What are the recommended treatments and evaluations for right lower back pain?

Right Lower Back Pain: Evaluation and Treatment

Initial Evaluation

Begin with a focused history and physical examination to categorize the pain into one of three groups: nonspecific low back pain (85% of cases), pain with radiculopathy/spinal stenosis, or pain from a specific spinal cause requiring urgent evaluation. 1

Key History Elements to Assess

• Pain characteristics: Location (unilateral right lower back), radiation pattern, duration (<4 weeks = acute, 4-12 weeks = subacute, >12 weeks = chronic), and intensity 2, 3

• Red flags requiring urgent evaluation: 1, 3

  • Progressive motor weakness or sensory loss at multiple levels
  • New urinary retention, overflow incontinence, or fecal incontinence (cauda equina syndrome)
  • History of cancer (increases cancer probability from 0.7% to 9%)
  • Unexplained weight loss or fever (infection/malignancy)
  • Significant trauma relative to age
  • History of osteoporosis or chronic steroid use (fracture risk)
  • Age >50 with new onset pain (higher cancer/fracture risk)

• Psychosocial risk factors: Depression, anxiety, catastrophizing, fear-avoidance beliefs, job dissatisfaction—these predict progression to chronic disabling pain 1, 2, 3

Physical Examination Focus

• Neurologic examination: Motor strength testing at multiple levels, sensory examination, reflexes, straight leg raise test for radiculopathy 3
• Midline tenderness: May indicate vertebral compression fracture (especially with osteoporosis/steroid use) or infection (if accompanied by fever) 3
• Signs of radiculopathy: Leg pain worse than back pain, dermatomal sensory changes, specific motor weakness 1

Imaging Decisions

Do not routinely obtain imaging for nonspecific low back pain without red flags. 1, 3

When to Image Immediately

• Obtain urgent MRI (preferred) or CT if: 1, 3
  • Severe or progressive neurologic deficits present
  • Cauda equina syndrome suspected
  • Serious underlying condition suspected (cancer with spinal cord compression, vertebral infection)
  • MRI is superior because it avoids radiation and better visualizes soft tissues, vertebral marrow, and spinal canal 1, 3

When to Delay Imaging

• For nonspecific low back pain without red flags: Wait 4-6 weeks of conservative management before considering imaging 1, 3
• For persistent radicular symptoms: Only obtain MRI/CT if patient is a potential candidate for surgery or epidural steroid injection 1
• For patients >50 without other cancer risk factors: Delaying imaging while offering standard treatment and reevaluating within 1 month is reasonable 1

Treatment Approach

Acute/Subacute Low Back Pain (<12 weeks)

Start with nonpharmacologic treatments as first-line therapy, adding medications only if specifically desired by the patient. 1, 3

First-Line Nonpharmacologic Options:

• Superficial heat (heating pads): Moderate-quality evidence 1, 3
• Spinal manipulation: Moderate-quality evidence for short-term benefit 1
• Massage therapy: Low-quality evidence 1, 3
• Acupuncture: Low-quality evidence 1, 3
• Advise to remain active: Strong evidence—more effective than bed rest 1, 3

Pharmacologic Options (if desired):

• First-line: NSAIDs or acetaminophen (up to 4g daily) 1, 3
• Second-line: Skeletal muscle relaxants (short-term use only) 1
• Avoid: Opioids for initial management due to abuse potential and lack of superior efficacy 3

Chronic Low Back Pain (>12 weeks)

Prioritize nonpharmacologic treatments with proven benefits before escalating to medications. 1, 3

First-Line Nonpharmacologic Options:

• Exercise therapy: Moderate-quality evidence 1, 3
• Multidisciplinary rehabilitation: Moderate-quality evidence 1, 3
• Cognitive behavioral therapy: Low-quality evidence 1, 3
• Mindfulness-based stress reduction: Moderate-quality evidence 1, 3
• Yoga or tai chi: Low-quality evidence 1, 3
• Acupuncture: Moderate-quality evidence 1, 3
• Spinal manipulation: Low-quality evidence 1, 3

Pharmacologic Escalation (if inadequate response):

• First-line: Continue NSAIDs 1, 3
• Second-line: Tramadol or duloxetine 1, 3
• Last resort: Opioids with careful monitoring and risk assessment 1, 3

Patient Education and Prognosis

Inform patients of the generally favorable prognosis—most acute low back pain improves substantially within the first month. 1

• Explain that routine imaging does not improve outcomes and incurs unnecessary expense 1
• Emphasize staying active rather than bed rest 1, 3
• Provide self-care education materials based on evidence-based guidelines 1
• Set realistic expectations: up to one-third may have persistent moderate pain at 1 year, but most improve significantly 1

Follow-Up and Reassessment

• Reevaluate at 4-6 weeks if symptoms persist without improvement 3
• Earlier reassessment for: older patients, signs of radiculopathy/stenosis, or worsening symptoms 3
• Consider referral if no response to standard therapies after 3 months minimum, or if progressive neurologic deficits or persistent functional disabilities occur 3
• Use STarT Back tool at 2 weeks to risk-stratify patients and direct resources appropriately 3

Common Pitfalls to Avoid

• Ordering routine imaging for uncomplicated acute low back pain exposes patients to unnecessary radiation without clinical benefit 3
• Prescribing prolonged bed rest worsens outcomes compared to staying active 1, 3
• Overreliance on opioids for pain management increases abuse risk without superior efficacy 3
• Failing to assess psychosocial factors that contribute to delayed recovery and chronic disability 1, 2, 3
• Missing red flags that require urgent evaluation can lead to delayed diagnosis of serious conditions with poorer outcomes 1, 3