Low back pain
Don't miss
- INESSS Institut national d'excellence en santé et services sociaux
- CWC Choosing Wisely Canada
- CAR Canadian Association of Radiologists
| Decision | Guideline |
|---|---|
| Red flags, Quebec | Urgent:Cauda equina: saddle anaesthesia, urinary or fecal incontinence, urinary retention.
Fracture: trauma, osteoporosis or its risk, long-term corticosteroids. Also
INESSS tool opens in a new tabChoosing Wisely Canada, Radiology opens in a new tabCAR 2025 spine guideline opens in a new tab |
| Leave now | Refer at once for urgent imaging and surgical assessment if neurological signs are severe or progressively worsening. |
| Not spinal | Consider referred pain from an abdominal organ (pancreatitis, kidney stone, aortic dissection) or a pelvic organ. |
| Urgent | Suspected epidural abscess or hematoma with acute pain: image urgently, even without neurological symptoms. |
| Compression fracture | Vertebral imaging: see Osteoporosis. |
Diagnose
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Duration | Acute: under 6 weeks. Subacute: 6 to 12 weeks, the window to step up care. Chronic: over 12 weeks. |
| Pain mechanism | Classify the predominant pain as nociceptive, neuropathic or nociplastic. |
| Chronicity risk | Assess biopsychosocial factors systematically, from the first visit.
|
| Risk tools | Consider a validated tool.The INESSS tool box names STarT Back and the short Örebro. |
Investigate
- INESSS Institut national d'excellence en santé et services sociaux
- CWC Choosing Wisely Canada
- CAR Canadian Association of Radiologists
| Decision | Guideline |
|---|---|
| No red flags | Do not image, whatever the duration, unless imaging will plan a specific intervention. Choosing Wisely Canada, Spine opens in a new tabINESSS tool opens in a new tabINESSS imaging état des pratiques opens in a new tab X-ray first for axial pain that has not resolved after conservative care. |
| When to image | Consider imaging for:red flags;
poor course despite combined drug and non-drug care;
neurogenic claudication;
an invasive treatment is planned (epidural, facet or SI injection). If not indicated
|
| Disc or stenosis | Suspected uncomplicated herniated disc or spinal stenosis: image only after 6 weeks or more of conservative care, and only if surgery is being considered. |
| Radicular pain with red flags | MRI first if not resolved after conservative care.CT only as an interim for lumbar radiculopathy when MRI is unavailable or contraindicated. |
| HLA-B27 | Only when spondyloarthritis is suspected:inflammatory back pain 3 months or more, onset before 45, plus SpA features. Not a test for non-specific low back pain. |
Treat
- INESSS Institut national d'excellence en santé et services sociaux
- CWC Choosing Wisely Canada
- NPC McMaster National Pain Centre
| Decision | Guideline |
|---|---|
| Drug always with non-drug | Drugs go alongside non-drug care, never alone.Step up by response. |
| Nociceptive pain | NSAID, alone or with acetaminophen.Acetaminophen alone if NSAIDs are contraindicated or poorly tolerated. |
| Spasm, acute or subacute | Short-term non-benzodiazepine muscle relaxant, alone or with analgesics. |
| Neuropathic pain | SNRI or tricyclic, alone or with a gabapentinoid. |
| Nociplastic pain | SNRI, tricyclic or gabapentinoid, chosen by comorbidity. |
| Before adding a drug | Confirm the first drug reached an effective dose. Reassess biopsychosocial factors and self-care. Stop drugs that did not help. |
| Do not | No epidural steroid injection for axial pain without leg-dominant radicular symptoms. |
| Opioids | Never routine.Possible for selected patients who failed first-line care, or with severe acute or subacute pain.
Lowest effective dose, a few days, low-potency agent, close follow-up.
Chronic: not recommended except as an exception.
Nociplastic: not recommended. INESSS tool opens in a new tabChoosing Wisely Canada, Spine opens in a new tab No trial with a history of opioid overdose or an active alcohol use disorder.
During a trial, avoid over 80 mg MED a day, seldom if ever over 150. |
| Drug | Main start | Max per day | How long |
|---|---|---|---|
| Nociceptive pain | |||
| Ibuprofen | 400–800 mg q6–8h | 2400 mg | Regular dosing, under 30 days, preferred over PRN |
| Naproxen | 250–500 mg q12h | 1000 mg | Same as ibuprofen |
| Diclofenac | Immediate release: 50 mg q6–8h titration: see INESSS tool opens in a new tab | 100 mg | Same as ibuprofen |
| Celecoxib | 200 mg DIE or 100 mg BID | 200 mg | Same as ibuprofen |
| Ketorolac | 10 mg q4–6h | 40 mg | Same as ibuprofen |
| Diclofenac gel | 1.16%: TID–QID titration: see INESSS tool opens in a new tab | Not stated | |
| Acetaminophen | 325 mg tablet: 325–650 mg q4–6h titration: see INESSS tool opens in a new tab | 4000 mg short term 3000 mg long term 1500 mg in stable chronic liver disease | Not stated |
| Spasm, acute or subacute | |||
| Cyclobenzaprine | 5–10 mg at bedtime titration: see INESSS tool opens in a new tab | 1 to 2 weeks | |
| Methocarbamol | 400–1000 mg q4–6h (coformulated with ASA, NSAID or acetaminophen) titration: see INESSS tool opens in a new tab | 1 to 2 weeks | |
| Orphenadrine | 100 mg DIE–BID titration: see INESSS tool opens in a new tab | 1 to 2 weeks | |
| Neuropathic or nociplastic pain | |||
| Duloxetine | 30 mg DIE titration: see INESSS tool opens in a new tab | Taper over several weeks to stop | |
| Venlafaxine | 37.5 mg DIE titration: see INESSS tool opens in a new tab | Taper over several weeks to stop | |
| Tricyclic | 10–25 mg DIE, at supper titration: see INESSS tool opens in a new tab | Taper over several weeks to stop | |
| Gabapentin | 100–300 mg at bedtime titration: see INESSS tool opens in a new tab | Taper over at least 3 weeks to stop | |
| Pregabalin | 25–75 mg at bedtime or BID titration: see INESSS tool opens in a new tab | Taper over at least 3 weeks to stop | |
Older adults: lower start and slower titration for gabapentinoids and tricyclics.
Contraindications and side effects: INESSS tool opens in a new tab and annexes, July 2026 opens in a new tab.
Follow-up
- INESSS Institut national d'excellence en santé et services sociaux
- NPC McMaster National Pain Centre
| Decision | Guideline |
|---|---|
| Cadence | High complexity: early and frequent follow-up, at least every 2 weeks. Low to moderate complexity: follow up only when needed. |
| Not improving | No gain in pain or function, or worse: reassess drug and non-drug care. New red flags or changed biopsychosocial factors: reassess the plan. |
| New worry | Urgent investigation or specialist assessment for any new worrying finding at follow-up. |
| Opioid trial | Stop if there is no important gain in pain or function by 2 months. |
| Stable long-term opioids | Offer a voluntary taper to the lowest effective dose.If declined, offer again every 6–12 months. No forced taper. |
Reviewed 17 October 2026 against the official sources below.
Sources
Blue square: Québec · red round: Canada. The code names the body; each section's key gives its full name.