Spinal Pain: Causes, Diagnosis, Treatment

The term "vertebral pain" is not a precise medical diagnosis. In clinical practice, it can cover pain in the cervical, thoracic, or lumbar spine, nerve root pain, vertebral fractures, vertebral infections, metastatic disease, inflammatory spinal disease, or even referred pain from the chest, abdomen, and pelvis. Therefore, the doctor's first task is not to choose the "best pain reliever," but to clarify what exactly the patient refers to as "vertebrae."

From a coding perspective, this complaint also lacks a single universal code. In the International Classification of Diseases, 10th revision, back pain is classified within group M54, which includes, among other things, neck pain, sciatica, low back pain, and thoracic spine pain. This reflects an important practical fact: the location and mechanism of pain should be clarified, not replaced by a general, everyday term. [1]

In real-world outpatient practice, most people with back pain cannot reliably identify a single, specific anatomical structure as the sole source of their symptoms. Recent reviews emphasize that for the vast majority of patients, this is nonspecific musculoskeletal pain, the course of which is influenced not only by the spinal tissues but also by physical activity, sleep, stress, patient expectations, comorbidities, and social factors. [2]

This doesn't make the pain "non-serious." On the contrary, back pain remains the leading cause of disability worldwide. According to the World Health Organization, low back pain affected 619 million people in 2020, and this number is expected to rise to 843 million by 2050. While not all "spinal pain" is limited to the lower back, it is the lumbar region that generates the bulk of complaints and the evidence base. [3]

Therefore, a modern clinical approach is best built not around the phrase "vertebrae hurt," but around five questions: are there signs of a dangerous cause? Is there a neurological deficit? Does the picture indicate a fracture, infection, or tumor? Does the pain resemble inflammation? Is it nonspecific musculoskeletal pain, which primarily requires competent conservative care? This logic underlies modern recommendations for back pain and spondyloarthritis. [4]

Table 1. What may be hidden behind the complaint of “vertebral pain”

Clinical group	What is usually meant
Non-specific back pain	Musculoskeletal and facet pain syndrome, without a dangerous structural cause
Radicular pain	Compression or irritation of a nerve root with irradiation to the arm or leg
Vertebral fracture	Most often, an osteoporotic or traumatic compression fracture
Spinal infection	Vertebral osteomyelitis, spondylodiscitis, epidural abscess
Tumor lesion	Spinal metastases, spinal cord compression
Inflammatory disease	Axial spondyloarthritis
Referred pain	Source outside the spine

Sources for the table. [5]

The main causes and how they usually manifest themselves

The most common scenario is nonspecific back pain. It may intensify after awkward postures, prolonged sitting, bending, heavy lifting, or unusual physical activity, but the patient has no compelling signs of a fracture, infection, cancer, or significant neurological deficit. Modern reviews emphasize that in this scenario, trying to find one "broken vertebra" on an X-ray is usually unhelpful and often leads to overdiagnosis. [6]

The second common cause is radicular pain. In this case, the patient may describe not only localized back pain but also shooting pain, numbness, tingling, or weakness down the arm or leg. Evidence-based guidelines for low back pain consider these cases separately, as they emphasize the importance of a neurological examination, and imaging becomes appropriate if symptoms persist, progress, or invasive treatment is being considered. [7]

If we are talking about true "vertebral" pain, one of the key causes is a vertebral compression fracture. This is especially true in the elderly, in patients with osteoporosis, with long-term use of glucocorticosteroids, and after even minor trauma. Current guidelines from the UK National Osteoporosis Group emphasize that such fractures can cause acute and chronic pain, decreased height, spinal deformity, impaired function, and a reduced quality of life. [8]

Spinal infection is less common but clinically more serious. The Infectious Diseases Society of America recommends suspecting vertebral osteomyelitis in patients with new or worsening back or neck pain accompanied by fever, elevated erythrocyte sedimentation rate or C-reactive protein, bacteremia, or infective endocarditis. Importantly, fever is not always present, and a delay in diagnosis can lead to sepsis or irreversible spinal cord damage. [9]

