Acute back pain

Last updated: June 14, 2023

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Summary

Acute back pain, typically defined as lasting less than 4–6 weeks, 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). In rare cases, back pain may be referred pain resulting from thoracic, abdominal, pelvic, retroperitoneal, or cardiovascular causes. 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. Assessment for red flag features of acute 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. 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.

Epidemiology

Up to 8 out of 10 individuals experience low back pain in their lifetime. ^[2]
2–3% of visits to the ED are for acute nontraumatic back pain. ^[3]
85% of patients with acute low back pain have nonspecific back pain. ^[4]
Approx. 2% of patients presenting with acute back pain have an underlying etiology that requires urgent management. ^[4]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Spinal causes of acute back pain are conditions of the spinal column or surrounding muscles and soft tissue; these can be divided into:
- Urgent spinal causes: conditions that cause, or have the potential to cause, permanent neurological damage or life-threatening complications
- Nonurgent spinal causes: conditions that require specific (but not immediate) treatment
Nonspinal causes include thoracic, abdominal, pelvic, retroperitoneal, or cardiovascular conditions that can manifest with referred pain to the back.

Common etiologies of acute back pain
Origin	Spinal	Nonspinal
Musculoskeletal	Cauda equina syndrome Conus medullaris syndrome Vertebral fractures Muscular strain Intervertebral disk herniation Spinal stenosis Spondylolisthesis	Rib fractures
Neoplastic	Spinal metastases Primary spinal tumors	Renal malignancy Pancreatic malignancy
Infectious	Spinal epidural abscess Diskitis Osteomyelitis Pott disease	Intrathoracic: pneumonia, pericarditis, pleurisy Intraabdominal: cholecystitis, cholangitis Genitourinary: pyelonephritis, prostatitis Retroperitoneal: psoas abscess
Vascular	Spinal epidural hematoma Spinal cord infarction	Abdominal aortic aneurysm Aortic dissection Pulmonary embolism Myocardial infarction Renal infarction Retroperitoneal hematoma
Other	Inflammatory arthropathies, e.g.: Ankylosing spondylitis Psoriatic arthritis Reactive arthritis	Intrathoracic Esophageal perforation Esophageal spasm Intraabdominal Perforated ulcer Pancreatitis Genitourinary Renal colic Hydronephrosis

Traumatic back pain

Significant trauma related to age ^[5]

Significant trauma related to age is a red flag feature of acute back pain; examples include:

Motor vehicle accidents, direct high-impact injuries, fall from a height in a young, otherwise healthy individual
Low-impact injuries, such as a minor fall or lifting heavy weights in individuals with risk factors for fragility fractures

Etiology of traumatic acute back pain

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

Acute management

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. ^[6]
- 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 acute back pain”)
Further management depends on imaging findings: See “urgent spinal causes of acute back pain”, “nonurgent spinal causes of acute back pain”, and “nonspecific back pain” for details.

Consider imaging the entire spine, as injuries may occur at multiple levels. $Vertebral compression fractures$

Nonurgent spinal causes

Nonurgent spinal causes refers to conditions that require specific (but not immediate) treatment.

