Back pain

Summary

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-
threateningnonspinal 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 flagsdo 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.

Classification

By etiology [2][3]

• Specific back pain

o Back pain attributable to a pathophysiological condition (e.g., trauma,
deformity, disease, injury, or infection); see “Etiology” section for details.
o 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 [5][6][2]

• 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]

o 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
o 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

Epidemiology

• 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]

Etiology

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

Clinical evaluation

• 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.
o Sensation, power (motor strength), deep tendon reflexes, and superficial
reflexes (e.g., Babinski reflex) below the level of the painbilaterally
(including relevant myotomes and dermatomes)
o Signs of radiculopathy/nerve root irritation (e.g., straight leg raise test)
o Perianal sensation and anal tone [10]

Red flags for back pain

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

Red flags for back pain [2][8][10]

Features

Patient • Age < 18 or > 50 years

characteristics
• Immunosuppression

Relevant medical
• History of cancer or unexplained weight loss [8]
history
• History of abdominal aortic aneurysm
• Recent history of any of the following:
o Bacterial infection [14]

o Spinal anesthesia
 o Spinal surgery [15]
o Significant trauma related to age [2]

Medication use
• Long-term glucocorticoid use
• Anticoagulants
• IV drug use [15]

Paincharacteristics
• Pain that does not improve with rest and/or worsens at night
• Persistent or progressive pain and/or neurological findings despite > 4
weeks of conservative therapy

Examination
• Fever
findings
• Abnormal vitals
• Signs of aortic pathology (e.g., aortic regurgitation, unequal blood
pressures)
• Signs of cord compression syndromes (spinal cord compression, cauda
equina syndrome, conus medullaris syndrome),
such as: [16]
o Motor weakness
▪ Spasticity and hyperreflexia (upper motor
neuron signs) distal to the site of compression
▪ Flaccid paralysis and hyporeflexia (lower motor
neuron signs) can occur distal to the site of
compression in spinal shock. [17]
o Paresthesias or anesthesia (including saddle anesthesia)
o Bladder, bowel, or sexual dysfunction

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.

Management approach

Initial management approach

• Perform focused clinical history and examination.

• Assess for red flag features of back pain and risk stratify accordingly.
o Low suspicion for serious or urgent etiology: supportive care, pain
management, close follow-up and return precautions usually sufficient [8]

o High suspicion for serious or urgent etiology: targeted and expedited

evaluation to identify and treat the underlying cause [10][19]
• Evaluate and treat the underlying cause.

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!

Diagnosis

Imaging [6][7][21][22]

Approach to imaging in back pain [6][7]

Suspected urgent spinal cause (e.g., severe or • Urgent MRI spine without and with IV
progressive neurological deficits, features of spinal
contrast
infection, features of spinal malignancy, cauda
equina)
 • Post-void bladder scan

Suspected inflammatory cause (e.g., ankylosing • X-ray spine

spondylitis)
Suspected vertebral fracture
• X-ray spine
• OR CT spine without contrast
• OR MRI spine without contrast

Isolated radiculopathy and/or clinical features of • Imaging typically not required for acute
spinal stenosis without any red flags
symptoms [6]

• Consider MRI spine without IV contrast

if symptoms progress or persist
despite 4–6 weeks of conservative
management. [6]

Suspected nonspinal causes of back pain

• Depends on suspected etiology

Nonspecific back pain

• Imaging not routinely required
• Consider MRI spine and possibly x-
ray if pain persists for > 6 weeks despite
therapy and the patient is a surgical
candidate. [6]

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.:
o CBC and inflammatory markers: for suspected spinal infections,
inflammatory arthritis, or malignancy
o Blood cultures: for suspected spinal infections
 o Serum calcium and vitamin D levels: for suspected fragility fractures

Urgent spinal causes of acute back pain

• Urgent spinal causesof 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]

Overview of urgent spinal causes of back pain

Characteristic clinical features Diagnostic findings Management

Compressiv • Risk factors for spinal • Urgent MRIs • Urgent surgic

e spinal
cord compression pine without al
emergencie
s[17][23] • Sudden severe and with IV decompressio
back pain or radicular contrast n
pain • Edema of the • Treat the
• Neurological deficits spinal cord underlying
below the level of the or cauda cause.
lesion equina • Suspected
(including urinary • Extrinsic malignant
retention, saddle compression cord
anesthesia, fecal compression:
incontinence) high-
dose IV dexa
methasone
• Urinary
catheter if
indicated

