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

Initial Management of Lumbago (Acute Low Back Pain)

For uncomplicated acute lumbago without red flags, initiate conservative management with NSAIDs or acetaminophen, advise continued activity, and avoid imaging for at least 6 weeks—imaging provides no clinical benefit and increases unnecessary healthcare utilization. 1

Immediate Assessment: Screen for Red Flags

Before initiating conservative management, rapidly assess for conditions requiring urgent intervention:

• Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction, bilateral leg weakness) 2, 3
• Suspected malignancy (history of cancer, unexplained weight loss, age >50 with new onset pain) 2, 3
• Infection (fever, immunosuppression, IV drug use) 2, 3
• Fracture (significant trauma, osteoporosis, chronic steroid use) 3, 4
• Progressive neurological deficits 2

If any red flags are present, obtain immediate MRI and specialist consultation. 2, 3 If red flags are absent, proceed with conservative management below.

First-Line Conservative Management (Weeks 0-6)

Pharmacologic Treatment

Start with NSAIDs or acetaminophen as first-line medication. 2, 4, 5

• NSAIDs are preferred for their anti-inflammatory properties 5, 6
• Add muscle relaxants if significant muscle spasm is present 2
• Reserve short-term opioids only for severe pain unresponsive to NSAIDs, and use judiciously 2
• Avoid COX-2 inhibitors as they have not demonstrated superiority over standard NSAIDs 5

Non-Pharmacologic Interventions

Advise patients to remain active and continue ordinary activities within pain limits—bed rest worsens outcomes. 2, 3, 5

• Apply heat or cold therapy as needed for symptomatic relief 2, 4
• Recommend activity modification without complete restriction 2
• Provide patient education emphasizing the favorable prognosis: 90% of acute episodes resolve within 6 weeks regardless of treatment 3, 5
• Consider McKenzie exercises if pain radiates below the knee 5

Critical Pitfall: Avoid Early Imaging

Do not order X-rays, CT, or MRI in the first 6 weeks unless red flags are present. 1 This is a common error with significant consequences:

• Early imaging in acute uncomplicated low back pain provides no clinical benefit 1
• Studies show 27.2% of patients inappropriately receive imaging within 4 weeks 1
• Early imaging leads to increased healthcare utilization, including unnecessary injections, surgery, and disability compensation 1
• Many imaging findings (disc bulges, protrusions) are present in asymptomatic individuals and do not correlate with symptoms 1, 3
• Even disc herniations show reabsorption or regression by 8 weeks in most cases 1

Management After 6 Weeks of Failed Conservative Therapy

If symptoms persist beyond 6 weeks despite appropriate conservative management, consider MRI (preferred over CT) only if the patient is a candidate for surgery or epidural steroid injection. 2, 3

• MRI is preferred because it avoids ionizing radiation and provides superior soft tissue visualization 3
• Reassess for development of new red flags or progressive neurological deficits 2, 3
• Consider referral for goal-directed manual physical therapy if no improvement occurs in 1-2 weeks 5

Additional Considerations for Radiculopathy

If radicular symptoms (leg pain, numbness, weakness) are present but no red flags exist:

• The same conservative approach applies—radiculopathy with acute low back pain is self-limiting in most patients 1
• Continue conservative management for 6 weeks before considering imaging 2
• Add directional preference exercises and consider neurodynamic mobilization in the subacute phase 7

What NOT to Do

• Do not order bone scans, CT myelography, discography, or PET/CT for initial evaluation of uncomplicated lumbago 1
• Do not recommend bed rest—it increases disability 2, 5
• Do not refer for surgery in the absence of red flags or failed conservative management 5
• Do not use opioids as first-line therapy 4