Another critical cause is metastatic spinal disease and metastatic spinal cord compression. The UK's National Institute for Health and Care Excellence classifies severe, persistent back pain, progressive pain, pain that worsens with coughing, sneezing, or straining, nocturnal pain, localized tenderness, as well as gait disturbances, weakness, numbness, radicular pain, and bladder or bowel dysfunction as warning signs. In a patient with current or previous cancer, this presentation requires urgent oncological referral. [10]

Finally, inflammatory back pain associated with axial spondylitis constitutes a separate group. The National Institute for Health and Care Excellence recommends considering this cause if the pain began before age 45, lasts more than 3 months, and is accompanied by features of an inflammatory phenotype: awakening in the middle of the night, buttock pain, improvement with movement, a good response to nonsteroidal anti-inflammatory drugs, as well as the presence of psoriasis, enthesitis, arthritis, or a family history. It is important to remember that this condition also occurs in women and in patients with a negative human leukocyte antigen B27 test result. [11]

Table 2. Common causes of pain in the vertebrae and clinical clues

Cause	What to look out for
Non-specific pain	Relationship with load, movement, posture, without severe systemic symptoms
Radicular pain	Irradiation, numbness, tingling, weakness
Osteoporotic fracture	Age, osteoporosis, steroids, pain after light exertion
Spinal infection	Fever is not always present, but inflammatory markers, bacteremia, and immune risk factors are important.
Metastases	History of cancer, nocturnal pain, progression, local tenderness
Spinal cord compression	Weakness, gait disturbance, pelvic disorders, sensory disturbances
Axial spondyloarthritis	Young age, morning stiffness, relieved by movement, night awakenings

Sources for the table. [12]

Red flags and when urgent help is needed

Not all back pain is dangerous, but a doctor must always first rule out a small group of truly threatening conditions. Modern recommendations for back pain are structured precisely this way: first, risk assessment is performed, then discussion of pain relief, exercise, and lifestyle restrictions is considered. For the user, this means a simple rule: severe pain alone is not always a sign of disaster, but the combination of pain with certain additional symptoms requires expedited or urgent evaluation. [13]

One of the most dangerous situations is cauda equina syndrome. When suspected, low back pain is accompanied by urinary dysfunction, pelvic disorders, perineal numbness, bilateral radicular symptoms, or progressive leg weakness. The American College of Radiology identifies this scenario as a separate emergency imaging option, and current national care pathways in the UK require emergency MRI to be performed as quickly as possible, ideally within 4 hours of the request. [14]

If a person has current or previous cancer, new back pain should be assessed especially carefully. The National Institute for Health and Care Excellence classifies signs of possible spinal cord metastases or compression as continuous or progressive pain, nocturnal pain, tenderness to palpation, pain that worsens with coughing and straining, as well as weakness, numbness, gait disturbances, and bladder or bowel dysfunction. If symptoms of compression are present, this is considered an oncologic emergency. [15]

Spinal infection should also not be overlooked. Fever, diabetes mellitus, immunosuppression, intravascular catheters, recent infections, injection drug use, elevated inflammatory markers, and bacteremia increase suspicion. According to the Infectious Diseases Society of America, new or worsening back pain in this setting warrants a targeted search for vertebral osteomyelitis. [16]

Signs of a fracture include advanced age, osteoporosis, decreased height, kyphosis, glucocorticosteroid use, and sudden pain after minimal exertion. Signs of an inflammatory spinal disorder include a young age of onset, a duration of more than 3 months, nighttime awakenings, buttock pain, and improvement with movement. In both cases, a mistake in initial triage leads to prolonged, inappropriate treatment. [17]

Table 3. Major "red flags" for back pain

Sign	What to think about
Urinary retention, incontinence, perineal numbness	Cauda equina syndrome
Weakness in the legs, gait disturbance	Compression of nerve structures or spinal cord
Constant pain at night due to cancer	Metastases to the spine
Fever, bacteremia, high C-reactive protein	Spinal infection
Old age, osteoporosis, steroids, minimal trauma	Compression fracture
Onset before age 45, relieved by movement, night awakenings	Axial spondyloarthritis
Localized sharp pain with progression of symptoms	Specific spinal lesion

Sources for the table. [18]

