🩺 Back pain

## Overview Back pain is one of the most common reasons adults seek medical care worldwide. It refers to any pain felt along the spine or paraspinal structures — from the base of the skull (cervical region) to the coccyx — though the term most often describes **low back pain** (lumbago), coded under ICD-10 M54. The Global Burden of Disease Study 2017 ranked low back pain as the leading cause of years lived with disability globally, affecting an estimated 577 million people at any given time [1]. In the United States alone, roughly 80 % of adults will experience at least one episode of significant back pain during their lifetime, and it is the single largest contributor to lost workdays [2]. People search for information about back pain because episodes are often sudden, frightening, and functionally limiting. Most acute back pain (lasting < 6 weeks) resolves with conservative measures, but a small subset signals serious underlying pathology. Understanding the difference is critical. > **Disclaimer:** This article is for educational purposes only and does not replace individualized medical advice. Always consult a qualified healthcare provider for diagnosis and treatment. --- ## Common Causes Back pain can be broadly categorized as **mechanical/non-specific** (≈ 85–90 % of cases), **radiculopathic** (nerve root involvement), or **secondary to systemic disease** (< 1–5 %) [3]. The following list is ranked roughly by frequency in primary-care settings. ### 1. Non-specific Musculoligamentous Strain (most common) Overuse, poor posture, sudden awkward movements, or heavy lifting can strain paraspinal muscles and spinal ligaments. Microtrauma triggers local inflammation and protective muscle spasm. Pain is usually diffuse, worsens with movement, and improves with rest over days to weeks [4]. ### 2. Degenerative Disc Disease / Spondylosis Age-related desiccation and loss of disc height reduce the intervertebral disc's ability to absorb axial loads. Facet-joint arthropathy often co-exists. Prevalence increases sharply after age 40 and is visible on imaging in the majority of asymptomatic adults — so MRI findings must be correlated clinically [3]. ### 3. Herniated (Prolapsed) Intervertebral Disc Nucleus pulposus material protrudes through the annulus fibrosus and may compress an adjacent nerve root, producing **radiculopathy** — sharp, dermatomal leg pain (sciatica when L4–S1 roots are involved). A 2016 review noted that most herniations improve within 6–12 weeks with conservative care [5]. ### 4. Spinal Stenosis Narrowing of the central canal or lateral foramina — usually from a combination of disc bulging, ligamentum flavum hypertrophy, and osteophyte formation — causes **neurogenic claudication**: bilateral leg heaviness and pain on walking, relieved by sitting or leaning forward. Most common in adults > 60 years [3]. ### 5. Spondylolisthesis Anterior displacement of one vertebra over the one below. Isthmic type (pars interarticularis defect) is more common in younger patients and athletes; degenerative type predominates in older adults. May be asymptomatic or cause mechanical pain and radiculopathy. ### 6. Osteoporotic Vertebral Compression Fracture Low-energy fractures of vertebral bodies occur predominantly in postmenopausal women and older men with osteoporosis. Sudden, localized midline pain after minimal trauma (or even coughing) is the hallmark. ### 7. Sacroiliac Joint Dysfunction Pain localized to the sacroiliac region, often unilateral. May follow pregnancy-related ligamentous laxity or trauma. Provocation tests (e.g., FABER, compression) aid diagnosis. ### 8. Less Common but Important Causes - **Ankylosing spondylitis / axial spondyloarthritis** — inflammatory back pain in younger adults (< 45), worse with rest, improves with exercise. - **Spinal infection** (discitis, vertebral osteomyelitis, epidural abscess) — fever, unrelenting pain, elevated inflammatory markers. - **Primary or metastatic spinal tumor** — progressive pain unresponsive to rest, weight loss, history of malignancy. - **Cauda