Back pain

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Back pain is experienced by most adults. The majority of cases are benign, nonspecific back pain (pain that is not attributable to a specific pathology). Spinal causes of acute back pain are conditions of the spinal column or surrounding muscles and soft tissue. Spinal causes include conditions that require urgent management to prevent or minimize permanent neurological dysfunction (e.g., spinal cord compression, spinal infections) and nonurgent causes (e.g., inflammatory arthritis, bone metastases without cord compression or unstable vertebral fracture). Nonspinal causes of back pain is referred pain from a thoracic, abdominal, pelvic, retroperitoneal, or cardiovascular cause. Assessment for red flag features of back pain and a focused neurological examination is required in all patients. Initial diagnostics and management should be guided by the pretest probability of the underlying condition. Patients with new neurological findings other than isolated unilateral radiculopathy require immediate imaging, typically MRI, and urgent spinal surgery consultation. Serious and life-threatening nonspinal causes, such as myocardial infarction and aortic pathology, should be considered particularly in patients with abnormal vital signs and no neurological abnormalities. Neurologically intact patients without red flags do not require urgent imaging and typically improve with nonpharmacological treatment options (e.g., superficial application of heat, massage), symptomatic treatment with NSAIDs, and early mobilization.

By etiology ^[2][3]

• Specific back pain
  • Back pain attributable to a pathophysiological condition (e.g., trauma, deformity, disease, injury, or infection); see “Etiology” section for details.
  • Mechanical back pain: specific back pain caused by disorders of the spine, intervertebral discs, or surrounding soft tissue ^[4]
• Nonspecific back pain: back pain that cannot be attributed to a specific cause after a full evaluation.
• Spinal causes: conditions of the spinal column or surrounding muscles and soft tissue
• Nonspinal causes: include thoracic, abdominal, pelvic, retroperitoneal, or cardiovascular conditions that can manifest with referred pain to the back.

By duration ^[2][5][6]

• Acute back pain: pain lasting ≤ 4 weeks
• Subacute back pain: pain lasting 4–12 weeks
• Chronic back pain: persistent or recurring back pain lasting > 12 weeks

By location

• Low back pain (LBP) ^[2][3]
  • Pain localized to the lumbar region (below the costal margin) and above the gluteal folds; may be associated with pain that radiates down the legs
  • LBP is typically further classified into three broad categories: ^[7]
    • Nonspecific LBP (most common) ^[8]
    • LBP associated with radiculopathy or spinal stenosis
    • LBP associated with a specific spinal cause (see “Spinal causes of back pain”)
• Upper back pain: pain localized to the thoracic spine region

By severity ^[9]

• Uncomplicated back pain: no red flag features of back pain
• Complicated back pain: presence of red flag features of back pain

• 2–3% of visits to the ED are for acute nontraumatic back pain. ^[10]
• In the US, low back pain affects up to 85% of individuals and, worldwide, is the leading cause of years lived with disability. ^[11][12][13]

Epidemiological data refers to the US, unless otherwise specified.

Trauma can cause both spinal and nonspinal causes of back pain.

Musculoskeletal

• Intervertebral disc herniation or disc protrusion
• Spinal stenosis
• Scoliosis
• Spinal osteoarthritis (spondylosis), degenerative disc disease
• Spondylolysis, spondylolisthesis
• Vertebral fractures
• Musculoskeletal spinal injury (back strain)
• Rib fractures

Neoplastic

• Spinal metastases
• Referred pain from primary neoplastic process (e.g., renal cancer, pancreatic cancer)
• Primary spinal tumors

Infectious

• Spinal epidural abscess
• Discitis
• Vertebral osteomyelitis
• Pott disease

Vascular

• Spinal epidural hematoma
• Spinal cord infarction

Inflammatory

• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis

Referred pain

• Cardiovascular: abdominal aortic aneurysm (AAA), aortic dissection, myocardial infarction, pericarditis
• Pulmonary: pneumonia, pleurisy, pulmonary embolism
• Gastrointestinal: esophageal perforation, esophageal spasm, perforated peptic ulcer, pancreatitis, cholecystitis, cholangitis
• Genitourinary: pyelonephritis, prostatitis, nephrolithiasis, hydronephrosis, renal infarction
• Other: psoas abscess, retroperitoneal hematoma