Nonurgent spinal causes of acute back pain
Common etiologies	Characteristic clinical features	Diagnostics ^[7]	Treatment
Spinal stenosis ^[8]^[9]	Risk factors: older patients (> 60 years of age) Clinical features Pain in buttocks and legs that worsens on walking or standing (neuropathic claudication) Pain improves on sitting or bending forward Low back pain (not always present) Wide-based gait Thigh pain after 30 seconds of lumbar extension	Preferred initial imaging modality: MRI spine without IV contrast (confirmatory test) ^[10] Compression of the cord may be visible. Narrowing of the spinal canal Alternatives CT myelography if there are contraindications to MRI; similar findings to MRI X-ray: degenerative spine alterations	Conservative NSAIDs Physiotherapy Epidural steroid injections Nonurgent surgical consult for decompression in severe stenosis or in moderate stenosis if conservative treatment fails For further information, see “Treatment of spinal stenosis.”
Intervertebral disk herniation ^[11]	Risk factors ^[12] Repetitive weight lifting Smoking Clinical features Unilateral radicular pain (commonly L4/L5 and L5/S1 with positive straight leg raise test) ^[13] Paresthesia and muscle weakness	Preferred initial imaging modality: MRI spine without contrast (gold standard) ^[4] Intervertebral disk herniation Signs of cord or nerve root compression may be present. Alternative: CT myelography if there are contraindications to MRI; similar findings to MRI	Conservative Continuation of activity (no bed rest) NSAIDs Surgical decompression: in cases of severe/progressive neurological deficits or evidence of spinal cord compression
Spondylolisthesis ^[14]^[15]	Risk factors ^[16] Congenital lumbar and sacral spinal defects High-impact activities Degenerative changes secondary to aging Spondylolysis Clinical features Pain that worsens with activity Pain may radiate to the thighs. Possible radicular syndromes, symptoms of neuropathic claudication	Preferred initial imaging modality : x-ray of the spine (lateral view) ^[10] Anterior displacement of the vertebral body Alternatives CT spine: similar findings to x-ray; higher sensitivity MRI spine or CT myelography may show associated spinal stenosis.	Conservative Physiotherapy Orthotic braces Steroid/anesthetic injections for radicular pain Surgery: if conservative treatment fails or patients develop signs of spinal stenosis Vertebral fusion Decompression For further information, see “Treatment of spondylolisthesis.”
Bone metastases ^[4]	Risk factors History of cancer ^[4] Advanced age Clinical features Pain that worsens at night Localized spinal pain that may radiate to the shoulder and neck (common in spinal metastases) Thoracic pain ^[4] Weight loss, night sweats A sudden increase in pain secondary to pathological fracture	Laboratory studies ↑ ALP CBC: may show anemia Serum calcium: may be elevated in myeloma or hypercalcemia of malignancy Serum total protein: may be elevated in myeloma Preferred initial imaging modality: MRI with IV contrast Areas of T2 hyperintensity within the vertebral body ^[17] Alternative: CT with and without contrast if there are contraindications to MRI Additional imaging: in patients with unknown primary malignancy	Consult oncology and spine surgery for locoregional control (e.g., surgical stabilization and radiation therapy). ^[18] Consider osteoclast inhibitors (bisphosphonates, denosumab). ^[19] See “Urgent spinal causes of acute back pain” for malignant cord compression and vertebral fractures.
Inflammatory back pain (ankylosing spondylitis, reactive arthritis, psoriatic arthritis)	Risk factors: typically occur in teenagers and adults aged 20–40 years ^[4] Clinical features ^[20] Insidious onset of pain Pain mostly at rest or at night Symptoms improve with activity. ^[4] Restricted spinal mobility (e.g., on Schober test) Extra‑articular symptoms may be present.	Laboratory studies CBC: may show elevated WBC and/or normocytic normochromic anemia Inflammatory markers: ↑ CRP, ↑ ESR HLA-B27: may be positive in patients with ankylosing spondylitis Autoantibodies: Anti-CCP, ANA, ANCA, or other antibodies may be positive. STI testing: Chlamydia or gonorrhea infection can trigger reactive arthritis. Preferred initial imaging modality: X-ray sacroiliac joints and lumbar spine: inflammatory changes, including erosion, sclerosis, ankylosis, and vertebral body squaring ^[21]^[22] Additional imaging MRI without and with IV contrast: high signal intensity representing inflammatory changes ^[21]^[23] CT sacroiliac joints (with or without lumbar spine) without contrast: if there are contraindications to MRI: similar findings to x-ray	Consult rheumatology. NSAIDs, DMARDs Physical therapy Surgery in severe cases For further information, see “Treatment” sections in “Ankylosing spondylitis,” “Reactive arthritis,” and “Psoriatic arthritis.”

Lumbar spinal stenosis Degenerative disk disease with disk extrusion Spinal disk herniation with migration (1/3) Spondylolisthesis Sacroiliitis Lumbar ankylosing spondylitis Bilateral sacroiliitis in ankylosing spondylitis

Nonspecific back pain

Nonspecific back pain is one of the most common types of back pain; . It often occurs secondary to muscular or ligamentous strain and usually resolves spontaneously within 4–6 weeks.