Vertebral
• Trauma significant for • X-ray spine: • Immediate sp
fractures
(pathologica age • Vertebralmisali inal
l or
• Localized vertebralpai gnment precautions
traumatic)[24]
n and/or contusion • ↓ vertebral • Unstable
• Uneven alignment of body height or vertebral
the vertebral spinous wedging [25][6]
fractures or
processes cord
 • Chronic corticosteroid compression:
use
• Surgical
stabilization
(spondylodesis)
• Surgical
decompression
for cord
compression
• Stable
vertebral
fractures with
out cord
compression:

• Conservative
management
• Vertebroplastyo
r kyphoplasty

Spinal • Risk factors for • ↑ WBC and i • Empiric

infections[26]
spinal infection nflammatory antibiotic
• Fever, rigors markers therapy for
• Tender point • Blood spinal
• Limited spine mobility cultures: Sta infection
• Signs of spinal cord phylococcus • Urgent neurosurgery
compression aureus (most evaluation
common) [26]

• Urgent MRI
with and
without IV
contrast:
inflammatio
n, abscess : [6
]
 Spinal
• Possible history of: • MRI with • Strict bed rest
epidural
hematomac • Thrombocytopenia and without • Anticoagulant
ausing cord
• Bleeding disorders IV reversal, if indicated
compressio
n[27] • Use of anticoagulants contrast [28]
• Urgent neurosurgery
• Vascular malformations • Blood in consult for surgical
• Localized trauma (e.g., the epidural decompression
following lumbar space with a (laminectomy and
puncture, pulling of smooth evacuation of blood)
the epidural catheter) contour [28]
• Loss of epidural
fat signal

Acute urinary retention in a patient with sudden back pain and neurological deficits is

strongly suggestive of cauda equina syndrome(90% sensitivity). [7]

➔ Compressive spinal emergencies

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]
 Overview of compressive myelopathies [17]

Spinal cord compression Conus medullaris syndrome Cauda equina syndrome

• Damage to
• Damage to
or
or compression
compression
of the spinal
• Damage to or compression of the cauda
cordat any level
of the spinal cord at equina (nerv
due to:
the vertebral level T12–L2, e fibers L3–
• Degenerative
resulting in injury to S5)
disc disease
the conus medullaris(sacral located belo
• Neoplasms
Etiology and coccygeal spinal w L2
• Vertebralmetast
segments) [29][30] • Common
ases
• Common causes causes
• Trauma
include spondylolisthesis, include large
(epidural
tumors, and trauma posteromedi
hematoma, vert
(e.g., vertebral fracture). al disc
ebral fracture)
herniation,
• Epidural absces
trauma, and
s
tumors.

• Gradual,
• Variable,
Onset • Sudden, bilateral typically
bilateral
unilateral

• Lower back
• Localized neck • Lower back pain pain
Pain
or back pain • Less severe radicular pain • Severe radic
ular pain

• Bilateral paralys
Motor • Symmetric, hyperreflexic dis • Asymmetric,
is below the
sympto talparesis of lower limbs, areflexic, fla
ms affected level of
possibly fasciculations ccid
the spinal cord
 Overview of compressive myelopathies [17]

Spinal cord compression Conus medullaris syndrome Cauda equina syndrome

• Hyperreflexia • Achilles reflex may be paresis of

• Positive Babins absent. the legs
ki sign • Muscle atrop
• Ataxia hy

• Saddle
anesthesia:
lack
of sensitivity
in
the dermato
mes S3–S5,
affecting the
areas around
• Loss or
the anus,
reduction of all
• Symmetric bilateral perianal genitalia,
Sensory sensation below
sympto numbness and inner
the affected
ms • Sensory dissociation thighs (may
level of the
be
spinal cord
asymmetric)
• Asymmetric
unilateral
numbness
and/or parest
hesia in
lower
limb dermat
omes
 Overview of compressive myelopathies [17]