• Assess for red flag features of back pain in all patients.
• Duration of symptoms
• Evaluate for psychosocial risk factors
• Perform a thorough neurological examination to assess for any neurological deficits.
  • Sensation, power (motor strength), deep tendon reflexes, and superficial reflexes (e.g., Babinski reflex) below the level of the pain bilaterally (including relevant myotomes and dermatomes)
  • Signs of radiculopathy/nerve root irritation (e.g., straight leg raise test)
  • Perianal sensation and anal tone ^[10]

Red flag features on history or clinical examination indicate an urgent or serious underlying etiology.

Hypotension and bradycardia in a patient with signs of spinal cord compression are likely indicators of spinal shock. ^[18]

Pathological fractures, bone metastases, or referred pain (e.g., myocardial infarction, abdominal aortic aneurysm, aortic dissection) are more likely in older individuals with back pain.

Initial management approach

• Perform focused clinical history and examination.
• Assess for red flag features of back pain and risk stratify accordingly.
  • Low suspicion for serious or urgent etiology: supportive care, pain management, close follow-up and return precautions usually sufficient ^[8]
  • High suspicion for serious or urgent etiology: targeted and expedited evaluation to identify and treat the underlying cause, e.g., ^[10][19]
    • Concern for spinal infection: urgent MRI with and without IV contrast, empiric antibiotics, neurosurgery consult
    • Concern for compressive spinal emergency: urgent MRI spine with and without IV contrast, urgent neurosurgery consult; See “Management of compressive spinal emergencies.”
    • Suspected fracture: spinal precautions, XR spine; See “Management of traumatic back pain.”
• Evaluate and treat the underlying cause.
• Administer analgesics (preferably NSAIDs) after baseline neurological function and pain severity are documented. ^[7][10]

Most cases of acute, nonspecific back pain do not require imaging and improve without intervention. ^[20]

Acute spinal cord compression is a surgical emergency. Obtain immediate MRI or CT myelography, give IV glucocorticoids for malignant compression, and decompress the cord (e.g., with surgery) as soon as possible!

Imaging ^{[6][7][21][22]}

• Indications for imaging may include: ^[6]
  • Suspicion of a serious underlying etiology
  • Pain that persists despite at least 4–6 weeks of conservative management.

In patients presenting with acute back pain without red flags or neurological deficits, imaging is not typically indicated. ^[7]

Laboratory studies

• Laboratory studies are not routinely required for the evaluation of acute or chronic back pain.
• Consider obtaining laboratory studies based on the likely underlying etiology and/or the presence of red flags for back pain, e.g.:
  • CBC and inflammatory markers: for suspected spinal infections, inflammatory arthritis, or malignancy
  • Blood cultures: for suspected spinal infections
  • Serum calcium and vitamin D levels: for suspected fragility fractures

• Urgent spinal causes of back pain include conditions that cause, or have the potential to cause, permanent neurological damage or life-threatening complications.
• Immediate management is required for patients with severe and/or progressive neurological deficits. ^[10]

Acute urinary retention in a patient with sudden back pain and neurological deficits is strongly suggestive of cauda equina syndrome (90% sensitivity). ^[7]

Spinal boards should only be used for transport; remove patients from them on arrival at the hospital to reduce pain and prevent the development of pressure ulcers!

The following table outlines common symptoms following compression of the spinal cord or cauda equina. Patients may also present with symptoms of incomplete spinal cord syndromes depending on the location of compression.

Spinal cord compression, conus medullaris syndrome, and cauda equina syndrome are medical emergencies that have the potential to cause permanent neurological damage. ^[10]

Cauda equina syndrome typically manifests with lower motor neuron signs. Spinal cord compression and conus medullaris manifest with a combination of lower motor neuron signs (at the level of compression) and upper motor neuron signs (below the level of compression).

