Red Flags

Sometimes back pain is already improved or gone by the time of your medical appointment. Other times it has continued or is a type of pain that needs to be seen right away. If you have back pain from these causes, you need to see a doctor quickly to be evaluated.


If you have had recent serious trauma, including a soccer injury, football contact injury, or motor vehicle accident, see a doctor. Serious trauma is a good reason to be seen.

Older age

If you’re over the age of seventy, even insignificant trauma should be seen because stress fractures, osteoporosis fractures, and other injuries can happen to people in that age group.

Urinary or bowel incontinence

This symptom is frequently misunderstood. If the symptom happens once or occasionally comes and goes, it’s very rarely associated with back problems. If you have symptoms of urinary or bowel incontinence and back pain and they do not stop, you need to be seen in an emergency room.

History of cancer or unexplained weight loss

If you have back pain and a history of malignancy, including colorectal cancer, breast cancer, and other cancers, or if you’re not trying to lose weight and are seeing five, ten or fifteen pounds of weight loss and you have back pain, please see your doctor.

Chronic corticosteroid use

Steroid use weakens bone so back pain is a much more serious symptom in people who regularly use steroids, such as people with asthma or rheumatoid arthritis. If you’re a chronic steroid user and are having back pain, go see a doctor.

Sciatica in both legs

Sciatica is the old term for pain in the lower part of your back, into your buttocks and down your legs. If you have sciatica in both legs, you should be seen soon by a doctor. If you can’t make an appointment within a day or two, go to an emergency room.

Bacterial infections

If you’ve had any kind of a severe bacterial infection like pneumonia or intestinal infections, they can seed in the back or neck and cause severe back pain.

Injection drug use

If you’re a user of injection drugs of any kind and have back pain, please see a doctor.

Acute vs chronic back pain

Acute back pain begins and ends within a couple of weeks. It’s very common for me to see someone who has had very severe back or neck pain, but the appointment is a week or 10 days after the pain started and the pain is gone. Acute back pain usually can be taken care of by over-the-counter analgesics (painkillers) and by exercise. Do not lay around in bed. Get up and walk and move and acute back pain will get better if it is not associated with the red flag list above.

Chronic back pain goes on for over a month typically and is getting worse, not better. When you’ve been having it for 4-6 weeks, it’s not unreasonable to check in with a medical professional to find the cause. It’s especially important for teenagers who have had back pain for 4-6 weeks to see a medical professional. Children with back pain should be seen quickly.

X-rays and MRIs

Patients often ask if they need X-rays. X-rays are very overrated, particularly if you don’t have the red flag signs. If you’re at a medical appointment in the office and your back pain is already starting to diminish, you do not need X-rays. Additionally, X-rays do not need to be repeated on every visit. It’s not a lot of radiation, but it is radiation. Unless you’re recovering from a surgery or an injury and your doctor is specifically asking for the X-rays, in general you do not need to keep repeating X-rays as the changes in your bone happen slowly.

Another common question is patients asking if they need an MRI. MRIs are very expensive tests, and I think they should typically be ordered by PAs, nurse practitioners or physicians after they have reviewed X-rays to make the determination that more advanced imaging is necessary. MRIs show almost too much because they show abnormalities that may not necessarily have anything to do with why you’re having pain.

In general, you don’t need X-rays frequently and you need MRIs even more infrequently.

Back pain treatment

If your medical provider has done a physical exam and determined that you need further treatment beyond home exercise, our excellent physical therapy team will get involved and help you make progress. Additionally, medications can be prescribed. Narcotics are not needed for back pain except in very rare circumstances. The more common medications are over-the-counter anti-inflammatories, Tylenol, and occasionally muscle relaxers for people with acute muscle strain type back pain that are having a hard time sleeping.

Back pain education

Since you don’t have much time with your doctor, I want to recommend and as excellent sources of information about back and neck pain. I recommend using them in conjunction with your visit with your provider. I encourage you to write down questions and to think of things you can get out of the visit ahead of time.

When you’re looking at your information in MyChart, especially when you’re looking at MRI results, you may find words you don’t recognize like spondylolisthesis, spondylosis, spinal stenosis, bulging discs, or other terms. You can spend all day looking them up, but they could also be called standard degenerative changes of your back. Patients usually feel more comfortable realizing that the reports just mean that their spine is aging. If you know your back is aging regularly, you feel more comfortable staying active which helps your health long-term.

Stem cells and PRP for back pain

Patients will ask me about stem cells and PRP for back pain. However, there is no reputable literature currently that shows that these treatments have any effect on the back. If someone suggests it, be skeptical and question it.

Stem cells and PRP can help athletes with sports injuries to the tendons, ligaments, muscles and so on get back to vigorous activities quickly. However, those situations are different than the spine. I want to separate out the treatments that my sports medicine colleagues do from the spine colleagues because there is a difference.

Surgery for back pain

Spine surgery is one of the safest, most effective procedures you can get. It works and it changes people’s lives. However, most patients don’t need it. Out of 200 patients a week, 1-3 patients will need spine surgery. It is very, very rare to need surgery on your back.

Frequently asked questions

Are back muscle spasms a red flag?

No, back muscle spasms are the most common cause of back pain. There are hundreds of muscles in the back and it’s easy to strain them, so acute muscle spasms are one of the most common reasons for doctors’ visits. Most of the time the pain is gone or significantly improved by the time you get to the appointment.

How can you determine what is a spine issue and what is a muscle issue?

Typically, it's by the rapidity of how much it improves. Muscle spasm is going to let up very quickly and within 24 to 48 hours patients will be seeing rapid improvements in their symptoms. If someone has a fracture, their pain will increase over that same time period.

Should someone be concerned with the constant cracking in their lower back?

No, the cracking of joints is simply nitrogen gas bubbles popping as the joint moves. These are not something to be worried about.