What is the appropriate assessment and management approach for a patient presenting with back pain?

Assessment and Management of Back Pain

The appropriate assessment of back pain requires a focused history and physical examination to classify patients into one of three categories: nonspecific low back pain, back pain with radiculopathy or spinal stenosis, or back pain associated with a specific spinal cause, which guides subsequent management decisions. 1

Initial Assessment

Diagnostic Triage

• Conduct a focused history and physical examination to categorize patients into one of three groups 1:
  1. Nonspecific low back pain (85% of cases)
  2. Back pain potentially associated with radiculopathy or spinal stenosis (7% of cases)
  3. Back pain potentially associated with another specific spinal cause (8% of cases)

History Taking

• Inquire about 1:
  • Location, frequency, duration, and intensity of pain
  • Previous symptoms, treatments, and responses
  • Risk factors for cancer: history of cancer (positive likelihood ratio 14.7), unexplained weight loss (positive likelihood ratio 2.7), failure to improve after 1 month (positive likelihood ratio 3.0), age >50 years (positive likelihood ratio 2.7)
  • Risk factors for infection: fever, intravenous drug use, recent infection
  • Risk factors for fracture: history of osteoporosis, steroid use, trauma

Physical Examination

• Perform a neurologic and musculoskeletal evaluation 1
• Assess for red flags requiring urgent attention 2, 3:
  • Severe or progressive neurologic deficits (motor deficits at multiple levels)
  • Bladder or bowel dysfunction (urinary retention has 90% sensitivity for cauda equina syndrome)
  • Fever or other signs of systemic illness

Psychosocial Assessment

• Evaluate psychosocial factors as they are stronger predictors of outcomes than physical examination findings 1
• Look for factors associated with poorer outcomes 1:
  • Depression
  • Passive coping strategies
  • Job dissatisfaction
  • Higher disability levels
  • Disputed compensation claims
  • Somatization

Diagnostic Testing

Imaging

• Do not routinely obtain imaging for nonspecific low back pain 1
• Consider imaging in the following situations 1, 4:
  • Presence of severe or progressive neurologic deficits
  • Suspected serious underlying condition based on red flags
  • Pain persisting >4-6 weeks despite conservative therapy
  • Plain radiography for suspected vertebral compression fracture in high-risk patients (history of osteoporosis or steroid use)
  • MRI or CT for suspected radiculopathy or spinal stenosis that may require intervention

Laboratory Testing

• Consider ESR, CRP, and CBC if infection or malignancy is suspected 1, 3
• Consider additional testing based on suspected etiology 3, 5

Management Approach

Nonspecific Low Back Pain

• Provide education and reassurance about favorable prognosis 1
• Recommend remaining active and avoiding bed rest 4
• Consider heat application for short-term relief 1
• First-line medications 1, 4:
  • Acetaminophen (reasonable first-line option due to favorable safety profile)
  • NSAIDs (more effective than acetaminophen but with greater risks)
• Second-line medications for severe pain not controlled with first-line options 1:
  • Tramadol or opioid analgesics (short-term use with careful monitoring)
• Consider physical therapy and exercise programs 1
• Consider cognitive behavioral therapy, especially for chronic pain 1

Back Pain with Radiculopathy or Spinal Stenosis

• Similar self-care approaches as for nonspecific back pain 1
• Consider epidural steroid injections for short-term symptom relief 4
• Consider surgical evaluation for patients with persistent functional disabilities or refractory pain despite multiple nonsurgical treatments 6, 4

Back Pain with Specific Spinal Cause

• Direct treatment at the underlying condition 1
• Urgent referral for cauda equina syndrome, spinal infection, or malignancy 2, 3

Follow-up

• Reevaluate patients with persistent, unimproved symptoms after 1 month 1
• Consider earlier or more frequent reevaluation for patients with severe pain, functional deficits, older age, or signs of radiculopathy or spinal stenosis 1

Common Pitfalls to Avoid

• Ordering routine imaging for nonspecific back pain, which exposes patients to unnecessary radiation and may lead to unnecessary interventions 1
• Recommending bed rest, which can delay recovery 4
• Failing to assess psychosocial factors, which are strong predictors of outcomes 1
• Overreliance on opioids for chronic pain management without considering risks 1, 4
• Missing red flags that may indicate serious underlying conditions requiring urgent attention 2, 3