Risk factors ^[4]

Obesity
Inactivity, smoking
Advanced age

Characteristic clinical features ^[4]

Acute back pain and paravertebral stiffness, difficulty bending
No neurological abnormalities (e.g., no loss of sensory or motor function)
Pain may radiate to the gluteal region or posterior aspect of the thighs; but not below the knees
Tenderness over lumbar spine may be present
Negative straight leg raise tests

Diagnostics ^[10]^[24]^[25]

Not routinely required
Consider imaging for pain persisting for > 4 weeks despite conservative management.
Imaging findings are nonspecific.

Treatment ^[4]^[26]^[27]

Patient education
- Recommend early mobilization and reassure patients that activity will not worsen their condition. ^[3]
- Inform patients that most cases of acute back pain self-resolve in 4–6 weeks.
- Set realistic expectations: Pain is likely to be improved but not eradicated by treatment.
Consider nonpharmacological treatment (e.g., local heat application, massage, spinal manipulation therapy, acupuncture) alone or as adjunctive therapy with pharmacological treatment. ^[26]
Pharmacological treatment
- First-line: NSAIDs (see “Oral analgesics” for dosage information) ^[25]^[28]
- Alternative (may also be used in combination with NSAIDs): muscle relaxants, e.g., cyclobenzaprine Cyclobenzaprine 5–10 mg PO three times daily; titrate as needed (max. duration 2–3 weeks)., metaxalone , or tizanidine ^[29]
- Refractory pain: tramadol (preferred opioid for refractory back pain)

Opioids should only be prescribed if all other treatment options have been unsuccessful!

Prevention

Regular exercise
Education on how to correctly lift heavy items
- Squatting down and keeping the back straight
- Rising from the knees when lifting the load
- Keeping the load close to the body

Acute management checklist

Obtain a focused history and examination to distinguish between urgent spinal and nonspinal causes.
Assess for red flag features of acute 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 acute back pain.”
Catheterize patients with bladder dysfunction.
Obtain urgent consults based on suspected/confirmed etiology, for example:
- Urgent spinal surgery consult for patients with new or rapidly progressive neurological symptoms
- Urgent vascular surgey consult for ruptured abdominal aortic aneurysm
- Urgent gastroenterology or general surgery consult for acute pancreatitis
Administer immediate medical management as needed (e.g., IV steroids for malignant cord compression, empiric antibiotic therapy for spinal infections).

Reference: ^[3]^[4]^[30]

Red flag features

Red flag features on history or clinical examination should guide further diagnostics. Patients with no red flag features and normal neurological examination are unlikely to have a serious underlying cause. Patients with red flag features but normal neurological examination are unlikely to need urgent spinal surgery. ^[3]

Red flags for acute back pain ^[3]^[4]^[27]
	Features
Patient characteristics	Age < 18 or > 50 years Immunosuppression
Relevant medical history	History of cancer or unexplained weight loss ^[4] History of abdominal aortic aneurysm Recent history of any of the following: Bacterial infection ^[31] Spinal anesthesia Spinal surgery ^[32] Significant trauma related to age ^[27]
Medication use	Long-term steroids Anticoagulants Intravenous drugs ^[32]
Pain characteristics	Pain that does not improve with rest and/or worsens at night Persistent or progressive pain and/or neurological findings despite > 4 weeks conservative therapy
Examination findings	Fever Abnormal vitals Signs of aortic pathology, including: Pulse deficits in the lower extremities Unequal blood pressure measurements in the upper extremities The murmur of aortic regurgitation Signs of cord compression syndromes (spinal cord compression, cauda equina syndrome, conus medullaris syndrome), such as: ^[33] Motor weakness Spasticity and hyperreflexia (upper motor neuron signs) distal to the site of compression Flaccid paralysis and hyporeflexia can occur distal to the site of compression in spinal shock. ^[30] Paresthesias or anesthesia (including saddle anesthesia) Bladder, bowel, or sexual dysfunction

Hypertension, hypotension, and/or tachycardia in a patient with a normal neurological examination should raise suspicion for an urgent nonspinal pathology. Hypotension and bradycardia in a patient with signs of spinal cord compression are likely indications of spinal shock.

Management approach

Focused history and clinical examination ^[5]^[25]^[27]

Assess for red flag features of acute back pain in all patients. A thorough neurological examination is essential to adequately triage patients who need urgent imaging and neurosurgery consult.