Spinal cord compression Conus medullaris syndrome Cauda equina syndrome

• Late onset
of urinary
retention
• Change in
• Sphincter bowel
dysfunction habits due to
• Early onset
Urogeni with urinary or loss of anal
tal and of bladderand fecal
rectal bowel sphincter
incontinence
sympto urgency, control
ms • Erectile dysfunction
retention, or • Decreased
incontinence rectal tone
or bulbocave
rnosus reflex
• Erectile
dysfunction

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.
• Administer analgesics (preferably NSAIDs, see “Pain management”). [10][7]
 • Treat the underlying cause (e.g., suspected malignant cord compression: high-
dose IV dexamethasoneD OSA G E ) [32]

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).

Nonurgent spinal causes

Overview of nonurgent spinal causes of back pain [21]

Characteristic clinical Diagnostic findings Management

features
Symptomatic d
• Risk factors • MRI spinewithout • Isolated radicu
egenerative
disc disease for contrast may lopathy and
(without cord
degenerative show any of the no red
compression) [34
][35][36]
disc disease following : [8] flags: conserv
• Back pain (of • Intervertebral disc ative
ten L5–S1) herniation or management
with or prolapse • Pain management
without radic • Physiotherapy
ulopathy(e.g., • Continuation of
sciatica) usual activity
• Worsened (minimize bed
by coughing/s rest)
neezing • Persistent or
• Positive straig severe
ht leg raise neurological
test (for inter deficits: surger
vertebral disc y(discectomy)
herniation)

Spinal
• Risk factors • MRI spinewithout • Mild or
stenosis[37][38]
for spinal IV contrast: moderate
stenosis symptoms: co
nservative
 • Neurogenic Narrowed spinal management (
claudication canal e.g., NSAIDs,
physical
therapy,
epidural steroi
d injection)
• Severe or
persistent
symptoms: sur
gery (high
recurrence
rate)

Uncomplicated
• History of • MRI with IV • Consider osteo
spinal metasta
ses [8] cancer contrast: clast inhibitors
• Nonspecific confirmation . [40]

symptoms of tumor size and

(weight loss, spinal cord
night sweats) involvement
• Deep
dull pain;
worse at
night
• Localized pai
n(often
thoracic) [8]

Inflammatory
• Risk factors • CBC: ↑ WBC, an • NSAIDs, DM
back pain
(e.g., ankylosin for emia ARDs
g
spondylitis, rea inflammatory • ↑ • Physical
ctive arthropathies Inflammatorymar therapy
arthritis, psoria
tic • Insidious kers
arthritis) [8][41] onset of • Autoantibodiesma
lumbar pain o y be positive.
r stiffness • HLA-B27: may
that : [41] be positive in
 • Lasts ≥ 3 patients
months [41]
with ankylosing
• Improves with spondylitis
exercise or NS • X-
AIDs ray of sacroiliac
• Worsens at rest joints and lumbar
• Extraarticular spine: sacroiliitis
symptoms
• Restricted
spinal
mobility

Spondylolisthe
• Risk factors • X-ray spine • Conservative
sis[42][43]
for lateral view management
spondylolisth (preferred): antero • Severe or
esis [44]
listhesis, spondylo persistent
• Possible radic lysis [6] symptoms: sur
ulopathysymp gery
toms
of neuropathi
c claudication
• Gait
abnormalities
• Step-off
sign (in
advanced
stage)

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 causes (referred pain)

Overview of nonspinal causes of back pain

Characteristic clinical Diagnostic findings Initial management

features

Abdominal • Risk factors • Ultrasound abdome • Vascular surgery

aortic
for AAA n or CTA (stable consult
aneurysm (A
AA) [45] • LBP [46]
patients): dilatation • Small aneurysms
• Pulsatile of the aorta ≥ 3 with low risk of
abdominal cm [47]
rupture: AAA
mass surveillance
• Bruit on aus
cultation