equina syndrome** — see Red Flags below. --- ## RED FLAGS The following signs and symptoms may indicate a serious or life-threatening cause of back pain. **Seek emergency medical attention (ER / call 911) if any are present:** - **Saddle anesthesia** — numbness in the perineum, inner thighs, or buttocks (suggests cauda equina syndrome) - **New-onset bowel or bladder incontinence or urinary retention** - **Progressive motor weakness** in one or both legs (e.g., foot drop) - **Severe, unremitting pain at rest**, especially at night, unresponsive to position changes - **Fever > 38 °C / 100.4 °F with back pain** — raises concern for spinal infection or epidural abscess - **History of significant trauma** (fall from height, motor-vehicle collision) with acute onset pain - **Known history of cancer**, unexplained weight loss (> 5 % in 6 months), or age > 50 with new-onset pain - **History of intravenous drug use or recent spinal procedure** with worsening pain - **Anticoagulant use** with new neurological deficit (risk of spinal epidural hematoma) - **Abdominal aortic aneurysm signs** — pulsatile abdominal mass, tearing back pain, hemodynamic instability Cauda equina syndrome is a **surgical emergency** — delay beyond 24–48 hours significantly worsens long-term outcomes [5]. --- ## Self-Care at Home For most acute non-specific back pain, the following evidence-based non-pharmacological measures are first-line [6][7]: 1. **Stay active.** Bed rest beyond 1–2 days is discouraged. A landmark ACP guideline (2017) emphasized that continued activity accelerates recovery compared with prolonged rest [6]. 2. **Superficial heat.** Applying a heat wrap (40 °C) for 20–30 minutes several times daily may reduce pain and muscle spasm. A Cochrane review found moderate evidence supporting heat for acute low back pain. 3. **Gentle stretching and mobility exercises.** Walking, pelvic tilts, and cat-cow stretches help maintain range of motion. Avoid high-impact activities during acute flare. 4. **Cold therapy.** Ice packs (wrapped in cloth, 15–20 minutes at a time) may help in the first 48–72 hours when inflammation predominates. 5. **Correct posture and ergonomics.** Adjust workstation height, use lumbar support, and avoid prolonged sitting (> 30–45 minutes without a break). 6. **Mind-body approaches.** Yoga, tai chi, and mindfulness-based stress reduction have moderate evidence for chronic low back pain (NICE NG59 recommends group exercise programmes) [7]. 7. **Spinal manipulation.** May offer short-term relief for acute low back pain when performed by a qualified practitioner (chiropractor, osteopath, or physiotherapist) [6]. 8. **Cognitive behavioral therapy (CBT).** Recommended for subacute and chronic pain to address fear-avoidance behavior and catastrophizing [7]. --- ## OTC Medications That Help Over-the-counter analgesics are appropriate for short-term management of mild-to-moderate non-specific back pain. Always read the label and observe maximum daily limits. | Class | Example | Typical Adult Dose | Mechanism | Key Notes / Contraindications | |---|---|---|---|---| | **NSAIDs** | Ibuprofen (Advil, Motrin) | 200–400 mg every 4–6 h (max 1200 mg/day OTC) | Inhibits COX-1/COX-2 → reduces prostaglandin synthesis, lowering inflammation and pain | Avoid in renal impairment, active peptic ulcer, third-trimester pregnancy. GI-protective agent (e.g., famotidine) advisable if use > 5–7 days. | | **NSAIDs** | Naproxen sodium (Aleve) | 220 mg every 8–12 h (max 660 mg/day OTC) | Same as above; longer half-life allows twice-daily dosing | Same contraindications as ibuprofen. Cardiovascular risk with prolonged use — FDA boxed warning [8]. | | **Acetaminophen (Paracetamol)** | Tylenol | 500–1000 mg every 4–6 h (max 3000 mg/day; some guidelines allow 4000 mg for healthy adults) | Central analgesic — inhibits central COX and activates descending serotonergic pathways | Avoid exceeding dose limits; hepatotoxic in overdose. Recent evidence suggests limited efficacy as sole agent for back pain [4]. | | **Topical NSAIDs** | Diclofenac gel 1 % (Voltaren) | Apply 