Examine sensation, power (motor strength), deep tendon reflexes, and superficial reflexes (e.g., Babinski reflex) below the level of the pain bilaterally.
Assess for signs of nerve root irritation (e.g., straight leg raise test).
Assess perianal sensation and anal tone.

Administer analgesics (preferably NSAIDs) after baseline neurological function and pain severity are documented (see “Pain management”). ^[3]^[25]

Because irreversible damage to the spinal cord occurs within 6 hours of compression, a thorough neurological examination is essential to detect damage early and minimize long-term disability. ^[34]

Dermatome map Saddle anesthesia

Pretest probability of the underlying etiology ^[5]^[25]

Estimate the pretest probability (PTP) of the underlying etiology based on the patient history and clinical features.

New or rapidly progressive neurological findings : See “Urgent spinal causes of acute back pain.”
Features of isolated radiculopathy or normal neurological examination in a patient with a high PTP of a spinal etiology: See “Nonurgent spinal causes of acute back pain.”
Normal neurological examination in a patient with a high PTP of a thoracic, abdominal, pelvic, or retroperitoneal condition : See “Nonspinal causes of acute back pain.”
Acute back pain that cannot be attributed to any specific pathology: See “Nonspecific back pain.”
Patients with significant trauma related to age: See “Traumatic back pain.”

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

Suspect inflammatory arthritis (detailed in “Nonurgent spinal causes of acute back pain”) in young adults with back pain that does not improve with rest or medication and/or worsens at night.

Suspect spinal epidural abscess or vertebral osteomyelitis (detailed in “Urgent spinal causes of acute back pain”) in patients with acute back pain, fever, and risk factors for spinal infections.

Approach to imaging ^[10]^[24]

Imaging is not routinely required for acute back pain. Indications for imaging include suspicion for a serious underlying etiology (e.g., severe or progressive neurological findings, red flag features of underlying malignancy or spinal infection) or pain that persists despite at least 4 weeks of conservative management.

Approach to imaging in acute back pain See the relevant sections below for information on preferred initial imaging modalities and alternatives for specific suspected etiologies.
Suspected spinal causes	Isolated radiculopathy, no red flag features for acute back pain	Urgent imaging is typically not required.
	New or rapidly progressive neurological symptoms	Urgent MRI spine without and with IV contrast Post-void bladder scan to exclude urinary retention in patients with suspected spinal cord compression
	Suspected vertebral fracture (traumatic/pathological) or ankylosing spondylitis in a patient with no neurological symptoms apart from isolated radiculopathy	X-ray spine
Suspected nonspinal causes		Initial imaging modality should be chosen based on the pretest probability of the underlying etiology; examples include: ECG Ultrasound abdomen See “Nonspinal causes of acute back pain” for further details.
Nonspecific back pain		Imaging is not routinely required in patients with atraumatic back pain with normal neurological examination and no red flag features for acute back pain. Consider MRI spine if pain persists for 4–6 weeks despite therapy. ^[7]^[24]

Nonspinal causes of back pain can be life-threatening; consider alternative diagnoses such as abdominal aortic aneurysm!

In the acute setting, imaging is not indicated when no red flags for back pain and no neurologic deficits are present. ^[25]

Laboratory studies

Laboratory studies are not routinely required for acute back pain. Consider obtaining laboratory studies based on the presence of red flag features for acute back pain. Examples include:

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
HLA-B27: for suspected inflammatory arthritis
Liver chemistries and serum amylase and lipase: for suspected gastrointestinal pathology
D-dimer levels: for suspected aortic dissection
See also “Diagnostics” in “Chest pain” and “Acute abdomen.”

Immediate management of back pain with new neurological symptoms ^[3]^[4]^[30]

Obtain urgent spinal surgery or neurosurgery consult (e.g., for surgical decompression).
If there is concern for unstable vertebral fractures :
- Initiate immediate spinal precautions.
- Obtain urgent x-ray or noncontrast CT of the spine.
All other suspected causes: Order urgent MRI or transfer to an appropriate facility.
- MRI positive:
  - Administer etiology-specific urgent pharmacotherapy.
  - Obtain additional consults depending on the diagnosis.
- MRI negative ^[3]
  - Reassess the patient and consider alternative diagnoses (e.g., Guillain Barré syndrome, transverse myelitis).
  - Obtain urgent neurology consultation.
Clearly document the patient's current neurological deficits and reassess frequently. ^[35]
Administer analgesics (preferably NSAIDs) after baseline neurological function and pain severity are documented (see “Pain management”). ^[3]^[25]
Catheterize patients with bladder dysfunction.
Patients with neurological abnormalities are at high risk of pressure sores: See “Prevention” in “Decubitus ulcer.”

