What is the workup and treatment plan for acute low back pain?

Workup and Treatment Plan for Acute Low Back Pain

For acute low back pain, the recommended approach is to start with conservative therapies including local heat application, maintaining tolerable physical activity, and using acetaminophen or NSAIDs for pain management, while avoiding imaging unless red flags are present. 1

Diagnostic Workup

Initial Assessment

• Document presence of red flags that require urgent intervention:
  • Fever, night pain, constant pain unrelieved by position change
  • Bowel/bladder dysfunction, saddle anesthesia
  • Progressive neurological deficits
  • Recent trauma (especially in elderly or osteoporotic patients)
  • History of immunosuppression (HIV, chronic steroids, transplant medications)
  • Unexplained weight loss or cancer history 1

Imaging

• Avoid routine imaging for acute low back pain without red flags
• If red flags are present, MRI of the lumbar spine without IV contrast is the preferred initial imaging modality
• Consider upright radiographs with flexion/extension views only if instability is suspected 1

Treatment Algorithm

First-Line Interventions (0-2 weeks)

1. Non-pharmacological approaches:

   • Apply local heat (moderate efficacy)
   • Maintain tolerable physical activity; avoid prolonged bed rest
   • Education on self-care and body mechanics
   • For patients with radiculopathy, 2-3 days of bed rest may be appropriate 1, 2

2. Pharmacological management:

   • Acetaminophen (up to 3000mg/day) as first option due to safety profile
   • NSAIDs (ibuprofen, naproxen) if acetaminophen is insufficient
     • Use with caution in elderly patients or those with renal/hepatic impairment
   • Short-term muscle relaxants (e.g., cyclobenzaprine) for 2-3 weeks maximum
     • Start with 5mg dose in elderly or those with mild hepatic impairment
     • Avoid in moderate to severe hepatic impairment
     • Monitor for drowsiness and dry mouth 1, 3

Second-Line Interventions (2-4 weeks if no improvement)

1. Physical treatments:

   • Massage therapy (short-term efficacy)
   • Spinal manipulation (especially in patients with history of good response)
   • Acupuncture (moderate benefit)
   • Referral for physical therapy is appropriate if symptoms persist beyond 2-4 weeks 1, 4

2. Adjunctive approaches:

   • Mind-body approaches (mindfulness-based stress reduction, tai chi, yoga)
   • Cognitive-behavioral therapy to address fear of movement 1

For Persistent Pain (4-6 weeks)

• Reassess for missed serious pathology
• Consider gabapentin or pregabalin if neuropathic pain component is present
• Multidisciplinary rehabilitation program combining exercise, physical therapy, and cognitive-behavioral therapy 1

Special Considerations

Medication Cautions

• Avoid opioids as first-line treatment due to risks outweighing benefits
• For cyclobenzaprine:
  • Titrate slowly in elderly patients and those with hepatic impairment
  • Start with 5mg dose in these populations
  • Combination with NSAIDs may increase drowsiness 3

When to Refer

• Surgical consultation only for:
  • Persistent disabling symptoms despite 4-6 weeks of conservative treatment
  • Progressive neurological deficits
  • Cauda equina syndrome (requires immediate surgical investigation) 1, 2

Prognosis and Follow-up

• 90% of acute low back pain cases follow a benign course with resolution
• Recurrence is common; educate patients on prevention strategies
• Reassess treatment plan if patient does not return to normal activity within 4-6 weeks 2, 4

Common Pitfalls to Avoid

• Ordering unnecessary imaging for acute, non-specific low back pain
• Prescribing prolonged bed rest (more than 2-3 days)
• Using muscle relaxants for extended periods (beyond 2-3 weeks)
• Initiating opioid therapy for routine back pain
• Failing to reassess patients who don't improve within 4-6 weeks 1, 4