4 g to affected area up to 4 times/day | Local COX inhibition with lower systemic absorption | Useful when oral NSAIDs are contraindicated. Do not apply to broken skin. | | **Topical counterirritants** | Menthol/capsaicin (Icy Hot, Salonpas) | Apply to affected area 3–4 times/day | Menthol activates TRPM8 (cooling); capsaicin depletes substance P | May irritate skin. Wash hands after application. Limited high-quality evidence, but generally safe. | **Important note on acetaminophen:** A pivotal 2014 RCT (PACE trial) found that paracetamol was no more effective than placebo for acute low back pain, though it remains useful as an adjunct and is well-tolerated [4]. NSAIDs are generally preferred as the first-line OTC analgesic for back pain per ACP 2017 guidelines [6]. --- ## Prescription Options Prescription medications are generally reserved for moderate-to-severe pain that does not respond to OTC agents, or when specific pathology (e.g., radiculopathy, inflammatory disease) is identified. Prescribing varies by country; below are common classes. | Class | Examples | Indication | Key Notes | |---|---|---|---| | **Prescription-strength NSAIDs** | Meloxicam 7.5–15 mg/day; Celecoxib 200 mg/day | Moderate inflammatory or mechanical pain | Celecoxib (COX-2 selective) has lower GI risk but similar cardiovascular risk. Monitor renal function. | | **Skeletal muscle relaxants** | Cyclobenzaprine 5–10 mg TID; Tizanidine 2–4 mg TID; Methocarbamol | Acute muscle spasm (short-term, ≤ 2 weeks) | Sedation is the main side effect. Avoid in elderly (Beers criteria). Do not combine with alcohol or CNS depressants. | | **Tricyclic antidepressants (TCAs)** | Amitriptyline 10–75 mg at bedtime | Chronic back pain, especially with sleep disturbance or neuropathic component | Start low, titrate slowly. Anticholinergic side effects. ECG recommended in patients > 45 years. | | **SNRIs** | Duloxetine 30–60 mg/day | Chronic musculoskeletal pain (FDA-approved for chronic low back pain) | Nausea common initially. Taper on discontinuation. Avoid with MAOIs. | | **Gabapentinoids** | Gabapentin 300–1200 mg TID; Pregabalin 75–150 mg BID | Radicular / neuropathic component | Evidence for non-specific back pain is limited. Dose-dependent sedation. NICE does not recommend gabapentinoids for non-specific low back pain [7]. | | **Oral corticosteroids** | Prednisone taper (e.g., 60 mg → taper over 5–7 days) | Acute severe radiculopathy (controversial) | Short-term only. Hyperglycemia, insomnia, mood changes. Limited evidence of sustained benefit [5]. | | **Epidural steroid injections** | Methylprednisolone or dexamethasone (fluoroscopy-guided) | Radiculopathy or spinal stenosis refractory to 6 weeks of conservative care | Performed by pain medicine specialist or interventional radiologist. May provide weeks-to-months of relief; repeat injections limited to ≤ 3 per year. | | **Opioid analgesics** | Tramadol 50–100 mg Q6H; Oxycodone/acetaminophen (short course only) | Severe acute pain unresponsive to all other measures | **Last resort.** ACP and CDC guidelines strongly discourage opioids for chronic back pain due to addiction risk and lack of long-term benefit [6]. Short course (≤ 3–5 days) only when benefits clearly outweigh risks. | **Who prescribes:** Primary-care physicians, orthopedic surgeons, physiatrists (PM&R), neurologists, and pain-management specialists may prescribe or refer depending on complexity. --- ## Lab Tests Typically Ordered Most acute non-specific back pain does **not** require laboratory testing or imaging. Tests are ordered when red-flag features are present, pain persists beyond 4–6 weeks, or a specific diagnosis is suspected [3]. | Test | Rationale | When Ordered | |---|---|---| | **Complete blood count (CBC)** ([details](/tests/complete-blood-count)) | Elevated WBC may suggest infection; anemia may hint at malignancy or chronic disease | Fever, unexplained weight loss, suspicion of infection or tumor | | **Erythrocyte sedimentation rate (ESR)** ([details](/tests/esr)) | Non-specific inflammatory marker; elevated in