One-liner#
Adult/geriatric approach to acute vs chronic low back pain: separate mechanical vs radicular vs red-flag etiologies, and set an outpatient-safe initial plan.
Quick nav#
- Red flags / send to ED
- Key history
- Focused exam
- Differential (quick pattern recognition)
- Workup
- Initial management
- Management by diagnosis
- Follow-up
- Patient instructions
- Smartphrase snippets
Red flags / send to ED#
- Suspected cauda equina: urinary retention/overflow incontinence, saddle anesthesia, new bilateral leg weakness, rapidly progressive neurologic deficits
- Suspected spinal infection: fever/systemic illness plus focal severe back pain (esp. IVDU, immunosuppression, recent bacteremia/procedure)
- Suspected fracture/instability: major trauma, or minor trauma with osteoporosis/older age, chronic steroid use
- Suspected malignancy: known cancer, unexplained weight loss, pain at rest/night, failure to improve as expected
- Suspected AAA or other vascular catastrophe: back/abdominal pain with hypotension/syncope, pulsatile mass, severe constant pain
- Any new objective focal neuro deficit that is progressive (motor weakness > sensory symptoms)
Key history#
- Time course: acute (<6 weeks) vs subacute/chronic; sudden vs gradual; first episode vs recurrent
- Trigger: lifting/twist, fall/trauma, prolonged sitting, new activity; occupational exposures
- Location/radiation: midline vs paraspinal vs buttock; radiation below knee; unilateral vs bilateral
- Neurologic symptoms: weakness, numbness, “pins/needles,” foot drop, gait change
- Bowel/bladder/saddle symptoms (screen every time)
- Systemic/infection risk: fever, chills, recent infection, IVDU, immunosuppression, diabetes, recent spinal injection/surgery
- Cancer/fracture risk: history of cancer, osteoporosis, chronic steroids, unexplained weight loss, night pain
- Functional impact: sleep, walking tolerance, work; what the patient is avoiding because of pain
- Prior care: prior imaging, PT, injections, surgery; response to NSAIDs/heat/activity modification
Focused exam#
- Vitals, general appearance, fever
- Gait (antalgic, foot drop), sit-to-stand; ability to heel/toe walk
- Lumbar ROM (pain with flexion/extension); palpation for focal midline tenderness (fracture concern)
- Neuro screen (compare sides): strength (hip flexion, knee extension, ankle dorsiflexion, great toe extension, plantarflexion), sensation, reflexes
- Straight-leg raise / crossed SLR (radicular pain); femoral stretch test if anterior thigh symptoms
- Hip exam if pain is “back” but really hip (ROM, FABER/FADIR as appropriate)
- If cauda equina suspected: perineal sensation, anal wink/tone (urgent evaluation)
Differential (quick pattern recognition)#
Common/likely (outpatient)#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Mechanical low back pain (strain/sprain) | “Pulled muscle,” “tight/spasms,” worse with bending/lifting | After activity, improves with movement; no true neuro symptoms | Paraspinal tenderness; neuro exam normal | Activity as tolerated, heat, NSAID/topical, home exercises/PT |
| Lumbar radiculopathy (disc herniation) | “Sciatica,” “shooting,” “burning,” “electric,” numbness/tingling | Radiates below knee in dermatomal pattern; worse with cough/sneeze | +SLR; sensory/reflex changes; possible motor weakness | Conservative care if stable; urgent imaging if progressive motor deficit |
| Lumbar spinal stenosis | “Legs get heavy,” “can’t walk far,” “better leaning forward” | Older; neurogenic claudication; better with sitting/flexion | Often normal at rest; symptoms with walking/extension | Flexion-based PT, activity pacing; imaging if persistent/consider procedures |
| Facet arthropathy | “Stiff,” “worse standing,” “worse extension” | Older; worse with extension/rotation | Pain with extension/rotation; neuro exam normal | NSAIDs/topicals, PT; consider injections/referral if refractory |
| SI joint pain | “Pain near one dimple,” buttock pain | Worse with prolonged standing/transitions | Tender over SI; provocative tests may reproduce pain | PT/core/glute strengthening; consider injection if persistent |
| Hip OA referred as back pain | “Groin pain,” “can’t put on socks” | Pain with weight-bearing; limited hip ROM | Decreased hip internal rotation; pain with hip ROM | Hip-focused evaluation and management; consider hip imaging |
Can’t-miss / urgent#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Cauda equina | “Can’t pee,” “numb when I wipe,” bilateral symptoms | Urinary retention/incontinence, saddle anesthesia, bilateral weakness | Objective weakness, decreased perineal sensation | ED now; emergent MRI/neurosurgery |
| Spinal epidural abscess / discitis | “Worst back pain,” “feels sick” | Fever or recent bacteremia; IVDU/immunosuppression | Focal severe tenderness; neuro may be normal early | ED now; ESR/CRP, MRI, blood cultures |
| Vertebral compression fracture | “Sudden pain after minor strain,” “can’t stand up” | Older/osteoporosis/steroids; focal midline pain | Midline tenderness; kyphosis | Same-day imaging; pain control; consider osteoporosis workup |
| Malignancy/metastasis | “Pain at night,” “won’t go away” | Cancer history, weight loss; progressive symptoms | Possible neuro deficits; midline tenderness | Urgent evaluation; MRI if suspicion high |
| AAA | “Back and belly pain,” syncope | Vascular risk; hypotension; severe constant pain | Pulsatile abdominal mass (often absent) | ED now; emergent imaging |
Workup#
- No imaging for uncomplicated acute low back pain (<6 weeks) without red flags or objective neuro deficit.
