Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Acute Back Pain

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In one line

·Most sudden back pain comes from a pulled muscle, stretched ligament, or a disc that has shifted in the lower back, and it gets better on its own within 4 to 6 weeks without scans or surgery.

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Normal physiology

·The spine is a tall stack of backbones (vertebrae) with gel-filled shock absorbers (intervertebral discs) between them, held steady by small sliding hinges (facet joints), back muscles (paraspinal muscles that run up and down the spine), and tough straps (ligaments). This system carries the weight of your body, lets you bend and twist, and protects the spinal cord and nerve roots. Normal back movement does not hurt because the discs cushion pressure, muscles squeeze and relax smoothly, and joints slide without rubbing.

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What goes wrong

·In most cases of sudden back pain, one mechanical problem—a pulled muscle, stretched ligament, or pushed-out disc—explains all the symptoms.

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Hallmark signs

·Pain in the lower back (the area between your ribs and your buttocks)
·Pain worse with movement (bending, lifting, twisting) and better with rest
·Back muscle spasm and stiffness
·Cannot bend as far as usual (limited range of motion)
·Tender spot when you press on back muscles or the bumps along the spine
·Normal leg strength, feeling, and reflexes (in simple mechanical back pain)
·Shooting pain down the leg in a stripe pattern (sciatica) if a nerve root is pinched
·Numbness in the groin, buttocks, and inner thighs (saddle numbness—the area that would touch a saddle if you sat on a horse)

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Red flags · escalate now

·Age over 50 with new back pain (higher chance of a broken backbone from weak bones—osteoporosis—or cancer spread to the spine)
·History of cancer (risk the cancer has traveled to the backbone)
·Fever, chills, or losing weight without trying (points to infection or cancer)
·Recent injury or hard fall (risk of a broken vertebra—one of the bones in the spine)
·IV drug use or weak immune system (risk of an abscess—a pus pocket—in the spine or bone infection)
·Saddle numbness, cannot pee, or losing bowel control (cauda equina syndrome—nerves at the bottom of the spine are crushed)
·Legs getting weaker or losing feeling fast (progressive or severe nerve damage)
·Pain worse at night or not better with rest (suggests inflammation, infection, or cancer instead of simple strain)

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Workup

·No imaging in patients without red flags if symptoms are less than 6 weeks
·MRI of the lumbar spine if red flags are present (saddle anesthesia, fever, cancer history, progressive weakness, or bowel or bladder dysfunction)
·ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) if concern for infection or inflammatory spine disease
·Complete blood count (CBC) if fever or suspicion of infection
·Blood cultures (two sets from different sites) if fever and suspected epidural abscess
·Plain X-ray of the lumbar spine if history of trauma, suspected fracture, or age over 50 with new severe pain
·CT (computed tomography) of the lumbar spine if MRI is not available or contraindicated (pacemaker, certain metal implants, severe claustrophobia)
·Post-void residual bladder scan (ultrasound measurement of urine left in bladder after urinating) if concern for cauda equina syndrome

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Treatment

·NSAIDs (nonsteroidal anti-inflammatory drugs like ibuprofen 400 to 600 milligrams every 6 to 8 hours or naproxen 500 milligrams twice daily) or acetaminophen (650 to 1000 milligrams every 6 hours)
·Short-term muscle relaxant (cyclobenzaprine 5 to 10 milligrams at bedtime or methocarbamol 500 to 750 milligrams three times daily) for severe muscle spasm only, used 5 to 7 days maximum
·Physical therapy and graded return to normal activity (staying as active as tolerated from day one, avoiding bed rest beyond 48 hours)
·Avoid opioids (hydrocodone, oxycodone, morphine) in acute back pain without red flags
·Imaging (MRI or CT) only if red flags are present or symptoms persist beyond 6 weeks without improvement
·Urgent surgery (lumbar decompression within 48 hours) for cauda equina syndrome or progressive severe neurologic deficit, or IV antibiotics (vancomycin plus ceftriaxone or cefepime) for epidural abscess
·Spinal manipulation (chiropractic or osteopathic manual therapy) for select patients without red flags

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NCLEX trap

·Bed rest makes acute back pain worse. Lying in bed for more than 1 to 2 days weakens your muscles (they lose strength and stamina), slows healing, and makes it harder to get better. Gentle early movement — like walking or light stretching — keeps blood flowing to the hurt area, stops muscles from shrinking (wasting away), and helps you heal faster. Today's guidelines (American College of Physicians, 2017) say stay as active as you can handle and start physical therapy early.
·A positive straight leg raise (lifting your leg while lying down causes pain shooting down the leg) is common when a nerve in your back is irritated. It does NOT change your first treatment unless red flags show up. Red flags are danger signs: fever, numbness in your groin or bottom (saddle area), losing control of your bowel or bladder, leg weakness that is getting worse, a history of cancer, losing weight without trying, or a weak immune system. Most back pain from muscle strain or a bulging disc (when the cushion between spine bones pushes out) gets better with basic care — anti-inflammatory medicine like ibuprofen, adjusting your activities, and physical therapy — in 4 to 6 weeks. You only need an MRI if red flags are there or if your pain does not improve after 4 to 6 weeks of basic treatment (American College of Physicians guidelines).
·Anti-inflammatory medicines (NSAIDs like ibuprofen or naproxen) or acetaminophen (Tylenol) are the first medicines to try for new back pain, according to the American College of Physicians and CDC. Opioids (strong prescription pain pills) do NOT fix the injured muscle, ligament, or disc causing your pain. They do NOT help you move or function better than NSAIDs do, and they carry high risks: addiction, overdose, and death. Only use opioids if NSAIDs and acetaminophen fail, red flags are ruled out, and only for the shortest time possible — 3 to 7 days at most.
·Cauda equina syndrome (CES) happens in only 1 to 2 out of every 100 people with a bulging disc, but it causes permanent loss of bowel, bladder, and sexual function if you miss it and wait longer than 48 hours to treat it. Always check EVERY patient with new back pain for CES red flags: numbness in the groin, buttocks, or inner thighs (saddle anesthesia); cannot urinate or bladder leaks without control (urinary retention or incontinence); losing control of bowel movements (fecal incontinence); or weakness in both legs. If any of these are present, this is a surgical emergency. The patient needs an urgent MRI and surgery within 24 to 48 hours to save nerve function.
·A normal MRI is reassuring but does NOT rule out every serious problem. Early spine infection (epidural abscess — a pocket of pus pressing on the spinal cord) may not light up on the scan in the first 24 to 48 hours. A hidden bone break from weak bones (osteoporosis) might only show up on a CT scan or bone scan. Early cancer may not appear yet. Clinical red flags — fever, weak immune system, IV drug use, recent bloodstream infection, cancer history, losing weight without trying, pain at night that wakes you up, or tenderness over one spine bone — drive what you do next, not the scan alone. If red flags are present and the MRI is normal, consider repeating the scan in 48 to 72 hours, getting a CT, or calling an infectious disease or cancer specialist.

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