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!

Urgent spinal causes

Urgent spinal causes include conditions that cause, or have the potential to cause, permanent neurological damage or life-threatening complications. Patients with significant new neurological findings (e.g., bilateral neurological abnormalities, bladder or bowel dysfunction, saddle anesthesia) should be managed as an urgent priority to prevent worsening of spinal cord injury or the development of complications. ^[3]

Urgent spinal causes of acute back pain ^[30]
Common etiologies	Characteristic clinical features	Diagnostics ^[7]	Acute management
Spinal cord compression ^[30]	Major risk factor: history of cancer Clinical features: sudden onset or rapid progression of any of the following Back pain, radicular pain Neurological defects below the level of the lesion Sensory defects Progressive weakness of the legs Altered reflexes (initial hyporeflexia; followed by hyperreflexia and extensor plantar response) Bladder and bowel dysfunction; loss of spincter tone Features of incomplete cord syndromes (e.g., Brown-Séquard syndrome) ^[36]	Preferred initial imaging modality: urgent MRI with or without IV contrast Evidence of extrinsic cord compression (e.g., tumor, intervertebral disk herniation, hematoma High signal areas on T2 within the cord, representing acute edema Alternative: CT myelography; similar findings to MRI	Urgent neurosurgery consult for surgical decompression Malignant spinal cord compression: high-dose IV steroids ^[37] Treatment of the underlying cause (e.g., radiotherapy for metastases, surgical evacuation of abscesses, spine stabilization surgery)
Conus medullaris and cauda equina syndrome ^[38]	Major risk factor: preexisting degenerative disk disease Clinical features Severe low back pain Asymmetric, areflexic, flaccid paresis of bilateral legs (cauda equina syndrome) Symmetric, hyperreflexic paresis of lower limbs (conus medullaris syndrome) Saddle anesthesia Urinary retention with overflow incontinence Fecal incontinence; loss of sphincter tone	Preferred initial imaging modality: urgent MRI lumbar spine without and with IV contrast ^[10] Evidence of extrinsic cord compression (intervertebral disk herniation, hematoma, tumor) Edema of the cauda equina (high signal intensity on T2) Alternative: CT lumbar spine without IV contrast or CT myelography ^[10] Similar findings to MRI Hourglass-like constriction due to partial or complete block of contrast (on myelography) Bladder scan: may show retention	Urinary catheter if the patient has retention Urgent neurosurgery consult for surgical decompression.
Vertebral fractures ^[39]	Risk factors Atraumatic (pathological fracture): history of osteoporosis, steroid use, or malignancy Traumatic: history of injury (may be minor in older patients with osteoporosis) Clinical features: local pain on pressure, percussion, and compression	Laboratory studies Suspected fragility fractures: serum vitamin D and calcium may be low Suspected malignancy: See “Bone metastases” under “Nonurgent spinal causes of acute back pain.” Preferred initial imaging modality: x-ray spine (AP and lateral views) ^[10]^[40] Loss of vertebral body height or wedging Loss of normal contour of the vertebral body with fragments of bone Loss of vertebral alignment Widening of the pedicles Fracture of transverse processes Alternatives CT spine without contrast : similar findings to x-ray MRI spine without contrast: may help to differentiate types of fractures , and may show spinal cord injury. ^[41]^[42]^[43]	Unstable vertebral fractures or evidence of cord compression Surgical stabilization of the spine (spondylodesis) Cord decompression Stable vertebral fractures with no neurological symptoms or evidence of cord compression Analgesia Physiotherapy Consider an external brace. Kyphoplasty For further information, see “Treatment” in “Vertebral fractures.”
Spinal epidural abscess	Risk factors Recent bacterial infection IV drug use Diabetes Invasive procedures Alcohol use disorder Immunosuppression Clinical features Point tenderness Fever and rigors Radicular pain Limited spinal cord mobility Signs of spinal cord compression	Laboratory studies CBC: ↑ WBC Inflammatory markers: ↑ CRP, ↑ ESR Culture (blood, sputum, urine, aspirate): may identify the causative pathogen (Staphylococcus aureus in up to 75% of cases). ^[44] Consider HIV testing in patients with risk factors for bloodborne viruses. Consider IFN-γ release assay in patients with risk factors for tuberculosis. Lumbar puncture should be avoided. Preferred initial imaging modality: urgent MRI with and without IV contrast ^[10] Soft tissue mass in epidural space Rim enhancement surrounding a nonenhancing center Alternative: CT spine with IV contrast; similar findings to MRI	IV antibiotic therapy Referral to neurosurgery for consideration of drainage For further information see “Treatment” in “Spinal infections.”
Vertebral osteomyelitis ^[45]	Risk factors Older patients with comorbidities Immunocompromise IV drug use Clinical features Insidious onset of pain Fever ^[45]	Laboratory studies ↑ WBC, ↑ CRP, ↑ ESR Blood cultures may identify the underlying pathogen. Consider IFN-γ release assay in patients with risk factors for tuberculosis. Consider HIV testing in patients with risk factors for bloodborne viruses. Preferred initial imaging modality: MRI spine with IV contrast Changes to signal intensity in the intervertebral disks and vertebral bodies Alternatives CT spine with and without contrast: for patients with contraindications to MRI FDG-PET: in patients with equivocal MRI scans due to degenerative disease ^[46]	Neurological symptoms or evidence of sepsis: urgent neurosurgery consult and empiric antibiotic therapy No neurological symptoms; hemodynamically stable: culture-specific IV antibiotics once results are available
Spinal epidural hematoma ^[47]	Risk factors Male sex (1.5:1) ^[47]^[48]^[49] Peak incidence in the 2^nd and 6^th decades of life ^[48]^[49] Thrombocytopenia, bleeding diathesis Anticoagulation Vascular malformations Localized trauma (e.g., following lumbar puncture, pulling of the epidural catheter) Clinical features Acute severe back pain Signs of spinal cord compression	Preferred initial imaging modality: MRI with and without IV contrast Epidural hematoma that varies in intensity according to its age Can reveal the underlying cause, e.g., neoplasm or vascular malformation Alternative: CT without contrast if there are contraindications to MRI; similar findings to MRI	Urgent neurosurgery consult for surgical decompression (laminectomy and evacuation of blood) Treat coagulopathy if present (see “Anticoagulant reversal”). Keep the patient on strict bed rest until surgery.