infection, malignancy, and inflammatory spondyloarthropathy | Age > 50 with new-onset pain, suspected ankylosing spondylitis | | **C-reactive protein (CRP)** ([details](/tests/crp)) | More specific acute-phase reactant than ESR; rises rapidly with bacterial infection | Suspected discitis, epidural abscess, or osteomyelitis | | **HLA-B27** ([details](/tests/hla-b27)) | Positive in ~90 % of ankylosing spondylitis patients (Caucasian populations) | Young adult (< 45 y) with inflammatory-pattern back pain (morning stiffness > 30 min, improves with exercise) | | **Serum calcium, alkaline phosphatase, phosphate** | Screen for metabolic bone disease (Paget's disease, osteomalacia, hyperparathyroidism) | Unexplained compression fracture, diffuse bone pain | | **Prostate-specific antigen (PSA)** ([details](/tests/psa)) | Prostate carcinoma frequently metastasizes to the lumbar spine | Males > 50 with progressive pain and red-flag features | | **Urinalysis** ([details](/tests/urinalysis)) | Renal pathology (pyelonephritis, nephrolithiasis) can present as flank/back pain | Costovertebral angle tenderness, dysuria, hematuria | | **Vitamin D (25-hydroxyvitamin D)** ([details](/tests/vitamin-d)) | Deficiency may contribute to chronic musculoskeletal pain and osteoporosis risk | Chronic pain, limited sun exposure, risk factors for osteoporosis | | **DEXA scan (bone densitometry)** | Diagnoses osteoporosis/osteopenia — guides fracture-risk management | Postmenopausal women, men > 70, or anyone with fragility fracture | **Imaging notes:** Plain radiographs are first-line when fracture or structural abnormality is suspected. MRI is the gold standard for evaluating disc pathology, spinal-cord compression, infection, and tumors. CT is used when MRI is contraindicated. Routine imaging for acute non-specific back pain is **not recommended** and may lead to unnecessary interventions [3][7]. --- ## Special Populations ### Children and Adolescents Back pain in children is less common than in adults and warrants a lower threshold for investigation. Potential causes include spondylolysis (stress fracture of the pars interarticularis — common in young athletes), Scheuermann's disease, scoliosis, infection, and rarely tumor. **Pediatric medication dosing should always be determined by the child's physician** — do not extrapolate adult OTC doses. Ibuprofen is generally dosed at 5–10 mg/kg every 6–8 hours in children ≥ 6 months (per AAP guidance), but clinician confirmation is essential. ### Pregnancy Back pain affects 50–80 % of pregnant individuals, driven by hormonal ligamentous laxity (relaxin), anterior shift in center of gravity, and weight gain. Management focuses on non-pharmacological approaches: - Prenatal yoga and aquatic exercise - Pelvic support belts - Physical therapy **Medication considerations in pregnancy:** - **Acetaminophen** — generally considered the safest oral analgesic (FDA category not formally assigned post-2015 labeling change, but historically Category B). - **NSAIDs** — should be avoided after 20 weeks' gestation due to risk of premature ductus arteriosus closure and oligohydramnios (FDA safety communication, 2020) [8]. Use before 20 weeks only with clinician approval. - **Muscle relaxants** — limited safety data; generally avoided. - **Opioids** — associated with neonatal abstinence syndrome; use only under specialist guidance. ACOG recommends a multimodal, primarily non-pharmacological approach [9]. ### Elderly (≥ 65 years) Older adults face higher risks from both back pain causes (osteoporotic fracture, spinal stenosis, malignancy) and treatments: - **NSAIDs:** Increased risk of GI bleeding, renal impairment, and cardiovascular events. Use the lowest effective dose for the shortest duration. Consider topical NSAIDs as a safer alternative. - **Muscle relaxants:** Listed on the **Beers Criteria** as potentially inappropriate in older adults due to sedation and fall risk. - **Opioids:** Heightened sensitivity; start at 25–50 % of the usual adult dose. Fall and respiratory-depression risk is elevated. - **Acetaminophen:** Generally