Initial Approach to Low Back Pain
Immediate Assessment: Rule Out Red Flags
The first priority is to conduct a focused history and physical examination to identify red flags requiring urgent intervention, not routine imaging for uncomplicated cases. 1, 2
Red flags requiring immediate action include: 1, 2, 3
- Cauda equina syndrome (urinary retention, fecal incontinence, saddle anesthesia, bilateral leg weakness)
- Severe or progressive neurologic deficits
- History of cancer with unexplained weight loss
- Fever suggesting infection (especially with IV drug use or immunocompromised status)
- Significant trauma or risk factors for fracture (age >50, osteoporosis, steroid use)
If red flags are present: Obtain immediate MRI (preferred) or CT and arrange urgent specialist consultation 1, 2. MRI is superior because it avoids radiation and better visualizes soft tissue, vertebral marrow, and the spinal canal 1.
If no red flags are present: Proceed with conservative management—do NOT order imaging 1, 2, 3.
Initial Management Strategy (First 2 Weeks)
Advise patients to stay active and avoid bed rest, as maintaining activity reduces disability and improves outcomes 1, 2. This represents a fundamental shift from outdated recommendations for rest 1.
Provide self-care education and reassurance: 1, 2
- Most acute low back pain (90%) resolves within 6 weeks regardless of treatment
- Recommend application of superficial heat using heating pads
- Encourage continuation of ordinary activities within pain limits
- Direct patients to comprehensive self-management resources (online materials, telephone helplines, patient education programs)
First-line medication options: 1, 2
- Acetaminophen (up to 4g daily) for mild-to-moderate pain—safest option with favorable side effect profile
- NSAIDs if acetaminophen insufficient—more effective than acetaminophen but assess cardiovascular and gastrointestinal risk first; use lowest effective dose for shortest duration
- Avoid opioids for initial management due to abuse potential and lack of superior efficacy 1, 2
Review patient within 2 weeks to assess improvement 1.
Stratified Care at 2 Weeks (If No Improvement)
Use the STarT Back tool to risk-stratify patients at 2 weeks from pain onset—this evidence-based approach directs resources appropriately and improves cost-effectiveness 1:
Low-risk patients: 1
- Encourage continued self-management
- Maintain activity and reassurance
- No additional interventions needed
Medium-risk patients: 1
- Refer to physiotherapy
- Develop patient-centered management plan
- Consider nonpharmacologic treatments: massage, acupuncture, or spinal manipulation 1, 2
High-risk patients (at risk for chronic disability): 1
- Refer for comprehensive biopsychosocial assessment by physiotherapy with appropriate skills
- Review no later than 12 weeks
- Consider psychological interventions if psychosocial factors prominent
Management of Persistent Pain (4-6 Weeks)
If symptoms persist beyond 4-6 weeks without improvement: 1, 2, 3
- Consider plain radiography as initial imaging option (not MRI)—but only if patient has not improved with conservative therapy 1, 3
- Reassess for development of new red flags
- Intensify nonpharmacologic interventions
For radiculopathy or spinal stenosis symptoms: 1
- Obtain MRI or CT only if patient is a potential candidate for surgery or epidural steroid injection
- Most disc herniation with radiculopathy improves within 4 weeks with conservative management
- Do not image routinely—findings like bulging discs are often nonspecific and poorly correlated with symptoms 1
Chronic Low Back Pain (>12 Weeks)
Nonpharmacologic treatments are first-line: 2
- Exercise therapy (no single type superior to another)
- Multidisciplinary rehabilitation
- Cognitive behavioral therapy
- Mindfulness-based stress reduction
- Tai chi or yoga
- Acupuncture or spinal manipulation
Pharmacologic escalation if inadequate response: 2
- Continue NSAIDs or acetaminophen
- Second-line: tramadol or duloxetine
- Opioids only as last resort with careful monitoring
Consider specialist referral if no response after 3 months of comprehensive conservative therapy or if progressive neurologic deficits develop 2.
Critical Pitfalls to Avoid
Do NOT order routine imaging for nonspecific low back pain without red flags—this leads to unnecessary interventions, radiation exposure, and identification of incidental findings that correlate poorly with symptoms 1, 2, 3. This is the single most important pitfall to avoid.
Do NOT prescribe prolonged bed rest—this worsens disability 1, 2.
Do NOT use opioids as first-line therapy or for long-term management 1, 2.
Do NOT refer all patients to physical therapy—use stratified care to direct resources to those most likely to benefit 1.
Do NOT ignore psychosocial factors (yellow flags) that predict chronicity and disability 1.