up to 43% of asymptomatic 80‑year‑olds and do not correlate with symptoms. 2
• Early imaging (<6 weeks) is associated with worse patient outcomes without any improvement in pain or function. 1

Follow‑Up and Reassessment Protocol

• Reassess at 2–4 weeks after initiating therapy to evaluate pain and functional status. 1, 2
• If symptoms persist beyond 4–6 weeks of optimal conservative management, consider MRI lumbar spine without contrast only if the patient is being evaluated as a potential surgical or interventional candidate. 1, 2
• Refer to a specialist within 2 weeks if pain is disabling and persists beyond 6 weeks despite conservative therapy. 2
• Epidural steroid injections may be considered for radiculopathy specifically (not axial back pain alone), with fluoroscopic guidance as the gold standard. 2

Psychosocial Risk Factor Assessment

Screen for yellow flags that predict chronic disability and poor outcomes:

• Depression or anxiety symptoms strongly predict chronic disability. 3
• Passive coping strategies: catastrophizing about pain and fear‑avoidance behaviors. 3
• Job dissatisfaction or work‑related stress. 3

Addressing these psychosocial factors early is essential for preventing progression to chronic low back pain. 3, 6

Common Pitfalls to Avoid

• Ordering imaging "just to be safe" leads to detection of incidental findings in asymptomatic individuals, triggering unnecessary interventions and worsening outcomes. 1
• Prescribing opioids for acute uncomplicated low back pain—there is no high‑quality evidence supporting their use, and they carry significant risks of dependence. 1
• Recommending bed rest—this consistently delays recovery and should never be advised. 1, 2
• Relying solely on red‑flag screening to rule out serious pathology—absence of red flags does not meaningfully decrease the likelihood of serious disease. 4