Management of compressive spinal emergencies

• Urgent MRI spine without contrast
• Consult neurosurgery for urgent surgical decompression.
• Document the patient's current neurological deficits and reassess frequently. ^[31]
• Bladder scan to evaluate postvoid residual; Insert Foley catheter for patients with urinary retention.
• Administer analgesics (preferably NSAIDs, see “Pain management”). ^[7][10]
• Treat the underlying cause (e.g., suspected malignant cord compression: high-dose IV dexamethasone ) ^[32]
• Admit the patient for frequent neurological examinations and definitive management.

Treatment of acute spinal cord compression varies based on the underlying etiology and may include decompressive surgery (e.g., for disc herniation) or IV steroids and radiation therapy (for malignant compression).

In young adults with back pain that does not improve with rest or medication and/or worsens at night, suspect inflammatory arthritis.

Patients with unilateral neurological symptoms resulting from radiculopathy typically do not require urgent spinal surgical management.

• Nonspinal back pain is referred pain that originates outside of the spinal cord, vertebral column, and back muscles. ^[7]

Nonspecific back pain is the most common type of back pain and accounts for the majority of cases of low back pain (LBP). ^[7]

Definition

• Pain that cannot be attributed to an underlying disease or structural lesion after a full evaluation

Risk factors ^[3][64]

• Poor posture
• Sedentary lifestyle, low level of physical activity
• Heavy lifting
• Older age
• Psychological stressors (e.g., stress, anxiety, depression)
• History of lumbar surgery ^[6]

Clinical features ^[4][7][8]

• Typically LBP
• Evaluation of back pain does not reveal an underlying cause.
  • No red flags for back pain ^[10]
  • Normal neurological examination ^[8]
  • No features suggestive of specific back pain (e.g., negative straight leg raise test)
• Usually resolves spontaneously within 6 weeks ^[2][65]

Imaging ^[3][4][6]

Imaging is not routinely recommended for the evaluation of nonspecific LBP.

• Indications
  • Progressive symptoms during conservative management
  • Persistent symptoms despite 6 weeks of conservative management (if the patient is a surgical candidate)
• Modalities
  • MRI lumbar spine without IV contrast
  • X-ray lumbosacral spine
  • CT lumbar spine without IV contrast

Management ^{[2][3][4][5][66][67]}

• Reassure patients and provide patient education.
• Initiate conservative management alone or in combination with nonselective NSAIDs.
• For patients with risk factors for chronic back pain, consider more intensive therapy and multidisciplinary involvement.
• Reassess symptoms in 4–6 weeks or earlier if symptoms worsen during conservative management.
• Persistent symptoms despite 6 weeks of conservative management
  • Consider alternative causes of back pain.
  • Consider imaging for back pain if there is diagnostic uncertainty or to evaluate candidacy if surgery is being considered. ^[6]
  • Consider referral to specialists. ^[2]

Patient education ^{[2][4][5][66]}

• Maintain daily activities, including work and sports; avoid bed rest. ^[2][10]
• Stretching, exercises, and appropriate ergonomics for LBP
• Avoid movements that aggravate pain
• Reassurance and expectation management
• Self-management of pain

Conservative management of nonspecific back pain and analgesia ^{[2][3][4][5][66]}

• Conservative management is the preferred, first-line management of nonspecific LBP.
• When analgesics are required, nonselective NSAIDs are preferred.
• In older adults, avoid skeletal muscle relaxants and use NSAIDs with caution because of the risk of adverse effects; see “Principles of pharmacotherapy for older adults.” ^[5]
• Glucocorticoids and back traction are not recommended for the treatment of back pain. ^[2][66]

