What is the initial management for a patient presenting with lumbago?

Initial Management of Lumbago (Low Back Pain)

The initial management for a patient presenting with lumbago should include conservative treatment with maximum tolerated NSAIDs/COXIBs for 2-4 weeks, along with physical therapy. 1

Diagnostic Approach

• Diagnosis of lumbago is primarily clinical, based on:
  • Pattern of pain
  • Presence of neurological deficits (motor, reflexes, sensation)
  • Positive straight leg raise test (if radicular symptoms present) 2
• Imaging is generally not necessary in the initial evaluation unless:
  • Warning signs are present (trauma, age >50, fever, weight loss, history of cancer)
  • Pain persists or worsens despite conservative treatment 2, 3

First-Line Treatment

1. Medication Management:

   • NSAIDs at maximum tolerated doses for 2-4 weeks 1

     Medication	Recommended Dosage
     Naproxen	375-1100 mg/day
     Diclofenac	150 mg/day
     Ibuprofen	1800 mg/day

   • Acetaminophen may be used for patients who cannot tolerate NSAIDs 1

2. Physical Therapy:

   • Should be initiated concurrently with medication 1, 2
   • Focus on core strengthening and proper body mechanics

3. Activity Modification:

   • Limited bed rest (2-3 days maximum) for patients with acute radiculopathy 3
   • Gradual return to normal activities as tolerated
   • Avoid prolonged static positions 4

When to Consider Advanced Treatment

• If symptoms persist beyond 4-6 weeks despite conservative management 3
• If neurological deficits develop or worsen 1, 5
• For patients with persistent symptoms beyond 60 days, outcomes of surgical intervention may be less favorable 5

Red Flags Requiring Immediate Attention

• Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction)
• Progressive neurological deficits
• Suspected infection (fever, recent infection, immunocompromised state)
• Suspected malignancy (history of cancer, unexplained weight loss, pain worse at night) 6, 3

Common Pitfalls to Avoid

1. Overreliance on imaging in the absence of red flags
2. Prolonged bed rest (>2-3 days), which can worsen outcomes
3. Failing to reassess treatment plan if no improvement occurs within 4-6 weeks
4. Missing serious underlying pathologies by assuming all back pain is musculoskeletal
5. Delaying surgical consultation beyond 2 months in patients with persistent radicular symptoms, as this may lead to poorer outcomes 5

Second-Line Options

• If first-line treatment fails after 2-4 weeks:
  • Consider duloxetine for chronic pain 1
  • Reassess diagnosis and consider imaging if not previously done
  • Consider referral to spine specialist if symptoms persist beyond 6 weeks 3