What is the recommended initial conservative (non‑surgical) management for a patient with low back pain who has no red‑flag features?

Initial Conservative Management of Low Back Pain Without Red Flags

For a patient with low back pain and no red-flag features, immediately start oral NSAIDs (or acetaminophen if NSAIDs are contraindicated), advise the patient to remain active and avoid bed rest, provide reassurance about the favorable natural history, and do not order any imaging studies. 1

Pharmacologic First-Line Therapy

• Prescribe oral NSAIDs as the primary medication choice because they provide moderate short-term pain relief with stronger evidence than other analgesics—approximately 10 points greater improvement on a 100-point pain scale compared to acetaminophen. 1
• Specific NSAID regimens include ibuprofen 400–800 mg three times daily, naproxen 500 mg twice daily, or diclofenac 50 mg twice daily, all taken orally with food. 1
• Acetaminophen (up to 4 g daily) is the appropriate alternative when NSAIDs are contraindicated due to cardiovascular, gastrointestinal, or renal risk factors, though it is slightly less effective. 1
• Add a skeletal muscle relaxant for short-term use if NSAIDs or acetaminophen provide insufficient relief, recognizing moderate sedation risk. 1
• Avoid systemic corticosteroids entirely because high-quality evidence demonstrates no benefit over placebo for low back pain. 1
• Reserve opioids as a last resort only for severe, disabling pain uncontrolled by first-line agents, and prescribe time-limited courses with careful monitoring due to abuse potential. 1

Activity and Patient Education

• Instruct patients to stay active and continue usual daily activities within pain-limited tolerance—this approach is more effective than bed rest and reduces functional disability. 1, 2
• Explicitly discourage bed rest because it worsens outcomes; brief rest for severe symptoms is acceptable, but patients should resume normal activities as soon as possible. 2
• Reassure patients that approximately 90% of acute low back pain episodes resolve within 6 weeks regardless of specific treatment, and that most improve substantially within the first month. 2, 3
• Provide evidence-based self-care materials (such as "The Back Book") because they are nearly as effective as more costly interventions. 2

Non-Pharmacologic Adjuncts

• Apply superficial heat (heating pads or blankets) for short-term symptomatic relief of acute low back pain. 1, 2
• Consider spinal manipulation by a trained practitioner because it yields small-to-moderate short-term improvements in pain and function for acute low back pain of less than 4 weeks' duration. 1
• Supervised or home exercise programs are not recommended in the initial acute phase (< 4 weeks) because they have not demonstrated effectiveness during this period. 1

Imaging: When to Avoid and When to Consider

• Do not order any imaging (X-ray, MRI, or CT) during the initial evaluation because routine imaging provides no clinical benefit, increases unnecessary healthcare utilization, and often reveals incidental findings that prompt unwarranted interventions. 1, 4
• Imaging before 6 weeks is the single most common error leading to unnecessary procedures, higher rates of injections and surgery, and poorer outcomes. 1, 4
• Consider MRI lumbar spine without contrast only after 4–6 weeks of failed conservative therapy and only in patients who are potential candidates for surgery or epidural steroid injection. 1, 4
• The majority of disc herniations spontaneously reabsorb or regress by approximately 8 weeks after symptom onset, supporting the conservative approach. 1, 4

Red-Flag Screening and Immediate Imaging Indications

• Screen every patient for cauda equina syndrome (urinary retention or incontinence, saddle anesthesia, bilateral lower-extremity weakness, loss of anal sphincter tone) because these findings mandate emergency MRI and urgent surgical referral. 1, 2
• Progressive motor deficits such as new foot drop also require immediate imaging to prevent permanent neurologic injury. 1, 4
• Cancer-related red flags—unexplained weight loss, history of malignancy, or night pain unrelieved by rest in patients over 50 years—require prompt imaging. 1
• Infection red flags—fever, intravenous drug use, immunosuppression, or recent spinal procedure—mandate immediate MRI and infectious-disease evaluation. 1

Follow-Up and Reassessment Algorithm

• Reassess pain and functional status within 2–4 weeks of initiating therapy to evaluate response to conservative management. 1
• At 2 weeks, administer the STarT Back questionnaire to risk-stratify patients into low, medium, or high risk, directing appropriate therapeutic resources. 2
• For medium-risk patients, refer to physiotherapy and develop a patient-centered management plan. 2
• For high-risk patients (presence of psychosocial factors such as anxiety, depression, catastrophizing, fear-avoidance beliefs, or work dissatisfaction), arrange a comprehensive biopsychosocial assessment and consider psychological interventions if no improvement by 12 weeks. 2
• If symptoms persist beyond 4–6 weeks without improvement, consider imaging at that point only if the patient may be a candidate for interventional procedures or surgery. 1, 4

Common Pitfalls to Avoid

• Never order imaging "just to be safe" in the absence of red flags because it leads to detection of incidental findings in asymptomatic individuals, triggering unnecessary interventions and worsening outcomes. 1
• Do not prescribe prolonged bed rest because it increases disability and delays recovery. 1, 2
• Avoid prescribing opioids as initial therapy due to abuse potential and lack of superior efficacy compared to NSAIDs. 1, 2
• Monitor all NSAID use for gastrointestinal, cardiovascular, and renal adverse effects, especially with prolonged use or in high-risk patients. 1