Diagnostics

Diagnosis begins with a history and physical examination, not an X-ray. The doctor specifies the specific spinal region, duration of pain, relationship with movement, presence of nighttime awakenings, radiating pain to the extremity, numbness, weakness, trauma, cancer, fever, weight loss, psoriasis, inflammatory bowel disease, eye symptoms, and medications, especially glucocorticosteroids. Even at this stage, it often becomes clear whether the pain is nonspecific or whether the patient requires a more rapid, in-depth examination. [19]

In typical uncomplicated low back pain, routine early imaging is generally not necessary. The National Institute for Health and Care Excellence explicitly recommends against routine imaging in non-specialist care, and the American College of Radiology considers acute pain without "red flags" a situation where initial imaging is generally not indicated. This is one of the most important points in modern evidence-based medicine for back pain. [20]

If symptoms persist or progress, the logic changes. The American College of Radiology identifies a separate scenario for a patient with subacute or chronic pain who remains a candidate for intervention after approximately 6 weeks of optimal conservative treatment. In this situation, magnetic resonance imaging becomes justified because its results can change the treatment strategy. [21]

If a spinal infection is suspected, the Infectious Diseases Society of America recommends a neurological examination, two sets of blood cultures, an erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, and a spinal magnetic resonance imaging (MRI). If MRI is unavailable or contraindicated, other methods are considered, but it remains the primary imaging test. [22]

If axial spondyloarthritis is suspected, a separate workup is also necessary. The National Institute for Health and Care Excellence recommends first performing a sacroiliac joint X-ray. If this does not confirm sacroiliitis or the patient is skeletally immature, proceed to magnetic resonance imaging using the inflammatory back pain protocol. A negative human leukocyte antigen B27 test and normal inflammatory markers do not, by themselves, rule out the diagnosis. [23]

Table 4. What examinations are needed in different situations

Scenario	Usually the most appropriate step
Uncomplicated pain without red flags	Examination, risk assessment, without early imaging
Persistent or progressive radicular symptoms	Magnetic resonance imaging when changing tactics
Suspected cauda equina syndrome	Emergency magnetic resonance imaging
Suspected infection	Blood cultures, inflammatory markers, magnetic resonance imaging
Suspected metastases or spinal cord compression	Urgent magnetic resonance imaging
Suspected inflammatory pain	X-ray of the sacroiliac joints, then magnetic resonance imaging if necessary
Suspected fracture	X-ray, computed tomography if necessary

Sources for the table. [24]

Treatment

Treatment for back pain is not one-size-fits-all. For non-specific musculoskeletal pain, the mainstay of modern care remains an explanation of the diagnosis, maintaining activity, avoiding prolonged bed rest, and gradual conservative therapy. For chronic primary low back pain, the World Health Organization recommends educational programs, exercise, certain physical methods, psychological approaches such as cognitive behavioral therapy, and, if necessary, medications, including nonsteroidal anti-inflammatory drugs, as part of a holistic care plan. [25]

If medication is needed for non-specific low back pain, the National Institute for Health and Care Excellence suggests considering oral non-steroidal anti-inflammatory drugs (NSAIDs) based on gastrointestinal, hepatic, cardiovascular, and renal risks, prescribing them at the lowest effective dose and for the shortest duration. Paracetamol alone is not recommended. Weak opioids are acceptable only for acute pain if NSAIDs are contraindicated, not tolerated, or have been ineffective, and opioids are not recommended for chronic pain. [26]

There is also a long list of things that should not be done routinely. The National Institute for Health and Care Excellence recommends against corsets and belts, traction, acupuncture, ultrasound, transcutaneous electrical nerve stimulation, interferential therapy, gabapentinoids, and antiepileptic drugs for routine low back pain. The World Health Organization specifically warns against the routine use of opioids, lumbar braces, and certain passive techniques in most patients with chronic primary pain. [27]

If the cause is an osteoporotic vertebral fracture, the approach changes. The UK National Osteoporosis Group recommends the use of oral pain relief, regular review of its effectiveness and side effects, avoiding nonsteroidal anti-inflammatory drugs in the elderly whenever possible, adding laxatives to opioid therapy, early introduction of back extensor strengthening exercises, and mandatory secondary prevention of recurrent fractures. Routine use of vertebroplasty and kyphoplasty for painful osteoporotic fractures is not supported as standard care. [28]

