Low Back Pain

intervertebral discs degenerate

This is a common cause of back pain as a person ages.

L4-L5

L5-S1

The most affected areas for low back pain.

less than 3 months

duration for acute back pain

3 months or more without improvement

duration for chronic back pain

radiculopathy: pain from a diseased spinal nerve root

sciatica: pain from an inflamed sciatic nerve

Radiating back pain may suggest:

Cauda equina syndrome

A very serious cause of low back pain caused by compression of the lower spinal nerves. This results in bowel or bladder dysfunction, and saddle anesthesia (numbness/tingling in the perineal, inner thigh, or buttock area). This is a medical emergency and needs immediate referral for urgent treatment to prevent permanent nerve damage.

suspected spinal infection

severe neurologic weakness

urinary or fecal incontinence

new back pain in a patient with cancer

Diagnostic studies are needed when there are red flags such as:

NSAIDs (e.g., ibuprofen) → first-line for pain relief

Muscle relaxants (e.g., cyclobenzaprine) → short-term use

Medications for Acute Low Back Pain

Opioids

Used only for moderate to severe pain. Short-term only (1-2 weeks). Avoid in older adults, kidney disease, and those at risk for NSAID complications

Antidepressants (e.g., amitriptyline)

SNRIs (e.g., duloxetine)

Anticonvulsants e.g., gabapentin (especially for nerve pain/radiculopathy)

Medications for Chronic Low Back Pain

twisting

bending

lifting

reaching

Physical activities to avoid

frequent position changes

limit sitting to 20-50 minutes

early return to normal activities

avoid prolonged bed rest

Activity and Lifestyle Modifications to encourage

Start low-stress aerobic exercises (e.g., walking). Begin back and core strengthening exercises after ~2 weeks. Active movement improves recovery

Exercise modification

Semi-Fowler's (head elevated ~30° with knees slightly flexed)

Side-lying (curled position) with pillow between knees

Recommended positions:

prone position (increases lumbar curvature)

What position to avoid