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

Acute urinary retention in a patient with sudden back pain and neurological deficits is strongly suggestive of cauda equina syndrome (90% sensitivity). ^[25]

Patients with unilateral neurological symptoms resulting from radiculopathy do not require urgent spinal surgical management. Conus medullaris and cauda equina syndromes Cervical disk herniation $Thoracic wedge compression fracture$ Chronic lumbar compression deformity $T12 burst fracture and L1 fracture$ $Vertebral arch fracture deformity with spinal stenosis$ $Burst fracture of T12 vertebral body$ $Acute and chronic vertebral fractures$ Spondylodiscitis with abscess formation Spinal epidural abscess, osteomyelitis, and discitis Spinal epidural hematoma

Nonspinal causes (referred pain)

Nonspinal causes of back pain include thoracic, abdominal, pelvic, retroperitoneal, or cardiovascular conditions that can manifest with referred pain to the back.

Nonspinal causes of acute back pain
Common etiologies	Characteristic clinical features	Diagnostic findings	Acute management
Abdominal aortic aneurysm (AAA) ^[50]	Risk factors Age > 50 years Male sex Hypertension Smoking Clinical features Pulsatile abdominal mass Bruit on auscultation Signs of rupture Sudden, severe central abdominal, chest, and/or back pain ^[51] Hypotension, shock Grey Turner sign and/or Cullen sign	Laboratory studies: Routine tests may show signs of hemorrhage in ruptured AAA. Preferred initial imaging modality (only indicated in stable patients) : ultrasound abdomen ^[52] Dilation of the aorta ≥ 3 cm AAA rupture: periaortic fluid and intraabdominal free fluid AAA thrombosis: intraluminal defect Alternatives: CTA/MRA abdomen and pelvis Similar findings to ultrasound Localization of the ruptured/leaking site	Ruptured, rapidly growing, or large aneurysms : urgent vascular surgery consult for aneurysm repair (see “AAA rupture”) AAA thrombosis: urgent vascular surgery consult ^[53] Small aneurysms with low risk of rupture: surveillance See "Treatment of AAA" for further details.
Aortic dissection ^[54]^[55]	Risk factors Older age Male sex Hypertension Clinical features Severe, tearing chest or abdominal pain that radiates to the back Hypotension, syncope, neurological symptoms Syncope, diaphoresis, confusion or agitation Asymmetrical blood pressure and pulse readings between limbs New diastolic murmur Symptoms of myocardial ischemia Aortic dissection detection risk score ≥ 2	Laboratory studies: elevated D-dimer ^[55] Preferred initial imaging modalities ^[56] Transesophageal echocardiography (TEE) in unstable patients Dissection flap (with differential Doppler flow) Pericardial effusion Aortic regurgitation Chest x-ray: widening of the aorta MRA/CTA of the chest, abdomen, pelvis in stable patients: intimal flap with false lumen	Blood pressure control Immediate cardiovascular surgery consult for repair See “Treatment of aortic dissection” for details.
Retroperitoneal hematoma ^[57]^[58]^[59]	Risk factors Traumatic hematoma: Blunt trauma Iatrogenic Spontaneous hematoma (rare) Anticoagulant use Dialysis Renal tumors Hypertension Clinical features Flank pain Hypovolemic shock (if large)	Laboratory studies: Routine tests may show signs of hemorrhage. Preferred initial imaging modality: CT abdomen and pelvis with contrast ^[60]^[61] Abnormal soft tissue density in the retroperitoneal area Extravasation of contrast at the site of bleeding Alternative: CTA with IV contrast; detects site of active bleeding ^[60]	Fluid resuscitation with blood products as necessary Reversal of anticoagulants Urgent surgery and/or interventional radiology consult for source control
