What is the initial evaluation and management of a patient presenting with low back pain?

From the Guidelines

The initial evaluation of low back pain should begin with a focused history and physical examination to identify red flags that might indicate serious underlying conditions requiring urgent intervention, as recommended by the American College of Physicians and the American Pain Society 1. The evaluation process should categorize patients into one of three broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, and back pain potentially associated with another specific spinal cause. Key points to consider in the evaluation include:

• Assessing psychosocial risk factors, which predict risk for chronic disabling back pain 1
• Inquiring about the location of pain, frequency of symptoms, and duration of pain, as well as any history of previous symptoms, treatment, and response to treatment 1
• Evaluating patients for the presence of rapidly progressive or severe neurologic deficits, including motor deficits at more than one level 1
• Considering the possibility of low back pain due to problems outside the back, such as pancreatitis, nephrolithiasis, or aortic aneurysm, or systemic illnesses, such as endocarditis or viral syndromes 1 For most patients with nonspecific low back pain without red flags, conservative management is recommended, including remaining active within pain limits, avoiding bed rest, and using over-the-counter analgesics such as acetaminophen or NSAIDs 1. Additional treatment options may include:
• Muscle relaxants such as cyclobenzaprine for severe muscle spasm
• Heat or cold therapy for symptomatic relief
• Physical therapy focusing on core strengthening and flexibility, initiated within 2-4 weeks if pain persists
• Patient education about proper body mechanics, ergonomics, and weight management Imaging studies are not routinely recommended initially unless red flags are present, as they rarely change management and may lead to unnecessary interventions 1. The American College of Radiology also recommends that imaging be considered in patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain, or in those presenting with red flags, raising suspicion for a serious underlying condition 1.

From the FDA Drug Label

Muscle spasm, local pain and tenderness, limitation of motion, and restriction in activities of daily living were evaluated Primary endpoints for both trials were determined by patient-generated data and included global impression of change, medication helpfulness, and relief from starting backache.

The initial evaluation and management of a patient presenting with low back pain is not directly addressed in the provided drug label.

• Key points to consider in the evaluation of low back pain include assessing muscle spasm, local pain and tenderness, limitation of motion, and restriction in activities of daily living.
• However, the provided information does not offer a clear guideline for the initial evaluation and management of low back pain. 2

From the Research

Initial Evaluation of Low Back Pain

The initial evaluation of a patient presenting with low back pain involves a thorough history and physical examination to identify red flags that may indicate serious conditions requiring immediate intervention, as well as yellow flags that indicate risk of disability 3, 4. The examination should include an evaluation for radicular symptoms.

Components of Evaluation

• History taking: This component of the evaluation process has been shown to produce significant therapeutic effects related to pain, fear-avoidance, and functional measures of mobility and sensitivity 5.
• Physical examination: A thorough physical examination is essential to identify the underlying cause of low back pain and to rule out any serious conditions.
• Diagnostic testing: Imaging studies such as magnetic resonance imaging (MRI) or computed tomography (CT) may be necessary to establish a diagnosis and guide management, especially in patients with radiculopathy or spinal stenosis 4.

Management of Low Back Pain

• Nonpharmacologic treatment: This is the first-line management for low back pain and may include therapies such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy 3.
• Pharmacologic interventions: Nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial medication of choice, while duloxetine may also be beneficial 3. However, the evidence is inconclusive for the use of benzodiazepines, muscle relaxants, antidepressants, corticosteroids, insomnia agents, anticonvulsants, cannabis, acetaminophen, or long-term opioids.
• Surgical evaluation: This may be considered in patients with persistent functional disabilities and pain from progressive spinal stenosis, worsening spondylolisthesis, or herniated disk 3, 4.

Treatment Outcomes

• A study comparing ibuprofen plus acetaminophen versus ibuprofen alone for acute low back pain found no significant difference in pain and functional outcomes between the two groups 6.
• The evaluation process itself has been shown to produce small but significant therapeutic effects related to pain and functional measures 5.