Dr. Hiro K

Video 07

What I'd do if I had back pain: a spine surgeon's first six weeks

People ask me this all the time: if this were your back, what would you do? My answer for the first six weeks of new back pain, at any age: check the warning signs, don't rush to scan, don't count on pills, and keep moving.

In short

  • Emergency room now: numbness around your bottom, or new trouble with your bladder or bowels. Same day or the next: a leg getting weaker, fever with back pain, a history of cancer. Over 70: think fracture.
  • For back pain alone without warning signs, an early scan has not been shown to help. Pain, numbness or weakness down the leg changes that.
  • If I took something, it would be an anti-inflammatory, mostly early on, when the pain needs it, not automatically three times a day.
  • Staying active beats bed rest. A formal exercise program is a tool for pain that lasts, not clearly for brand-new pain.
  • Not clearly better by about six weeks, or it keeps coming back: see a doctor and make a plan, not just more pills.

Summary

First, check for the few signs that mean "don't wait": numbness between your legs or around your bottom, new trouble controlling your bladder or bowels, a leg getting weaker, fever with back pain, or a history of cancer. Numbness around your bottom or new bladder or bowel trouble means the emergency room now; for the others, get seen the same day or the next. Over seventy, add a spine fracture to the list. The good news: in primary care, fewer than one in a hundred people with back pain turns out to have something serious.

Second, I would not rush to get a scan. Scans show age, not necessarily the cause: worn discs show up in about a third of twenty-year-olds with no back pain at all, and in almost everyone by eighty. Without warning signs, an early scan has not been shown to help people get better, even over sixty-five. If the pain, numbness or weakness goes down the leg, a scan becomes more likely.

Third, I would not count on pills. Acetaminophen did no better than placebo in a trial of more than 1,600 people; anti-inflammatories help a little and upset the stomach more often; muscle relaxants give a small benefit with more side effects; opioids did no better than placebo for new back or neck pain. Fourth, keep moving: bed rest does not help, and in the first weeks the job is to keep living your normal life as much as the pain allows. Pain usually falls by more than half in six weeks. Aim for half the pain, not zero.

Sources

  1. Over seventy, sudden back pain can be a fracture: age over 70 is one of the few red flags that points toward a vertebral fracture.

    Diagnostic review of 14 studies. Few single red flags were informative; age over 70 (positive likelihood ratio 11.19 in single studies), trauma and steroid use were. Combinations of flags did better. Estimates were imprecise and could not be pooled.

    Han CS, Hancock MJ, Downie A, et al. Red flags to screen for vertebral fracture in people presenting with low back pain. Cochrane Database Syst Rev. 2023;8(8):CD014461. PubMed 37615643 · DOI

  2. In primary care, fewer than one in a hundred people with new back pain turned out to have something serious.

    1,172 people with acute back pain in Australian primary care: 0.9% had serious spinal pathology (8 of the 11 were fractures), while 80% had at least one red flag.

    Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009;60(10):3072-3080. PubMed 19790051 · DOI

  3. Worn discs show up in about a third of twenty-year-olds with no back pain, and in almost everyone by eighty.

    Review of 33 studies, 3,110 people without symptoms. Disc degeneration: 37% at age 20, 96% at age 80 (modelled age-specific estimates).

    Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. PubMed 25430861 · DOI

  4. Without warning signs, an early scan has not been shown to help people get better.

    Meta-analysis of 6 randomized trials, 1,804 people: immediate imaging vs usual care made no difference to pain or function, short or long term.

    Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463-472. PubMed 19200918 · DOI

  5. The same holds over sixty-five.

    5,239 adults aged 65 and over, propensity-matched: early X-ray or MRI/CT was not linked to better disability at 12 months. People with nerve pain down the leg were excluded.

    Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015;313(11):1143-1153. PubMed 25781443 · DOI

  6. Acetaminophen (Tylenol, paracetamol) did no better than placebo in more than 1,600 people with new back pain.

    Randomized trial, 1,652 people. Median time to recovery: 17 days with regular acetaminophen vs 16 days with placebo. Partly funded by GSK, which makes paracetamol; the result was still null.

    Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384(9954):1586-1596. PubMed 25064594 · DOI

  7. Anti-inflammatories like ibuprofen help a little, less than most people expect, and upset the stomach more often.

    Meta-analysis of 35 randomized trials of spinal pain: the effect on pain was not clinically important (number needed to treat 6), and stomach-related side effects were 2.5 times as common.

    Machado GC, Maher CG, Ferreira PH, et al. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann Rheum Dis. 2017;76(7):1269-1278. PubMed 28153830 · DOI

  8. Muscle relaxants give a small benefit with more side effects.

    Meta-analysis of 31 trials. For new back pain, pain was 7.7 points lower on a 0-100 scale at up to two weeks (very low certainty); side effects were 1.6 times as common.

    Cashin AG, Folly T, Bagg MK, et al. Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: systematic review and meta-analysis. BMJ. 2021;374:n1446. PubMed 34233900 · DOI

  9. For new back or neck pain, opioids did no better than placebo.

    Triple-blind randomized trial, 347 people. Pain at 6 weeks: 2.78 with an opioid vs 2.25 with placebo (0-10 scale), with more constipation on the opioid. Academic funding.

    Jones CMP, Day RO, Koes BW, et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023;402(10398):304-312. PubMed 37392748 · DOI

  10. Bed rest does not help; staying active does a little better.

    Review of 10 randomized trials. For new back pain, advice to stay active gave a small benefit in pain over advice to rest in bed. For sciatica, little or no difference.

    Dahm KT, Brurberg KG, Jamtvedt G, et al. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010;(6):CD007612. PubMed 20556780 · DOI

  11. For brand-new back pain, a formal exercise program has not clearly been shown to help.

    Review of 23 randomized trials: exercise therapy had no clinically relevant effect on new back pain compared with sham or no treatment (very low certainty). Exercise is a tool for pain that lasts.

    IJzelenberg W, Oosterhuis T, Hayden JA, et al. Exercise therapy for treatment of acute non-specific low back pain. Cochrane Database Syst Rev. 2023;8(8):CD009365. PubMed 37646368 · DOI

  12. People with sciatica who expected their pain to last a long time were much less likely to get better.

    609 people with sciatica or back-related leg pain in UK primary care: 55% had improved at 12 months. Believing the pain would last a long time cut the odds of improvement (odds ratio 0.27).

    Konstantinou K, Dunn KM, Ogollah R, et al. Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort. Spine J. 2018;18(6):1030-1040. PubMed 29174459 · DOI

  13. On average, new back pain falls by more than half in the first six weeks.

    Meta-analysis of 33 cohorts, 11,166 people. Average pain in new back pain: 52 at the start, 23 at 6 weeks, 6 at one year (0-100 scale). These are averages, not the share who recovered.

    da C Menezes Costa L, Maher CG, Hancock MJ, et al. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ. 2012;184(11):E613-E624. PubMed 22586331 · DOI

  14. About seven in ten people had fully recovered by one year, and older people tended to recover more slowly.

    973 people with recent back pain in Australian primary care: 72% completely recovered at 12 months; median recovery 58 days for pain. Older age was linked to slower recovery.

    Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337:a171. PubMed 18614473 · DOI

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