What are the initial steps in evaluating and managing back pain?

Initial Steps in Evaluating and Managing Back Pain

The initial evaluation of back pain should include a focused history and physical examination to classify patients into one of three categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. 1, 2

Initial Assessment

• Conduct a focused history and physical examination to categorize the patient's back pain and assess for psychosocial risk factors that predict chronic disabling back pain 1

• Evaluate for "red flags" that suggest serious underlying conditions requiring immediate evaluation 2, 3:

  • Severe or progressive neurologic deficits
  • Cauda equina syndrome (urinary retention, incontinence, saddle anesthesia)
  • History of cancer (especially one that metastasizes to bone)
  • Unexplained weight loss
  • Fever or recent infection (suggesting spinal infection)
  • Significant trauma, especially with risk factors for osteoporosis
  • Severe, unrelenting pain that doesn't improve with rest or worsens at night

• Assess for "yellow flags" that may indicate risk of developing chronic pain 2:

  • Psychological factors (depression, passive coping strategies)
  • Social factors (job dissatisfaction, compensation claims)
  • Higher disability levels with significant functional limitations

Diagnostic Testing

• For most patients with nonspecific back pain without red flags, no diagnostic testing is required initially 1, 4
• Do not routinely obtain imaging for nonspecific low back pain in the first 4-6 weeks unless red flags are present 1, 3
• Consider immediate MRI or CT when 1, 2:
  • Severe or progressive neurologic deficits are present
  • Serious underlying conditions are suspected (cancer, infection, cauda equina syndrome)
• For persistent symptoms (>4-6 weeks) that haven't responded to conservative treatment, consider MRI (preferred) or CT, especially if the patient is a potential candidate for surgery or epidural steroid injection 1, 3
• Simple tests may be appropriate in specific situations 1:
  • X-rays to exclude trauma
  • Erythrocyte sedimentation rate (ESR) for suspected inflammatory disease (an ESR ≥20 mm/h has 78% sensitivity and 67% specificity for cancer) 1, 5

Initial Management

• Advise patients to remain active within pain limits rather than prescribing bed rest 3

• Provide evidence-based information on expected course and self-care options 1

• First-line medications include 3, 6:

  • Acetaminophen
  • NSAIDs (consider patient risk factors)
  • Muscle relaxants for severe muscle spasm (short-term use)
  • Limited use of opioids may be considered for severe pain, but only for short duration

• Consider non-pharmacological approaches 3, 6:

  • Spinal manipulation for acute pain that doesn't improve with self-care
  • Structured exercise therapy
  • Massage therapy
  • Acupuncture

Follow-up and Referral

• Review the patient management plan within 6 months 1
• For persistent symptoms (>4 weeks), consider more intensive approaches or specialist referral 3, 7
• Consider surgical evaluation for 6, 8:
  • Patients with worsening neurologic deficits
  • Intractable pain resistant to conservative treatment
  • Cauda equina syndrome (requires immediate surgical investigation)

Special Considerations

• The natural history of lumbar disc herniation with radiculopathy in most patients is improvement within the first 4 weeks with noninvasive management 1
• Most cases of acute low back pain (lasting <4 weeks) resolve with self-care, but medical evaluation is recommended if red flags are present or pain is severe and disabling 2, 9
• For subacute pain (4-12 weeks), medical evaluation is recommended if pain persists beyond 4 weeks 2
• For chronic pain (>12 weeks), medical evaluation is recommended for all cases, and may require a more comprehensive assessment and treatment approach 2