Acute and subacute LBP

• Assess for risk factors for chronic back pain, which include: ^{[2][3][7][68]}
  • Severe pain and functional impairment ^[2]
  • Psychosocial and workplace factors ^[2][69][70]
  • Previous episodes of LBP ^[2]
  • Use of non-evidence-based management ^[68]
• Patients at low risk for chronic back pain: ^[68]
  • Initial conservative management
    • Superficial heat and/or massage
    • Spinal manipulation
    • Acupuncture
  • Pain management
    • Preferred: nonselective NSAIDs (e.g., ibuprofen , naproxen ) ^{[2][5][71][72]}
    • Alternatives: Consider a short-term (< 3 weeks) nonbenzodiazepine muscle relaxant, e.g., cyclobenzaprine. ^[3][5]
• Patients with risk factors for chronic back pain: Consider more intensive initial multidisciplinary rehabilitation. ^[3][7]

Patients with risk factors for chronic back pain are likely to benefit from early multidisciplinary rehabilitation rather than reassurance and patient education alone. ^[7][68]

Chronic LBP or patients at high risk for chronic LBP

• Initial conservative management ^[3]
  • Behavioral therapy
  • Structured exercise programs
  • Mobility assistive devices if needed
  • Consider adjunctive therapies. ^[2][5][66]
• Pain management
  • Preferred: nonselective NSAIDs (e.g., ibuprofen , naproxen ) ^{[2][5][71][72]}
  • Alternative: Consider short-term (< 3 months) topical capsicum. ^[2][66]
  • Avoid routine use of:
    • Adjuvant analgesics (e.g., skeletal muscle relaxants, antidepressants) ^{[2][3][5][66][73]}
    • Opioids (see “Opioids for chronic noncancer pain”) ^[2][5][66]

Interventional therapy ^[2][4][74]

• Interventional therapy is rarely required for nonspecific LBP; Refer patients with refractory disabling LBP to specialists (e.g., spine surgeons) for consideration of interventional management.
• Possible benefit: radiofrequency ablation
• Limited evidence of benefit: epidural steroid injections, spinal cord stimulation, surgery (e.g., discectomy, SI joint fusion)

Regular exercise combined with patient education (e.g., on posture, safe techniques for lifting and handling, and muscle strengthening) are effective preventive measures for back pain. ^[75][76][77]

Etiology

• Major trauma: e.g., motor vehicle accidents, direct high-impact injuries, fall from a height in a young, otherwise healthy individual
• Minor trauma in individuals at risk of fragility fractures: low-impact injuries, such as a minor fall or lifting heavy weights

Management of traumatic back pain

• Polytrauma patients: See “Management of trauma patients.”
• Spinal immobilization if the likelihood of unstable vertebral fracture or spinal cord compression is high
• Administer analgesics (preferably NSAIDs) after baseline neurological function and pain severity are documented (see “Pain management”).
• Obtain urgent spinal surgery or neurosurgery consult in patients with new or progressive neurological abnormalities.
• Obtain imaging. ^[78]
  • Preferred initial imaging modality: CT thoracic and lumbar spine without IV contrast .
  • Thoracolumbar injury detected on CT:
    • MRI thoracic and lumbar spine without IV contrast
    • Alternatively, CT myelogram to identify spinal cord compression or injury (see “Urgent spinal causes of back pain”)
• Further management depends on imaging findings

Consider imaging the entire spine, as injuries may occur at multiple levels.

Complications

• Vertebral fractures
• Intervertebral disc prolapse
• Spinal epidural hematoma
• Acute spinal cord compression (due to any of the above causes)
• Soft tissue injury

• Obtain a focused history and examination to distinguish between urgent spinal and nonspinal causes.
• Assess for red flag features of back pain.
• Suspected unstable vertebral fractures or history of significant trauma: Initiate immediate spinal precautions.
• Administer analgesics (preferably NSAIDs) after baseline neurological function and pain severity are documented (see “Pain management”).
• Order urgent initial imaging according to pretest probability of the underlying cause: See “Approach to imaging in back pain.”
• Catheterize patients with bladder dysfunction.
• Obtain urgent consults based on suspected/confirmed etiology
• Administer immediate medical management as needed (e.g., IV glucocorticoids for malignant cord compression, empiric antibiotic therapy for spinal infections).