- If symptoms are clearly radicular but stable (no progressive weakness), avoid early MRI; treat conservatively and image if it will change management (e.g., procedure/surgery consideration).
- X-ray: suspected fracture; older/osteoporosis with focal midline tenderness; persistent pain not improving as expected (context-dependent).
- MRI (urgent): progressive motor deficit, cauda equina concern, suspected infection/malignancy.
- MRI (non-urgent): persistent radicular symptoms not improving with conservative care and considering injections/surgery.
- Labs (when indicated): CBC + ESR/CRP if infection/malignancy concern; UA if urinary symptoms suggest stone/pyelo rather than spine.
When NOT to image:
- Acute mechanical low back pain <6 weeks without red flags
- Chronic low back pain that has been stable and previously evaluated
- “Just to see what’s there”—degenerative findings are ubiquitous and often not clinically relevant
Initial management#
- Reassure and set expectations: most mechanical/radicular episodes improve over weeks.
- Encourage activity as tolerated; avoid prolonged bed rest; consider “relative rest” from provoking movements.
- Symptom relief options (choose based on comorbidities/contraindications; verify local protocol/formulary)—see medication tables below.
- Start home exercise plan and/or refer to PT early if function-limiting or recurrent.
- Avoid escalation to opioids except rare, carefully selected cases; reassess diagnosis if pain is severe and out of proportion.
Analgesic options#
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Acetaminophen | 650–1000 mg q6–8h; max 3 g/day (2 g/day if liver disease/alcohol) | Severe hepatic impairment; chronic alcohol use (reduce max dose) | LFTs if prolonged use or hepatic risk | $ | First-line adjunct; limited efficacy alone for back pain but safe add-on |
| Ibuprofen | 400–600 mg q6–8h with food; max 2400 mg/day | CKD (eGFR <30), active GI bleed/ulcer, uncontrolled HTN, HF, anticoagulation | Cr, BP if prolonged use; GI symptoms | $ | Effective for inflammatory/mechanical pain; limit to 7–10 days if possible |
| Naproxen | 250–500 mg q12h; max 1000 mg/day | Same as ibuprofen | Same as ibuprofen | $ | Longer half-life; convenient BID dosing |
| Diclofenac gel 1% | Apply 4 g to affected area QID; max 16 g/day per joint | Avoid on broken skin; caution if systemic NSAID contraindications | Minimal systemic absorption | $$ | Good for localized pain; lower GI/renal risk than oral NSAIDs |
| Meloxicam | 7.5–15 mg daily | Same as ibuprofen; avoid if sulfonamide allergy | Same as ibuprofen | $ | Once-daily dosing; COX-2 preferential (slightly lower GI risk) |
Muscle relaxants (short-term use for prominent spasm)#
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Cyclobenzaprine | 5–10 mg TID or 5 mg at bedtime; max 30 mg/day | Arrhythmia, recent MI, hyperthyroidism, MAOIs; avoid in elderly (Beers) | Sedation, anticholinergic effects | $ | Most studied; highly sedating—use lowest dose at bedtime; limit to 1–2 weeks |
| Methocarbamol | 750–1500 mg TID–QID; max 6 g/day | Renal impairment (use caution) | Sedation | $ | Less sedating than cyclobenzaprine; reasonable alternative |
| Tizanidine | 2–4 mg q6–8h; max 36 mg/day | Hepatic impairment; concurrent CYP1A2 inhibitors (cipro, fluvoxamine) | LFTs at baseline and periodically; sedation, hypotension | $ | Alpha-2 agonist; can cause hypotension; useful if cyclobenzaprine not tolerated |
| Baclofen | 5 mg TID, titrate to 10–20 mg TID; max 80 mg/day | Renal impairment (renally cleared); abrupt withdrawal risk | Sedation; do not stop abruptly | $ | Less anticholinergic; requires slow taper if used >2 weeks |