Psoas abscess ^[62]	Risk factors Immunocompromise Recent infection (secondary psoas abscess) Clinical features Classic triad ^[63] Lower back/flank pain Antalgic gait Fever Ipsilateral hip held in flexed position at rest Pain on passive extension and/or internal rotation of the ipsilateral hip Lower abdominal pain Palpable mass (may be tender) in the ipsilateral inguinal or iliac region	Laboratory studies CBC: ↑ WBC Inflammatory markers: ↑ CRP, ↑ ESR Blood cultures as well as abscess aspirate cultures and Gram stain: may identify the underlying pathogen Further studies to investigate the underlying cause Preferred initial imaging modality: CT abdomen and pelvis with IV contrast ^[64] Enlargement of the psoas muscle with an encapsulated hypodense lesion. Possible signs of underlying etiology Alternative: MRI with IV contrast or abdominal ultrasound; similar findings to CT	Empiric antibiotic therapy for psoas abscess Surgery and radiology consult for drainage (percutaneous or open surgical) See “Treatment of psoas abscess” for details.
Pyelonephritis ^[65]	Risk factors Female sex Pregnancy Immunosuppression, e.g., diabetes mellitus Indwelling catheter Clinical features Fever, chills Flank pain Dysuria, urgency May be accompanied by nausea and vomiting	Laboratory studies CBC: ↑ WBC Inflammatory markers: ↑ CRP, ↑ ESR Normal or ↓ renal function Positive urinalysis Positive urine culture Preferred initial imaging modality : CT abdomen with and without IV contrast ^[66] Infected parenchyma may be visible as wedge-shaped areas of streaky contrast enhancement (striated nephrogram). ^[67] Alternative: ultrasound of the kidneys and bladder ^[67] Renal enlargement Loss of corticomedullary differentiation	Complicated pyelonephritis: empiric antibiotic therapy for complicated pyelonephritis Uncomplicated pyelonephritis: empiric antibiotic therapy for uncomplicated pyelonephritis See “Treatment of pyelonephritis” for details.
Nephrolithiasis (ureteric colic) ^[68]^[69]	Risk factors Family history Dehydration (chronic) Loop diuretic use Clinical features Severe, unilateral, colicky flank pain Nausea and vomiting Hematuria	Laboratory studies Normal or ↓ renal function Urinalysis: hematuria Preferred initial imaging modality: CT abdomen and pelvis without contrast ^[70] Visible stone Proximal ureteric dilation with possible hydronephrosis Alternative: ultrasound abdomen and pelvis; similar findings to CT	Treatment depends on the size of the stone. Urgent urology consult in the following: Stone ≥ 10 mm Associated infection and/or obstruction See “Treatment of nephrolithiasis” for details.
Acute pancreatitis ^[71]^[72]^[73]	Risk factors History of gallstones Alcohol use Clinical features Epigastric pain that radiates to the back Nausea and vomiting Hypoactive bowel sounds Possible fever	Laboratory studies ↑ Serum pancreatic enzymes Normal or ↑ liver chemistries Preferred initial imaging modality: ultrasound abdomen ^[74] Pancreatic edema, peripancreatic fluid, gallstones, and pseudocysts. Alternative : CT abdomen and pelvis with IV contrast ; similar findings to ultrasound	IV fluid resuscitation Urgent gastroenterology consult for biliary pancreatitis. For further information, see “Acute management checklist for acute pancreatitis.”
Acute cholecystitis ^[75]^[76]^[77]	Risk factors Female sex Pregnancy and hormone use Family history Clinical features Severe RUQ pain Referred pain in the right shoulder Fever, chills Nausea, vomiting Murphy sign	Laboratory studies ↑ WBC Liver chemistries: mild elevation in AST and ALT Preferred initial imaging modality: ultrasound abdomen ^[77]^[78]^[79] Sonographic Murphy sign Pericholecystic fluid collection Gallbladder wall thickening and/or edema (double-wall sign) ^[77]^[78]^[79] Alternatives: HIDA scan, CT abdomen with IV contrast, or MRI abdomen with IV contrast ^[80] See also “Diagnostic criteria for acute cholecystitis.”	Empiric antibiotic therapy for acute biliary infection Urgent surgery consult See “Treatment of acute cholecystitis” for details.