In vertebral osteomyelitis, the key is not pain relief, but timely microbiological verification and antibacterial therapy. The Infectious Diseases Society of America recommends, if possible, not initiating empirical antibiotics until a microbiological diagnosis is confirmed, unless the patient is sepsis or has neurological deterioration. For most bacterial cases, the total treatment duration is typically 6 weeks, and for brucellosis, more often 3 months. [29]

In cases of spinal metastasis and spinal cord compression, time is of the essence. The National Institute for Health and Care Excellence (NIH) recommends urgent referral to a specialist service, urgent magnetic resonance imaging (MRI), and rapid decision-making regarding corticosteroids, radiotherapy, and surgical decompression or stabilization as indicated. Suspected compression with neurological signs is considered an oncologic emergency, and surgical intervention, if indicated, should be aimed at halting or reversing neurological deterioration as early as possible. [30]

If the pain is inflammatory in nature and axial spondyloarthritis is confirmed, treatment is again different. International and British guidelines consider exercise and nonsteroidal anti-inflammatory drugs as the basic first step, and in cases of high activity and insufficient response, they move on to biological therapy under the supervision of a rheumatologist. Therefore, for such patients, the primary goal of primary care is not endless painkillers, but timely referral to a rheumatologist. [31]

Table 5. Treatment depending on the cause

Situation	The basic approach
Non-specific pain	Explanation, activity, exercise, short-term symptomatic treatment
Radicular pain	Conservative therapy; in cases of severe sciatica, epidural injections are possible; if unsuccessful and the images match the clinical picture, decompression is discussed.
Osteoporotic fracture	Pain relief, early mobilization, exercise, prevention of new fractures
Spinal infection	Cultures, magnetic resonance imaging, antibiotic therapy, sometimes surgery
Metastases and compression	Urgent magnetic resonance imaging, oncological and neurosurgical routing
Axial spondyloarthritis	Exercise, nonsteroidal anti-inflammatory drugs, rheumatologic management

Sources for the table. [32]

Table 6. What should not be done routinely for common non-specific back pain

Approach	Why this isn't considered a good routine tactic
Early visualization without red flags	Does not improve outcomes and often leads to unnecessary findings
Paracetamol as the only remedy	Lack of efficiency
Long-acting opioids	The risk of harm and dependence exceeds the expected benefit
Gabapentinoids and antiepileptic drugs	Not recommended for general low back pain
Corsets and belts	Not recommended routinely
Traction, acupuncture, ultrasound, electrical nerve stimulation	Not supported as standard help
Long-term bed rest	Impairs recovery and maintains chronicity

Sources for the table. [33]

Prevention and prognosis

The prognosis depends primarily on the cause of the pain. Many patients with nonspecific back pain improve with continued activity and appropriate conservative care, but relapses are common. Recent reviews emphasize that the primary mistake is not the pain's onset, but rather the patient and healthcare system's overly aggressive and ineffective treatments. [34]

The best prevention of recurrent episodes of common low back pain involves maintaining physical activity, weight control, smoking cessation, maintaining sleep, and gradually returning to normal activities after an exacerbation. The World Health Organization considers self-care training and exercise to be an important part of the long-term management of chronic primary low back pain. [35]

If a vertebral fracture has already occurred, prevention should be secondary and active. The UK National Osteoporosis Group emphasizes that a recent vertebral fracture means a high immediate risk of further fractures, so the patient should not be left on painkillers alone. Risk assessment, anti-osteoporosis therapy as indicated, and follow-up with fracture prevention services are necessary. [36]

In infections and metastatic lesions, the prognosis depends on the speed of recognition. The Infectious Diseases Society of America clearly states that delayed diagnosis of vertebral osteomyelitis can lead to sepsis and irreversible spinal cord damage. The National Institute for Health and Care Excellence similarly emphasizes that early diagnosis of metastatic spinal cord compression is essential to prevent neurological damage and improve outcomes. [37]

In chronic pain, a modern prognosis is determined not only by imaging but also by the integrity of care. The World Health Organization emphasizes that care should be personalized, non-stigmatizing, coordinated, and consider physical, psychological, and social factors. For the patient, this means that a good long-term outcome is often achieved not by a single injection or procedure, but by a well-designed care program. [38]

Frequently Asked Questions

Does "vertebral pain" always mean the bone hurts?
No. Most often, patients describe nonspecific back pain this way, in which it's impossible to reliably prove that the source is located specifically in the vertebral bone. However, with a fracture, infection, or metastatic process, the pain may indeed be related to the vertebra as a structure.

