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Summary![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
- 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![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
- 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 | ||
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Origin | Spinal | Nonspinal |
Musculoskeletal |
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Neoplastic |
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Infectious |
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Vascular |
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Other |
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Traumatic back pain![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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.
Nonurgent spinal causes![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
Nonurgent spinal causes refers to conditions that require specific (but not immediate) treatment.
Nonurgent spinal causes of acute back pain | |||
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Common etiologies | Characteristic clinical features | Diagnostics [7] | Treatment |
Spinal stenosis [8][9] |
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Intervertebral disk herniation [11] |
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Spondylolisthesis [14][15] |
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Bone metastases [4] |
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Inflammatory back pain |
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Nonspecific back pain![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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
- 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![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
- 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![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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] | |
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Features | |
Patient characteristics |
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Relevant medical history |
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Medication use |
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Pain characteristics |
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Examination findings |
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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![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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]
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. | ||
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Suspected spinal causes | Isolated radiculopathy, no red flag features for acute back pain |
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New or rapidly progressive neurological symptoms |
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Suspected vertebral fracture (traumatic/pathological) or ankylosing spondylitis in a patient with no neurological symptoms apart from isolated radiculopathy | ||
Suspected nonspinal causes |
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Nonspecific back pain |
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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.
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MRI positive:
- Administer etiology-specific urgent pharmacotherapy.
- Obtain additional consults depending on the diagnosis.
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MRI negative [3]
- Reassess the patient and consider alternative diagnoses (e.g., Guillain Barré syndrome, transverse myelitis).
- Obtain urgent neurology consultation.
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MRI positive:
- 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![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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] | |||
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Common etiologies | Characteristic clinical features | Diagnostics [7] | Acute management |
Spinal cord compression [30] |
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Conus medullaris and cauda equina syndrome [38] |
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Vertebral fractures [39] |
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Spinal epidural hematoma [47] |
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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.
Nonspinal causes (referred pain)![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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 | |||
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Common etiologies | Characteristic clinical features | Diagnostic findings | Acute management |
Abdominal aortic aneurysm (AAA) [50] |
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Aortic dissection [54][55] |
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Retroperitoneal hematoma [57][58][59] |
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Psoas abscess [62] |
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Pyelonephritis [65] |
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Nephrolithiasis |
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Acute pancreatitis [71][72][73] |
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[75][76][77] |
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Low back pain![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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]
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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.”
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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.”