When NOT to prescribe muscle relaxants:
- Elderly patients (fall risk, anticholinergic burden)—if needed, use lowest dose at bedtime only
- Concurrent sedatives, opioids, or alcohol use
- Prolonged use (>2 weeks) without reassessment
Oral steroids for acute radiculopathy (controversial)#
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Prednisone | 40–60 mg daily × 5 days (no taper needed for short course) | Uncontrolled DM, active infection, psychosis history | Blood glucose in diabetics | $ | Evidence is mixed; may provide short-term pain relief but no long-term benefit; discuss with patient |
| Methylprednisolone dose pack | 4 mg tabs, tapered over 6 days per package | Same as prednisone | Same as prednisone | $ | Convenient but lower total dose than prednisone burst; no evidence it’s better than prednisone |
When to consider oral steroids:
- Acute radiculopathy with significant pain limiting function
- Patient prefers to try before considering injections/surgery
- Short-term bridge while awaiting PT or specialist evaluation
When NOT to use oral steroids:
- Mechanical back pain without radicular component (no benefit)
- Uncontrolled diabetes (will spike glucose significantly)
- Recurrent use (not a long-term strategy)
- Chronic radiculopathy (no evidence of benefit)
Management by diagnosis#
Mechanical low back pain (strain/sprain)#
Education: Safe to stay active; brief flare-ups are common; “hurt ≠ harm” if no red flags.
Treatment:
- Heat, topical/oral analgesics as appropriate (see tables above)
- Early mobility: short, frequent walks; avoid bed rest
- PT/home program: hip hinge mechanics, core/hip strengthening, graded return to lifting
- Work/activity note: temporary restrictions can help patients stay active safely (avoid total inactivity)
Follow-up: 1–2 weeks if not improving or function-limiting; sooner if new neuro symptoms.
Lumbar radiculopathy (disc herniation)#
Education: Leg symptoms can take weeks to months to resolve; watch for progressive weakness.
Treatment:
- Activity modification without immobilization; avoid prolonged sitting if it worsens symptoms
- PT (often includes directional preference work, nerve glides, graded strengthening)
- Analgesics as above; treat pain enough to maintain function
- Consider gabapentinoids for neuropathic component if NSAIDs insufficient (see table below)
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Gabapentin | 100–300 mg at bedtime, titrate by 100–300 mg q3–7 days; target 300–600 mg TID | Renal impairment (reduce dose); sedation risk | Sedation, dizziness; Cr for dose adjustment | $ | Start low, go slow; takes 2–4 weeks for effect; taper to discontinue |
| Pregabalin | 25–75 mg BID, titrate to 150–300 mg BID | Renal impairment (reduce dose); HF (edema risk) | Sedation, edema, weight gain | $$$ | Faster onset than gabapentin; Schedule V controlled substance |
| Duloxetine | 30 mg daily × 1 week, then 60 mg daily | Hepatic impairment; concurrent MAOIs; uncontrolled glaucoma | BP, mood; hepatic function if risk | $$ | SNRI; also helps if comorbid depression/anxiety; avoid abrupt discontinuation |
Referral: Consider spine referral if persistent disabling symptoms despite 6–8 weeks conservative care or if considering procedures.
Follow-up: 1–2 weeks if significant symptoms; urgent re-eval for new/worsening weakness, bowel/bladder symptoms.
Lumbar spinal stenosis (neurogenic claudication)#
Education: Symptoms often posture-dependent; flexion can be relieving; this is a chronic condition.
