What is the initial approach to managing a patient with lower backache?

Initial Approach to Lower Backache Management

The initial approach to managing lower backache should focus on nonpharmacologic treatments including superficial heat, maintaining activity within pain limits, and providing patient education about the favorable prognosis, while avoiding routine imaging unless red flags are present. 1, 2, 3

Initial Assessment

• Conduct a focused history and physical examination to categorize patients into one of three groups: nonspecific low back pain, back pain with radiculopathy or spinal stenosis, or back pain associated with a specific spinal cause 3
• Assess for "red flags" that may indicate serious underlying conditions requiring immediate intervention:
  • Cauda equina syndrome (urinary retention, fecal incontinence, saddle anesthesia)
  • History of cancer or unexplained weight loss
  • Fever or recent infection suggesting possible vertebral infection
  • Significant trauma
  • History of osteoporosis or prolonged steroid use 2, 3
• Evaluate for neurological deficits through examination including straight leg raise test for radiculopathy 2
• Assess for psychosocial factors ("yellow flags") such as depression, passive coping strategies, job dissatisfaction, and somatization, as these are stronger predictors of outcomes than physical examination findings 3

Diagnostic Testing

• Avoid routine imaging for patients with nonspecific low back pain, even with midline tenderness, if no red flags are present 1, 2
• Consider plain radiography only for patients with risk factors for vertebral compression fracture (osteoporosis, steroid use) or persistent symptoms after 4-6 weeks of conservative management 1, 2
• Order MRI or CT immediately if:
  • Severe or progressive neurologic deficits are present
  • Cauda equina syndrome is suspected
  • Serious underlying condition is suspected (cancer, infection) 1, 2

Initial Management Approach

Nonpharmacologic Treatment (First-Line)

• Provide evidence-based information on the generally favorable prognosis of acute low back pain, with high likelihood for substantial improvement in the first month 1
• Recommend maintaining activity within pain limits rather than strict bed rest 1, 2
• Apply superficial heat (heating pads or heated blankets) for short-term relief of acute low back pain 1
• Consider recommending a medium-firm mattress rather than a firm mattress for patients with chronic low back pain 1
• For acute or subacute low back pain, consider nonpharmacologic treatments such as massage, acupuncture, or spinal manipulation 1

Pharmacologic Treatment (If Needed)

• For acute or subacute low back pain requiring medication, select:
  • NSAIDs as first-line medication option (more effective than acetaminophen but with gastrointestinal and cardiovascular risks) 1
  • Acetaminophen as a reasonable alternative with more favorable safety profile but slightly weaker analgesic effect 1
  • Skeletal muscle relaxants as an alternative option 1
• Avoid systemic corticosteroids and opioids for initial management 2, 4
• For patients with chronic low back pain who have had inadequate response to nonpharmacologic therapy, consider:
  • NSAIDs as first-line therapy
  • Tramadol or duloxetine as second-line therapy
  • Opioids only if other treatments have failed and potential benefits outweigh risks 1

Follow-up Recommendations

• Reevaluate patients with persistent, unimproved symptoms after 1 month 2, 3
• Consider earlier reassessment for:
  • Older patients
  • Patients with signs of radiculopathy or spinal stenosis
  • Patients with worsening symptoms 2, 3
• If symptoms persist beyond 4-6 weeks despite conservative management:
  • Consider imaging if not previously performed
  • Consider referral for physical therapy or more intensive rehabilitation 2

Common Pitfalls to Avoid

• Ordering routine imaging for uncomplicated acute low back pain, which exposes patients to unnecessary radiation without clinical benefit 2, 3
• Prescribing prolonged bed rest, which can delay recovery 1, 2
• Overreliance on opioid medications for pain management 2, 4
• Failing to assess for psychosocial factors that may contribute to delayed recovery 2, 3
• Overlooking red flags that may indicate serious underlying conditions requiring urgent attention 3