preferred first-line oral analgesic, but max dose may need to be reduced to 2000 mg/day in patients with hepatic impairment or alcohol use. - Prioritize physical therapy, fall prevention, and osteoporosis treatment (bisphosphonates, calcium, vitamin D) where indicated. ### Athletes Sports-related back pain is common, particularly in sports involving repetitive extension and rotation (gymnastics, cricket, tennis). Key considerations: - **Spondylolysis** should be suspected in any young athlete with extension-provoked low back pain persisting > 2 weeks. SPECT-CT or MRI is the preferred diagnostic modality. - Relative rest from the offending activity, bracing, and progressive rehabilitation are mainstays of treatment. - NSAIDs should be used cautiously around competition due to potential masking of injury. Some sports organizations have regulations around specific medications. - Return-to-play decisions should be guided by a sports-medicine physician. --- ## When to Escalate Use the following thresholds as a general guide: ### Same-Day GP / Primary-Care Visit - New back pain with any red-flag feature (see above) that is not immediately life-threatening - Pain persisting beyond 4–6 weeks without improvement despite self-care - Mild neurological symptoms (tingling, intermittent numbness) without motor weakness - Recurrent episodes interfering with daily function or work ### Urgent Care (same day or within 24 hours) - Moderate radicular leg pain with new onset of numbness or weakness - Back pain with fever < 38.5 °C and no hemodynamic instability - Pain following moderate trauma (e.g., sports injury, fall from standing) - Inability to bear weight or perform activities of daily living ### Emergency Room / Call 911 - **Cauda equina syndrome** features: saddle anesthesia, bladder/bowel dysfunction, bilateral leg weakness - Suspected spinal epidural abscess or hematoma (fever + neurological deficit, especially in immunocompromised or anticoagulated patients) - Severe trauma (high-energy mechanism — motor-vehicle accident, fall from height) - Signs of abdominal aortic aneurysm rupture (severe tearing pain, hypotension, pulsatile mass) - Acute onset of severe weakness or paralysis in the lower extremities **General rule:** When in doubt, err on the side of seeking medical evaluation sooner rather than later. Early assessment of red-flag symptoms can be life- and function-saving. --- ## References [1] GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. *Lancet*. 2018;392(10159):1789-1858. PMID:30496104. [2] Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. *Lancet*. 2018;391(10137):2356-2367. PMID:29573870. [3] Maher C, Underwood M, Buchbinder R. Non-specific low back pain. *Lancet*. 2017;389(10070):736-747. PMID:27745712. [4] Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial (PACE). *Lancet*. 2014;384(9954):1586-1596. PMID:25064594. [5] Deyo RA, Mirza SK. Clinical practice. Herniated lumbar intervertebral disk. *N Engl J Med*. 2016;374(18):1763-1772. PMID:27144851. [6] Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. *Ann Intern Med*. 2017;166(7):514-530. PMID:28192789. [7] National Institute for Health and Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]. Published November 2016, updated December 2020. Available at: https://www.nice.org.uk/guidance/ng59. [8] U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA recommends avoiding use of NSAIDs in pregnancy at 20 weeks or later. October 2020. Available at: https://www.fda.gov/drugs/drug-safety-and-availability. [9] American College of Obstetricians and Gynecologists (ACOG). ACOG Committee Opinion No. 711: Opioid use and opioid use disorder in pregnancy. *Obstet Gynecol*. 2017;130(2):e81-e94. PMID:28742676. [10] Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. *Lancet*. 2018;391(10137):2368-2383. PMID:29573872. --- *Last reviewed: April 2026. This article is peer-reviewed and intended for general informational purposes. It does not constitute medical advice. Consult your healthcare provider for personalized recommendations.*