A doctor can do quite a lot for back pain, from prescribing targeted medications and ordering physical therapy to performing spinal injections and, when necessary, surgery. The specific path depends on what’s causing your pain, how long you’ve had it, and whether you have any nerve involvement. Most back pain improves within six weeks with conservative treatment, and roughly 90% of acute sciatica cases resolve without surgery. But when pain persists or worsens, doctors have an increasingly precise toolkit to identify the source and treat it.
The Physical Exam and What It Reveals
Your visit starts with a physical exam designed to figure out whether your pain is muscular, joint-related, or caused by a compressed nerve. Two of the most useful tests involve simple leg movements. In the straight leg raise, you lie on your back while the doctor lifts your leg with the knee straight. If this reproduces shooting pain down that leg, it points toward a disc pressing on a nerve on the same side. If raising the opposite leg triggers pain in the affected leg, that suggests the disc is pressing from a more central position.
A second test, the slump test, is done while you’re seated. The doctor guides you through a sequence of bending your spine forward, tucking your chin, straightening your knee, and flexing your foot. Each step increases tension on the spinal nerves, and the doctor watches for which specific movement reproduces your symptoms. These maneuvers, combined with checks of your reflexes, muscle strength, and skin sensation, give the doctor a surprisingly detailed picture of what’s happening in your spine before any imaging is ordered.
When Imaging Is and Isn’t Needed
Most people with new back pain don’t need an MRI or CT scan right away. The American College of Physicians recommends advanced imaging only for patients who have severe or worsening neurological problems, are suspected of having a serious underlying condition like an infection or fracture, or are being considered for an injection or surgery. This isn’t about cutting corners. Many MRI findings, like bulging discs, show up in people with no pain at all, so scanning too early can lead to unnecessary worry and treatment.
If your pain hasn’t improved after several weeks of conservative care, or if your exam suggests nerve damage, imaging becomes much more useful because there’s now a specific clinical question to answer.
Medications Your Doctor May Prescribe
For acute back pain, the first-line medications are over-the-counter anti-inflammatories (like ibuprofen or naproxen) and acetaminophen. Anti-inflammatories tend to be more effective because they reduce the inflammation irritating the nerves and joints, not just the pain signal. Your doctor will aim for the lowest effective dose for the shortest time possible, since these drugs can affect the kidneys, stomach, and cardiovascular system with prolonged use. A newer class of anti-inflammatories called COX-2 inhibitors is sometimes preferred for a lower side-effect profile.
If muscle spasms are a major part of your pain, your doctor may add a muscle relaxant. Studies show these provide better pain relief than a placebo over about two weeks. Non-benzodiazepine options are generally preferred because they carry less risk of sedation and dependence.
Stronger pain medications like tramadol or other opioids are reserved for severe, disabling pain that hasn’t responded to anything else. When prescribed, they’re given for a limited time, and your doctor will reassess regularly for pain relief, improved function, side effects, and any signs of misuse.
Physical Therapy and Exercise
Six weeks of physical therapy is typically the first recommendation for back pain that isn’t resolving on its own. The most common approaches backed by evidence include core strengthening exercises, general strengthening programs, Pilates, aerobic exercise like walking, and mixed programs that combine several types. Cochrane reviews of the research show that exercise reduces pain and improves function compared to passive treatments like electrical stimulation or education alone.
The specific exercises your therapist chooses depend on your diagnosis. Someone with a disc issue might do repeated extension movements to shift pressure off the nerve, while someone with joint pain might focus on core stability to reduce load on the spine. The goal isn’t just to relieve the current episode but to build the strength and movement habits that prevent the next one.
Spinal Injections for Targeted Relief
When physical therapy and medication aren’t enough, your doctor may recommend a spinal injection. The two most common types target different structures. Epidural steroid injections deliver anti-inflammatory medication into the space around the spinal nerves, which is useful when a disc herniation or spinal narrowing is compressing a nerve. Facet joint injections target the small joints along the back of the spine, which can become arthritic and painful on their own.
Both types of injection have been shown to provide meaningful pain relief lasting up to six months. They also serve a diagnostic purpose: if an injection into a specific area eliminates your pain, it confirms that structure as the source, which helps guide further treatment.
Radiofrequency Ablation for Longer-Lasting Relief
If facet joint injections provide temporary relief but the pain keeps returning, your doctor may recommend radiofrequency ablation. This procedure uses heat to disrupt the tiny nerves that carry pain signals from the facet joints to the brain. It doesn’t fix the joint itself, but it interrupts the pain message.
In one well-known study, 60% of patients still had at least 90% pain relief a full year after the procedure, and 87% maintained at least 60% relief. Some doctors add a steroid during the procedure to reduce the inflammation that naturally occurs at the treatment site, which may improve short-term comfort. The nerves do eventually regenerate, so the procedure may need to be repeated, but it can provide months to years of significant relief for the right candidate.
When Surgery Becomes the Right Option
Surgery is considered when conservative treatments have been given a fair trial and failed, or when specific neurological warning signs appear. The clearest surgical indications are progressive weakness in the legs, loss of bladder or bowel control, and worsening numbness. These symptoms suggest the nerves are being damaged, not just irritated, and waiting longer risks permanent harm.
For a disc herniation causing sciatica that simply won’t quit after adequate conservative care, a microdiscectomy removes the portion of disc pressing on the nerve. Many of these procedures are now minimally invasive, meaning smaller incisions, less tissue disruption, and faster recovery. A spine surgeon’s role isn’t limited to operating. As one surgeon at the Hospital for Special Surgery puts it, the job is to diagnose people properly and get them to the right doctor if surgery isn’t going to help.
Which Type of Doctor to See
Your primary care doctor is a reasonable starting point and can handle most acute back pain episodes. If your pain persists beyond a few weeks, two types of specialists are worth knowing about. A physiatrist (physical medicine and rehabilitation doctor) specializes in diagnosing and treating musculoskeletal problems without surgery. They coordinate physical therapy, prescribe medications, and perform or refer for injections. Think of them as the primary care doctor of the spine.
An orthopedic spine surgeon or neurosurgeon enters the picture when imaging shows a structural problem that might need surgical repair, or when non-surgical options have been exhausted. Surgeons also order and interpret MRIs and frequently recommend non-surgical treatments like injections when surgery isn’t warranted.
Red Flags That Need Immediate Attention
Certain symptoms alongside back pain signal a potential emergency called cauda equina syndrome, where the bundle of nerves at the base of the spine is severely compressed. Go to the emergency room if you experience numbness in the groin or genital area, inability to urinate for more than six to eight hours, new loss of bowel control, or rapidly worsening weakness in both legs. This condition requires emergency MRI and often urgent surgery. Delays of even hours can mean the difference between full recovery and permanent nerve damage.