What is the initial management for a patient presenting with low back pain?

Initial Management of Low Back Pain

For patients presenting with acute low back pain, advise them to remain active within pain limits, provide reassurance about the favorable prognosis, and offer first-line pain relief with acetaminophen or NSAIDs—while avoiding routine imaging and bed rest. 1, 2

Immediate Assessment Priorities

Screen for Red Flags Requiring Urgent Action

• Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction, bilateral leg weakness) requires immediate MRI and neurosurgical consultation 2, 3
• Cancer history with metastatic potential to bone, unexplained weight loss, or constitutional symptoms 2, 3
• Infection indicators: fever, recent infection, IV drug use, or immunosuppression suggesting spinal infection 2, 3
• Fracture risk: significant trauma, osteoporosis history, chronic steroid use, or midline tenderness 2, 3
• Progressive neurologic deficits: severe or worsening motor weakness, sensory loss 2

Perform Focused Neurological Examination

• Conduct straight leg raise test to evaluate for radiculopathy 2
• Assess motor strength, sensory distribution, and reflexes in lower extremities 2
• Document any radicular symptoms (pain radiating below the knee) 1

First-Line Management Strategy

Patient Education and Activity Modification

• Reassure patients that 90% of acute low back pain episodes resolve within the first month, with or without treatment 1, 3
• Advise staying active and continuing ordinary activities within pain limits—this is more effective than bed rest 1, 3
• Avoid bed rest entirely; if severe symptoms require brief rest periods, encourage return to normal activities as soon as possible 1
• Provide evidence-based self-care resources (such as The Back Book) for patient education 1
• Apply heat with heating pads or heated blankets for short-term relief 1

Pharmacologic Management

• First-line medications: acetaminophen or NSAIDs 2, 3
• Avoid systemic corticosteroids—they show no greater effectiveness than placebo 3
• Avoid opioids for long-term management due to lack of superior efficacy and risk of dependence 2, 3
• COX-2 inhibitors and muscle relaxants have not demonstrated superiority over NSAIDs for acute low back pain 4

Imaging Decisions

When NOT to Image

• Do not order routine imaging for nonspecific low back pain without red flags, even with midline tenderness 2, 3
• Unnecessary imaging increases healthcare utilization and radiation exposure without clinical benefit 2, 3

When to Consider Imaging

• Immediate MRI or CT: if red flags present (cauda equina, severe neurologic deficits, suspected serious underlying condition) 2
• Plain radiography: only for patients with risk factors for vertebral compression fracture or after 4-6 weeks of persistent symptoms despite conservative management 2, 3
• MRI (preferred) or CT: for patients with persistent radicular symptoms who are potential candidates for surgery or epidural steroid injection 1

Risk Stratification and Follow-Up

Use STarT Back Tool at 2 Weeks

• Low-risk patients: encourage self-management 1
• Medium-risk patients: refer to physiotherapy with patient-centered management plan 1
• High-risk patients: refer for comprehensive biopsychosocial assessment and physiotherapy 1

Assess Psychosocial Yellow Flags

• Screen for depression, passive coping strategies, job dissatisfaction, catastrophizing thoughts, and disputed compensation claims—these predict poorer outcomes 3

Schedule Reassessment

• Review within 2 weeks from onset if no improvement or deterioration 1
• Reevaluate at 1 month for persistent unimproved symptoms 2, 3
• Consider earlier reassessment for older patients, those with radiculopathy/spinal stenosis signs, or worsening symptoms 2, 3
• Review no later than 12 weeks for high-risk patients receiving biopsychosocial interventions 1

Nonpharmacologic Interventions (If Symptoms Persist Beyond Initial Period)

Evidence-Based Options for Subacute/Chronic Pain

• Exercise therapy (individualized, supervised, with stretching and strengthening) 1
• Spinal manipulation (by trained clinician) 1, 5
• Cognitive-behavioral therapy or progressive relaxation 1
• Massage therapy 1
• Acupuncture 1
• Intensive interdisciplinary rehabilitation for persistent disability beyond 4-8 weeks 1

Avoid Ineffective Interventions

• Transcutaneous electrical nerve stimulation (TENS) and continuous/intermittent traction have not proven effective 1

Common Pitfalls to Avoid

• Ordering routine imaging for uncomplicated acute low back pain without red flags 2, 3
• Prescribing prolonged bed rest—this worsens outcomes compared to staying active 1, 3
• Failing to address psychosocial factors (depression, catastrophizing, job dissatisfaction) that contribute to chronicity 3
• Overreliance on opioids for pain management 2, 3
• Delaying work return—early return to work (with modifications if needed) improves outcomes 1

When to Consider Specialist Referral

• No improvement after 12 weeks of conservative management: consider referral to specialist pain center or spinal center 1
• Persistent radicular symptoms despite conservative therapy: consider evaluation for epidural steroids or surgery 1
• Severe functional disability with progressive spinal stenosis, worsening spondylolisthesis, or herniated disc after failed conservative treatment 6