What is the primary care physician (PCP) workup for lower back pain?

From the Guidelines

The primary care workup for lower back pain should begin with a thorough history and physical examination to identify red flags that might indicate serious pathology, as recommended by the American College of Physicians and the American Pain Society 1.

Key Components of the Workup

• Assessing pain characteristics, duration, radiation, and exacerbating/relieving factors
• Evaluating for red flags such as trauma, age >50, fever, weight loss, history of cancer, neurological deficits, or pain lasting >6 weeks despite conservative treatment
• Conducting a focused physical examination to help place patients into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause

Initial Management

• Recommending rest for 24-48 hours (not prolonged bed rest), followed by gradual return to normal activities
• First-line medications include acetaminophen (500-1000mg every 6 hours, not exceeding 4g daily) or NSAIDs like ibuprofen (400-800mg three times daily with food) for 1-2 weeks
• Physical therapy focusing on core strengthening exercises should be considered after acute pain subsides
• Muscle relaxants such as cyclobenzaprine (5-10mg three times daily) may be added for severe muscle spasm for short durations (5-7 days)

Imaging and Diagnostic Testing

• Imaging is not routinely recommended for acute back pain unless red flags are present
• Magnetic resonance imaging (MRI) or computed tomography (CT) may be considered for patients with persistent back and leg pain who are potential candidates for invasive interventions

Patient Education

• Patients should be educated about proper body mechanics, weight management, and regular exercise to prevent recurrence
• Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options 1.

From the Research

Lower Back Pain PCP Work Up

• The primary care physician (PCP) work up for lower back pain typically involves a thorough medical history and physical examination to determine the underlying cause of the pain 2.
• The diagnosis of lower back pain may lack precision, and most international guidelines recommend searching for "yellow, blue, and black flags" to stratify the risk of chronicity and/or persistent disability 2.
• Clinical examination and imaging are also important components of the work up, although their relevance is under debate 2.

Pharmacologic Management

• For acute mild to moderate lower back pain, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options 3.
• Topical NSAIDs are not typically recommended for lower back pain, but may be useful for non-low back, musculoskeletal injuries 3.
• Adjunctive medications, such as muscle relaxants, may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate 3.
• For severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors, or with the use of acetaminophen/opioid or NSAID/opioid combinations 3.

Alternative Treatment Options

• A fixed-dose combination of ibuprofen and acetaminophen is an appealing alternative to opioids in acute pain settings, with potential benefits including reduced need for rescue opioid medication and fewer adverse events 4.
• This combination has been shown to provide pain relief similar to or better than opioid and nonopioid comparators, and may be considered as a potential first-line option for the management of acute pain 4.