Should an MRI be performed immediately?
Usually not, unless there are red flags. Routine early imaging for uncommon low back pain without warning signs is not recommended. Exceptions include suspected cauda equina syndrome, infection, metastatic disease, spinal cord compression, and certain other specific situations. [39]

What symptoms are particularly dangerous?
The most concerning are urinary or bowel dysfunction, perineal numbness, leg weakness, gait disturbance, high fever, a history of cancer, persistent pain at night, and rapid progression of symptoms. This combination requires urgent examination. [40]

Can painkillers alone be used for treatment?
For common, nonspecific pain, medications alone rarely solve the problem completely. Current recommendations emphasize activity, exercise, and education, and only then the limited use of medications. In the case of a fracture, infection, tumor, or inflammatory disease, painkillers alone are even more insufficient. [41]

Do corsets, acupuncture, and electrotherapy help everyone?
No. For ordinary low back pain, such methods are not routinely recommended by current guidelines. Exceptions are possible in certain individual cases, but they are not considered a first-line standard. [42]

When should you consider an inflammatory spinal disease?
When pain begins at a young age, lasts more than 3 months, wakes you at night, is relieved by movement, and responds well to nonsteroidal anti-inflammatory drugs, especially if you have psoriasis, uveitis, enthesitis, or a family history. In this situation, a rheumatological approach is needed, not just pain management. [43]

Key points from experts

Christopher Maher, Professor at the University of Sydney's School of Public Health and Director of the Institute of Musculoskeletal Health, consistently emphasizes a key contemporary theme in back pain: patients are too often prescribed inappropriate care, including excessive imaging, opioids, injections, and surgery, while for non-specific pain, active rehabilitation and interventions with proven benefit should be prioritized. His position aligns well with The Lancet review of low-value care in low back pain. [44]

Rachel Buchbinder, a rheumatologist, clinical epidemiologist, senior principal investigator, and professor at Monash University, emphasizes that the key problem in modern back pain care is not only the prevalence of the symptom but also the epidemic of overdiagnosis and overtreatment. Her work and position in international reviews emphasize reducing low-value care and moving toward evidence-based, stepwise, and cost-effective approaches. [45]

Eli Berbary, MD, an infectious disease specialist, chair of the infectious diseases division at the Mayo Clinic in Minnesota, and one of the key authors of the Infectious Diseases Society of America guidelines on vertebral osteomyelitis, makes an important point about spine pain: persistent or worsening back pain accompanied by fever, elevated inflammatory markers, or bacteremia should not be automatically dismissed as simple back pain. In this area, the cost of delayed diagnosis is especially high. [46]

Sofia Ramiro, rheumatologist, co-author of the updated international guidelines on axial spondyloarthritis and visiting professor at the Nova School of Medicine in Lisbon, presents another key point: inflammatory back pain must be recognized early, because “ordinary back pain” sometimes masks a chronic inflammatory disease that requires completely different diagnostic and therapeutic solutions than mechanical pain. [47]

Conclusion

"Spinal pain" is not a single disease, but a complaint that most often masks nonspecific musculoskeletal pain, but can also be caused by a fracture, infection, metastatic lesion, spinal cord compression, or inflammatory spinal disease. A modern, appropriate approach begins with clinical risk triage rather than automatically ordering imaging or procedures. Routine imaging without warning signs is usually unnecessary, while neurological deficits, cancer, fever, pelvic disorders, and progressive nocturnal pain require expedited evaluation. Treatment should be determined by the cause: for nonspecific pain, the emphasis is on activity and conservative care; for fractures, secondary prevention is important; for infection, microbiological verification and antibiotics are needed; for metastases, urgent oncological referral; and for inflammatory pain, a rheumatological assessment. [48]