What is the recommended course of action if low back pain persists beyond 2 weeks?

Management of Low Back Pain Persisting Beyond 2 Weeks

If low back pain persists beyond 2 weeks, patients should be reevaluated and a stepped care approach should be implemented, beginning with nonpharmacologic treatments as first-line therapy, followed by pharmacologic options if necessary. 1

Initial Assessment at 2 Weeks

• Use the STarT Back tool at 2 weeks to predict risk of developing persistent disabling pain 2
• Assess for psychosocial factors (yellow flags) that may predict poorer outcomes:
  • Depression
  • Passive coping strategies
  • Job dissatisfaction
  • Higher disability levels
  • Disputed compensation claims
  • Somatization 1, 2
• Evaluate for red flags requiring immediate attention:
  • Cauda equina syndrome
  • Progressive neurological deficits
  • Suspected infection or malignancy
  • Recent significant trauma
  • Severe, unrelenting pain unresponsive to conservative measures 2

Diagnostic Imaging

• Do not routinely obtain imaging for nonspecific low back pain 1
• Consider imaging only when:
  • Red flags are present
  • Severe or progressive neurologic deficits exist
  • Serious underlying conditions are suspected 1
  • Pain persists despite 4-6 weeks of conservative therapy 1, 2
• MRI is preferred over CT when available as it provides better visualization of soft tissue, vertebral marrow, and spinal canal 1

Treatment Approach for Persistent Low Back Pain

First-Line: Nonpharmacologic Treatments

According to the most recent guidelines, nonpharmacologic treatments should be tried first 1:

• Exercise therapy (strongest evidence)
• Multidisciplinary rehabilitation
• Acupuncture
• Mindfulness-based stress reduction
• Tai chi
• Yoga
• Motor control exercise
• Progressive relaxation
• Spinal manipulation 1

Second-Line: Pharmacologic Options

If nonpharmacologic treatments are inadequate:

1. NSAIDs as first-line pharmacologic therapy 1
2. Skeletal muscle relaxants for acute/subacute pain 1
3. Tramadol or duloxetine as second-line options for chronic pain 1
4. Opioids only if other treatments have failed and potential benefits outweigh risks 1

Radicular Pain Considerations

For patients with radicular pain (sciatica):

• Consider referral to specialist services within 3 months (earlier if pain is severe) 1
• For severe radicular pain or neurological deficit, consider referral within 2 weeks 1
• Consider image-guided steroid injections or surgical evaluation based on patient choice and clinical appropriateness 1, 2

Follow-up Recommendations

• Patients with persistent, unimproved symptoms should be reevaluated after 1 month from initial presentation 1
• Earlier or more frequent reevaluation for:
  • Severe pain
  • Functional deficits
  • Older patients
  • Signs of radiculopathy or spinal stenosis 1
• If pain persists beyond 12 weeks, it is classified as chronic low back pain and requires a comprehensive management approach 1, 3

Important Clinical Pearls

• Advise patients to continue normal daily activities as much as pain allows rather than bed rest 2
• Psychosocial factors are stronger predictors of outcomes than physical examination findings 2
• Most patients with acute low back pain experience substantial improvement within the first month 1
• The evidence for acetaminophen in chronic low back pain is limited 3
• Supervised exercise programs show better outcomes than home exercises alone 2