Initial Management of Straightening of Lumbar Lordosis and Back Strain on CT Scan
Begin with conservative management for at least 6 weeks without any imaging-guided interventions, as straightening of lumbar lordosis is a nonspecific radiographic finding that does not correlate with symptoms or guide treatment decisions. 1, 2
Why the CT Scan Should Not Drive Your Management
The CT scan was unnecessary and should not have been ordered for uncomplicated acute low back pain without red flags, as routine imaging provides no clinical benefit and does not improve patient outcomes. 1, 2
Straightening of lumbar lordosis is a nonspecific finding that appears on imaging in both symptomatic and asymptomatic individuals—it does not indicate the source of pain or predict treatment response. 3
The finding of "back strain" on CT is a radiologic interpretation that lacks clinical correlation—muscle strain is a clinical diagnosis based on history and physical examination, not imaging. 1
Imaging abnormalities do not correlate with symptoms: disc protrusions, degenerative changes, and postural variations like lordosis straightening are present in 29-43% of completely asymptomatic individuals. 2, 4
Early imaging leads to increased healthcare utilization, unnecessary injections, surgeries, and disability compensation without improving outcomes. 1, 2
Conservative Management Protocol (First 6 Weeks)
Pharmacologic Management
- NSAIDs for pain control as first-line medication. 4
- Muscle relaxants for associated muscle spasms if present. 4
- Short-term opioids only for severe pain that is unresponsive to NSAIDs and muscle relaxants, used judiciously. 4
Non-Pharmacologic Management
- Activity modification without complete bed rest—patients should remain active as tolerated, as bed rest is less effective than staying active. 2, 4
- Heat or cold therapy as needed for symptomatic relief. 4
- Patient education emphasizing that acute low back pain is self-limiting with substantial improvement typically occurring within the first month. 2
- Reassurance that imaging findings like straightening of lordosis do not predict poor outcomes and that most patients improve with conservative care. 2, 4
Physical Therapy
- Initiate physiotherapy immediately with patient-centered, goal-oriented programs focusing on activity modification and gradual return to function. 4
- Lumbar stabilization exercises are more effective than passive conservative treatment for improving functional disability and may help restore normal lordosis angles. 5
- Exercise therapy has moderate evidence (Level B) for effectiveness in conservative treatment of lumbar spine conditions. 6
Red Flags That Would Change Management
If any of these are present, obtain MRI immediately and refer to specialist:
- Cauda equina syndrome: saddle anesthesia, bowel/bladder dysfunction, bilateral leg weakness. 2, 4
- Progressive neurologic deficits: motor weakness (e.g., foot drop), sensory loss, or reflex changes. 2, 4
- Suspected malignancy: history of cancer, unexplained weight loss, age >50 with new onset pain. 7
- Suspected infection: fever, IV drug use, immunosuppression. 7
- Fracture: significant trauma, osteoporosis, prolonged corticosteroid use. 7
When to Consider Imaging (Only After Conservative Failure)
Do not order any imaging before 6 weeks of conservative management unless red flags are present. 1, 2
After 6 weeks of failed conservative therapy, MRI lumbar spine without contrast (not repeat CT) is the appropriate study if the patient is a potential candidate for surgery or epidural steroid injection. 1, 2
CT provides no additional value for soft tissue evaluation and exposes the patient to unnecessary radiation—MRI is superior for evaluating disc pathology, nerve root compression, and spinal canal stenosis. 1
Critical Pitfalls to Avoid
Do not attribute symptoms to the straightening of lordosis—this is a postural variation that may be positional, related to muscle spasm, or simply a normal variant for that individual. 3
Do not order repeat imaging or additional studies based on the CT findings, as this leads to unnecessary healthcare costs and does not improve outcomes. 1, 2
Do not prescribe complete bed rest—patients should remain active as tolerated, as activity is more effective than rest for acute low back pain. 2, 4
Do not proceed with interventions (injections, surgery) based solely on imaging findings without clinical correlation and at least 6 weeks of conservative management. 1, 2, 7
Reassessment Timeline
Reevaluate at 1 month to assess response to conservative management—most patients show substantial improvement by this time. 2
Consider earlier reevaluation (within 2 weeks) if the patient has severe pain, significant functional deficits, or signs of radiculopathy/spinal stenosis. 2, 4
Refer to specialist at 6 weeks if symptoms persist despite optimal conservative management and the patient is a potential candidate for intervention. 1, 2, 4
Do not delay specialist referral beyond 3 months for persistent symptoms, as this can lead to prolonged disability. 7