From the Guidelines
Imaging is not recommended for acute low back pain with radiculopathy in the emergency department unless red flag symptoms are present, as stated in the 2021 update of the ACR Appropriateness Criteria for low back pain 1. When evaluating patients with acute low back pain and radiculopathy, it is essential to consider the patient's history, physical examination, and presence of red flags. Red flags include cauda equina syndrome, severe or progressive neurological deficits, suspected infection, suspected malignancy, recent significant trauma, or immunosuppression.
Key Considerations
- For most patients with acute low back pain and radiculopathy, conservative management should be initiated first, including NSAIDs and muscle relaxants.
- If imaging is deemed necessary due to red flags, MRI is preferred over CT as it better visualizes soft tissues, nerve roots, and potential disc herniations.
- Plain radiographs have limited utility in this setting as they cannot visualize disc herniations or nerve compression.
- The American College of Physicians and the American Pain Society emphasize a focused history and physical examination, reassurance, initial pain management medications if necessary, and consideration of physical therapies without routine imaging in patients with nonspecific LBP 1.
Management Approach
- Patients should be advised to maintain normal activities as tolerated and follow up with their primary care provider within 1-2 weeks if symptoms persist or worsen.
- The approach of not routinely obtaining imaging for acute low back pain with radiculopathy is supported by the fact that most cases resolve spontaneously within 4-6 weeks, and early imaging does not improve outcomes but increases costs and may lead to unnecessary interventions 1.
From the Research
Imaging for Acute Low Back Pain with Radiculopathy in the ED
- There is limited information available in the provided studies regarding the specific use of imaging for acute low back pain with radiculopathy in the Emergency Department (ED) setting 2.
- A study from 2015 discusses the evaluation and treatment of low back pain, including the use of diagnostic imaging studies, but does not specifically focus on the ED setting 3.
- The study from 2024 examines the current best practices and guidelines for integrating pharmacologic interventions, imaging, and physiotherapy in the management of low back pain, but does not provide detailed information on imaging for acute low back pain with radiculopathy in the ED 2.
- The other studies provided focus on the treatment of low back pain with non-steroidal anti-inflammatory drugs (NSAIDs) and do not discuss imaging in the ED setting 4, 5, 6.
Treatment of Acute Low Back Pain with Radiculopathy
- NSAIDs are often used in the treatment of acute low back pain, including cases with radiculopathy, and have been shown to be slightly more effective than placebo for short-term pain reduction and global improvement 4, 5, 6.
- The choice of treatment for acute low back pain with radiculopathy may depend on various patient factors, including age, sex, comorbidities, and prevalent pathologies/diagnoses 2, 3.
- Other treatment options, such as physical modalities and psychological treatments, may also be effective in improving pain and functioning in patients with acute low back pain with radiculopathy 3.