Lumbar spine erosion from abdominal aortic aneurysm Widened mediastinum Aortic dissection (Stanford A) Transesophageal echocardiography of aortic dissection Retroperitoneal hemorrhage from the left common iliac artery Psoas abscess Acute pancreatitis Acute pyelonephritis and renal calculi Acute calculous cholecystitis Gallbladder wall thickening Acute acalculous cholecystitis with sludge Acute cholecystitis

Low back pain

Definition ^[27]

Pain and/or stiffness localized to the lower back (below the costal margin) and above the buttocks.
May be accompanied by pain radiating down the legs.

Associated factors ^[81]

Poor posture
Sedentary lifestyle, low physical activity
Activities involving heavy lifting
Age
Psychological stressors (e.g., stress, anxiety, depression) ^[82]

Etiology ^[81]

Mechanical: trauma (e.g., spinal fracture)
Anatomical: scoliosis
Degenerative: disc herniation, spinal stenosis, disc protrusion, spondylolisthesis (see also “Degenerative disc disease”)
Inflammatory: ankylosing spondylitis, reactive arthritis, inflammatory bowel diseases
Infectious: abscess (e.g., paraspinal, epidural), osteomyelitis, discitis
Malignant: metastases, tumors, multiple myeloma

Classification ^[83]

According to severity
- Uncomplicated: without red flag features for acute back pain
- Complicated: with red flag features for acute back pain
- See “Red flag features for acute back pain.”
According to duration
- Acute: up to 4–6 weeks
- Subacute: 6–12 weeks
- Chronic: > 12 weeks

Management

Diagnostics and treatment depend on the underlying cause.
See “Management approach” above.
See also “Nonurgent spinal causes of acute back pain,” “Urgent spinal causes of acute back pain,” “Nonspecific back pain,” “Red flag features for acute back pain.”

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$Contributor Disclosures - Acute back pain. All of the relevant financial relationships listed for the following individuals have been mitigated: Eva-Maria Elfers (medical editor, previously owned Healthy Gut, now known as intestx GmbH). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
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