Back Pain

The protocol for Back Pain:

Back Pain


Let’s break it down!

Back pain is extremely common; ranking among the top 5 most common chief complaints in the ED.  Up to 84% of all adults will experience some form of back pain in their lives…so you can probably expect to have it yourself at some point.  There are tons of different causes of back pain, but only 5-10% have any serious pathology.  In fact, 85% of cases cannot be given an exact diagnosis, yet almost all of them in this subgroup recover in 4-6 weeks regardless of treatment.  Those are the cases this protocol is focusing on the most: simple, mostly lower, musculoskeletal back pain.

So when would we NOT use this protocol?  In two circumstances:

Acute Spinal Trauma: Any acute injury involving the spine itself and a significant mechanism (Ex. Motor vehicle accident, fall, blunt force trauma, penetrating trauma…..)

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Non-Musculoskeletal etiologies: If you suspect that the back pain is originating from a non-musculoskeletal source, such as a vascular source (ex. thoracic aortic dissection, pulmonary embolism), infectious source (meningitis, pyelonephritis), or anything else, then you will avoid this protocol.

Aortic Dissection | Aortic Aneurysm - Types, Causes, Symptoms ...

The above signs and symptoms are classically exhibited by those with non-life threatening back pain issues.  Specifically, this would include sprains and strains of the muscles and ligaments in the lumbosacral region…. things that will usually heal fairly quickly.

Still, it can be difficult to determine which back pain patients are benign and which ones are life-threatening.  The severity of the pain often serves as a poor marker for determining pathology.  Instead, these are some red flags that you should be looking for to confidently rule out life-threatening sources of pain:

Vital Sign Changes: Nobody with benign back pain should have any discrepancy in their vitals signs that can’t be accounted for by increased pain.  For example, none of these patients should have a fever(suggests infection) or high/low blood pressure(suggests cardiac or other vascular pathology).  They should be hemodynamically well.

Image result for vitals






“Back pain AND…” : Anybody who says “I have back pain AND…..” should cause you to be concerned.  This often suggests a different etiology:  Some examples:

  • Back pain AND severe headache (suggests meningitis)
  • Back pain AND difficulty breathing (suggests pneumothorax)
  • Back pain AND urinary incontinence (suggests cauda equina syndrome)

ColumbiaSpine_McCormick_cauda_equina – The Spine Hospital at The ...

Interesting stories: Nobody with a benign condition should have an interesting story.  Their story should not involve any fights, vehicle rollovers, major surgeries, terrible sicknesses, etc.  They should sound more like this:

  • “I lifted some furniture too quickly and I pulled my back out”
  • “I must’ve slept wrong because my back is killing me”
  • “I’ve been seeing a doctor for my chronic back pain for the past 12 years”

Image result for lifting back pain








1. Treat per Pain Management Protocol
Although opiates have historically been frequently prescribed to back pain patients, the first course of action from a field medical standpoint should be to try NSAIDs first.  Ibuprofen and Acetaminophen can be used for mild-moderate cases. For severe cases, a strong NSAID like Ketorolac (Toradol) can provide significant relief.

Image result for toradol





2. Apply Cold Compress to Painful Area for 20-25min tid
This is especially useful if the back pain is less than 4 weeks old follow a mild acute injury; the idea is to use the cold compress to constrict blood vessels, reduce swelling, and provide some numbing effect to the affected area.

When To Use A Cold Or Warm Compress For Pain And Swelling

3. Encourage fluid hydration, avoid bed rest, use an ice pack if acute or heat pack if subacute, stretch as tolerated
Of course, fluid hydration, heat packs, and stretching is helpful, but the big takeaway from this, which can’t be stated enough, is to avoid bed rest as much as possible.  Studies have consistently shown that maintaining active movement (w/o significant exercise) in patients with low-risk back pain helps improve outcomes.  Sedentary actions will not help the patient recover.

An Easy Stretch That Quells Back Pain




These drugs are the big guns for patients with severe back pain that they just can’t shake off.  Here’s a brief summary of each:

Cyclobenzaprine (Flexeril): This is a muscle relaxant that used to get prescribed very frequently to treat major sprains/strains in the body.  The idea of muscle relaxers is to help prevent spasms, thus reducing the pain.  However, muscle relaxers are not quite as popular as they used to be.  They have not been shown to have greater efficacy than NSAIDS/acetaminophen or aspirin.

Image result for flexeril







Diazepam (Valium): This is a benzodiazepine, which most commonly functions as a sedative and anxiolytic.  It’s not necessarily an analgesic agent, it does have muscle relaxant properties.  Like the rest of muscle relaxants, the evidence for their use is limited.


Lidocaine (Xylocaine): Functions as a local anesthetic.  If trained, you can inject lidocaine into particularly sore areas to provide a numbing relief.  This is a safe and very underutilized treatment option.  Below is a video on how to do it:

Remember the “Back pain AND…..” red flag?  Well if you find it with symptoms of a kidney infection, redirect yourself to the Flank Pain protocol so the patient can get the antibiotics they need.

Most cases of lower back pain will resolve in 4-6 weeks, regardless of what we do.  It can, however, be incredibly disabling.  If you’ve exhausted your resources and the patient still cannot find enough pain relief to continue the mission, then a Routine evacuation is going to be necessary.

Neurological involvement is something that you’ll need to ask about when interviewing all of your back pain patients.  Things like weakness, numbness, bladder dysfunction, and saddle anesthesia (numbness around the inner thighs, buttocks, and perineum) can all be signs of a very dangerous condition called cauda equina syndrome, which can occur following a massive disk herniation in the lumbar region.  This warrants an Urgent evacuation because, without it, the patient may suffer from permanent disability.


Good luck out there!



  • EMRAP CorePendium: Back Pain
  • Waljee JF, Brummett CM. Opioid Prescribing for Low Back Pain: What Is the Role of Payers?. JAMA Netw Open. 2018;1(2):e180236. Published 2018 Jun 1. doi:10.1001/jamanetworkopen.2018.0236
  • van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM; Cochrane Back Review Group. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the cochrane collaboration. Spine (Phila Pa 1976). 2003;28(17):1978–1992. doi:10.1097/01.BRS.0000090503.38830.AD
  • Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.
Brandon Simpson, PA-C
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