Management of Acute Lower Back Pain in Adults

Educational Objectives

The goal of this program is to improve management of acute low back pain in adults. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose and manage acute low back pain.

Summary

Acute back pain after activity: patients may present with acute, sharp, unilateral low back pain that began after activity, eg, deadlifting; examination may reveal lumbar tenderness with normal strength, sensation, and reflexes; pain worsens on extension; an acute onset associated with an activity is most likely acute paraspinal strain or facet irritation (pain provoked on extension); imaging is not recommended; reassurance is key; clinicians should recommend short interval follow up (3–6 wk) so that patients feel supported while the natural course of recovery occurs; the speaker advises against prescribing bed rest because early mobilization leads to better outcomes; first-line management includes the use of nonsteroidal anti-inflammatory agents (NSAIDs) or acetaminophen when appropriate, along with heat or gentle mobility (ice or cryotherapy may be more effective than heat in the acute phase; defer to patient preference); early physical therapy must be encouraged; opioids must be avoided; return to sport requires a functional, phased progression; pain with extension suggests facet involvement, and pain with flexion suggests disc pathology

Acute radiculopathy: patients may present with one sided leg pain radiating to the foot after activity, eg, hiking; examination findings may include a positive straight leg raise, inability to sit comfortably, sensory changes in L3 to L5 dermatomes, and worsening pain with prolonged sitting; radiculopathy alone does not automatically justify advanced imaging; short interval follow up (2-3 wk) is advised; corticosteroids may be considered only when true radiculopathy is present; comorbid conditions, eg, rheumatologic disease, may require coordination with primary care or specialists; a positive straight leg raise suggests disc irritation; the slump test is more sensitive because it places additional tension on the neural structures

Vertebral fracture: older individuals may develop sharp low back pain after activity, eg, sliding down a playground slide; they may struggle with bending and extending; there are no bowel or bladder issues, and lower limb strength and reflexes are intact; the pain is mild at rest but increases with percussion testing; vertebral fracture must be considered in older adults with acute pain; any patient >60 yr of age with point tenderness should undergo a radiograph or magnetic resonance imaging (MRI) when suspicion for fracture is strong; consider ordering MRI with short tau inversion recovery (STIR) sequences to detect bony edema

Initial management of vertebral fracture: avoid prolonged rest and consider bracing; adherence in older adults is poor; bracing helps prevent fracture progression; standard analgesics, eg, acetaminophen, NSAIDs, are recommended; a short course of opioids may be appropriate to manage severe pain with compression fractures; symptoms must be managed comprehensively; referral to a spine specialist is warranted when fractures are present, pain is severe, or functional impairment is significant; immediate referral is required for cases with disabling pain, high suspicion of fracture, worsening kyphosis, or stooped posture; untreated wedge fractures may worsen morbidity, including impairing lung function; any neurologic decline or failure to improve with conservative care indicates the need for specialist evaluation

Injections: epidural corticosteroid injections are reserved for radiculopathy that has not improved with conservative therapy; facet joint injections are rarely used for acute pain and are used for chronic, degenerative facet mediated pain; occasional trigger point injections may help with severe muscle spasms

Readings

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Mimbella was recorded at the 20th Annual UCSF Sports Medicine Conference, held on December 4-6, 2025, in San Francisco, CA, and presented by University of California, San Francisco, School of Medicine. For information about upcoming CME activities from this presenter, please visit https://meded.ucsf.edu. AudioDigest thanks Dr. Mimbella and University of California, San Francisco, School of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

FP742002

Qualifies for:

Pain Management

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.