Treatment:
- Flexion-based PT, pacing strategies, and walking aids as needed
- Analgesics as above; gabapentinoids may help neurogenic symptoms
- Consider imaging if symptoms persist and results would change management (e.g., injections/surgical discussion)
Referral: Consider when walking tolerance remains poor despite 6–8 weeks of rehab.
Follow-up: 4–6 weeks; earlier if rapid decline or objective deficits.
Vertebral compression fracture (suspected/confirmed)#
Education: Evaluate for osteoporosis and fall risk; set expectations for gradual improvement over 6–12 weeks.
Treatment:
- Analgesia (acetaminophen preferred; NSAIDs short-term if needed; avoid muscle relaxants in elderly)
- Short-term bracing in select cases; early mobilization
- Assess/treat osteoporosis risk (DXA pathway, calcium/vitamin D status, fall-risk interventions) per local protocol
- Consider referral based on severity or persistent functional limitation
Follow-up: Within 1 week; urgent escalation if neuro deficits or uncontrolled pain.
See also: Osteoporosis problem page for comprehensive bone health management.
Chronic low back pain (>12 weeks)#
Education: Chronic pain is complex; goal is function improvement, not necessarily pain elimination. Hurt ≠ harm.
Treatment:
- Multimodal approach: PT (active rehab, not passive modalities), cognitive-behavioral strategies, sleep optimization
- Avoid opioid escalation; if already on opioids, consider tapering with support
- Consider duloxetine or low-dose TCA (amitriptyline 10–25 mg at bedtime) for central sensitization component
- Address psychosocial factors: depression, anxiety, catastrophizing, work/disability issues
- Injections (epidural, facet, SI joint) may provide temporary relief but are not curative; use as bridge to active rehab
When to refer:
- Pain psychology/chronic pain program if significant functional impairment
- PM&R or pain management for procedural options
- Spine surgery only if clear structural pathology correlating with symptoms
What NOT to do:
- Repeated imaging without new symptoms (degenerative findings are ubiquitous)
- Escalating opioids for chronic non-cancer pain
- Passive treatments only (massage, chiro, acupuncture) without active rehab component
Follow-up#
- Typical: Reassess in 1–2 weeks for acute pain that limits function or is not clearly improving.
- Re-evaluate sooner if pain rapidly worsens, new fever/systemic symptoms, new objective weakness, or new bowel/bladder changes.
- If not improving by 4–6 weeks, reconsider the diagnosis (hip pathology, inflammatory disease, fracture) and escalate (PT adherence, imaging, referral).
Patient instructions#
- Stay active as tolerated (short, frequent walks); avoid prolonged bed rest.
- Use heat 15–20 minutes at a time for muscle spasm/tightness.
- Consider over-the-counter pain options if safe for you (avoid NSAIDs if kidney disease, ulcers, blood thinners, etc.; avoid excess acetaminophen if liver disease).
- Do the exercises your provider or physical therapist recommends.
- Call or seek urgent care now for: trouble urinating, new bowel/bladder accidents, numbness in the groin/saddle area, new leg weakness, fever with worsening back pain, or severe pain after a fall.
Smartphrase snippets#
Acute mechanical LBP, reassurance:
Acute low back pain without red flags; neuro exam intact. Discussed expected course (most improve within 2–4 weeks), activity as tolerated, home exercise/PT, analgesic options, and strict return precautions for weakness, numbness, or bowel/bladder changes.
Radiculopathy, conservative management:
Lumbar radiculopathy with [dermatomal] symptoms; no progressive motor deficit. Plan: conservative management with activity modification, PT referral, and analgesics. Discussed that most disc herniations improve without surgery. Return precautions reviewed; will reassess in 2 weeks or sooner if worsening weakness.
Related pages#
Complaint pages#
- Neck pain — cervical spine complaints
- Hip pain — hip pathology referred as back pain
- Numbness/Tingling — radicular symptoms
- Weakness — if motor deficit
- Falls (geriatric) — if fall-related injury
Problem pages#
- Osteoarthritis — chronic joint disease management including facet arthropathy
- Osteoporosis — bone health, fracture prevention, and compression fracture management
- Gout — if crystal arthropathy suspected in spine (rare but consider in polyarticular presentations)
Referral for persistent symptoms:
Persistent low back pain with [radicular symptoms/functional limitation] despite [X weeks] conservative care. Referring to [spine/PM&R/pain management] for evaluation and consideration of [imaging/injections/surgical consultation]. Continue current management pending appointment.