Aortic
• Risk factors • Elevated D- • Hemodynamic
dissection [48][4
9]
for aortic dimer [49] monitoring and
dissection • Screening CXR or blood pressure
• Severe, TTE(for unstable control
tearing chest patients) • Urgent
pain that • MRA/CTA of the cardiothoracic su
radiates to chest, rgery consult
the back abdomen, pelvis (in • Anticoagulant
• Symptoms stable reversal, if
of myocardi patients): intimal fla indicated
alischemia pwith false lumen
• Signs
of hypoperf
usion
• Asymmetric
blood
 pressure and
pulses
• New diastoli
cmurmur

Retroperiton
• Risk factors • ↓ Hemoglobin and • Intravascularvolu
eal
hematoma [50][ for hematocrit me repletion
51][52]

retroperiton • Possible • Anticoagulant

eal abnormal coagulati reversal
hematoma on parameters • Urgent surgeryan
• Flank pain • CT abdomen d/or
• Hypovolemi and pelvis with IV interventional
c contrast/CTA: fluid radiology consult
shock (if he in retroperitoneal sp for source
matoma is ace [53][54]
control [55]

large)

Psoas
• Risk factors • ↑ WBC and inflam • Empiric
abscess [56]
for psoas matory markers antibiotic therapy
abscess • Positive cultures [58] for psoas abscess
• Classic • CT abdomen • Surgery and
triad low and pelvis with IV radiology consult
back contrast: for drainage
pain, antalgi enlarged psoas mus (percutaneous or
c cle; open surgical)
gait, fever [5
encapsulated hypod
7] ense lesion [59]

• Ipsilateral hi
pin flexed
position at
rest
• Pain on
passive
extension
and/or inter
nal
 rotation of
the ipsilater
al hip
• Palpable
mass (may
be tender) in
the ipsilater
alinguinal or
iliac region

Pyelonephriti • Risk factors • ↑ WBC and inflam • Empiric

s[60]
for matory markers antibiotic therapy
pyelonephrit • Normal or ↓ renal for complicated
is function pyelonephritis
• Fever, chills • Urinalysis findings • Empiric
• Flank pain of UTI antibiotic therapy
• Dysuria, • Positive urine for
urgency culture uncomplicated
pyelonephritis

Ureteric colic
[61][62] • Risk factors • Hematuria on urinal • Stone ≤ 10
for ysis mm: tamsulosin
nephrolithia • Normal or ↓ renal • Stone ≥ 10 mm:
sis function urgent urology
• Severe, • CT abdomen consult for
unilateral, and pelvis without interventional
colicky contrast: visible management
flank pain stone, ureteric • Antibiotics for
• Nausea and dilatation, hydronep concurrent UTI
vomiting hrosis [63]

• Hematuria
Nonspecific back pain

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 [64][3]

• 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 [7][8][4]

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

Imaging [6][3][4]
Imaging is not routinely recommended for the evaluation of nonspecific LBP.

Management [3][2][5][66][67][4]

• Reassure patients and provide patient education.

• Initiate conservative management alone or in combination with
nonselective NSAIDs.
• Reassess symptoms in 4–6 weeks or earlier if symptoms worsen during conservative
management.
• Persistent symptoms despite 6 weeks of conservative management
o Consider alternative causes of back pain.
o Consider imaging for back pain if there is diagnostic uncertainty

Patient education [66][2][5][4]

• 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

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

• 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. [66][2]

Acute and subacute LBP

• Patients at low risk for chronic back pain: [68]

o Initial conservative management
▪ Superficial heat and/or massage
▪ Spinal manipulation
▪ Acupuncture
o Pain management
 ▪ Preferred:
nonselective NSAIDs (e.g., ibuprofen , naproxen ) [5][2][71][72]

▪ Alternatives: Consider a short-term (< 3 weeks)

nonbenzodiazepine muscle relaxant, e.g., cyclobenzaprine.[5][3]
• Patients with risk factors for chronic back pain: Consider more intensive initial
multidisciplinary rehabilitation. [3][7]

FEEDBACKYour notes

Shared NotesManage

Traumatic back pain

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]
o Preferred initial imaging modality: CT thoracic and lumbar
spinewithout IV contrast .
o Thoracolumbar injury detected on CT:
▪ MRI thoracic and lumbar spine without IV contrast
▪ Alternatively, CT myelogram to identify spinal cord
compressionor 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