What is the appropriate approach to managing a patient with low back pain?

Approach to Low Back Pain

Advise patients to stay active and avoid bed rest, provide appropriate pain relief with NSAIDs or acetaminophen, and use the STarT Back tool at 2 weeks to risk-stratify patients for targeted management. 1, 2

Initial Assessment and Red Flag Screening

Conduct a focused history and physical examination to identify red flags requiring urgent intervention:

• Cauda equina syndrome (urinary retention, fecal incontinence, bilateral leg weakness, saddle anesthesia) requires immediate MRI and neurosurgical consultation 2, 3
• Serious underlying conditions including history of cancer, unexplained weight loss, fever, significant trauma, or progressive neurologic deficits 2, 4
• Vertebral compression fracture risk factors such as osteoporosis, steroid use, or midline tenderness with fever 2
• Perform neurological examination including motor strength, sensory distribution, reflexes, and straight leg raise test for radiculopathy 2, 3

Do not order routine imaging for nonspecific low back pain without red flags, even with midline tenderness, as it exposes patients to unnecessary radiation without clinical benefit 2, 4

Immediate Management (First 2 Weeks)

Advise reactivation and explicitly avoid bed rest - maintaining activity within pain limits reduces disability and improves outcomes 1, 2, 5

Provide first-line pain relief:

• NSAIDs (ibuprofen, naproxen) are the initial medication of choice for moderate pain 2, 6, 4
• Acetaminophen (up to 4g daily) for mild-to-moderate pain 2, 5
• Avoid opioids for initial management due to abuse potential and lack of superior efficacy 2, 4

Initiate nonpharmacologic treatments immediately:

• Apply superficial heat using heating pads 1, 2
• Consider spinal manipulation, which may be helpful in the first month 1, 2, 7
• Provide self-care education and reassurance that 90% of episodes resolve within 6 weeks 5

Review and assess improvement within 2 weeks from onset 1

Risk Stratification at 2 Weeks (STarT Back Tool)

Use the STarT Back tool to predict risk for developing persistent disabling pain and direct resources appropriately 1, 2

Low-Risk Patients

• Encourage self-management with continued activity and simple analgesia 1
• Provide education on proper body mechanics and safe back exercises 5

Medium-Risk Patients

• Refer to physiotherapy and develop a patient-centered management plan 1, 2
• Consider massage, acupuncture, or continued spinal manipulation 2, 4

High-Risk Patients (with psychosocial factors)

• Refer for comprehensive biopsychosocial assessment by multidisciplinary team 1
• High-risk features include anxiety, depression, catastrophizing, fear-avoidance beliefs, and job dissatisfaction 2
• Review no later than 12 weeks 1
• Consider high-intensity cognitive behavioral therapy 1

Management of Persistent Pain (4-6 Weeks)

If symptoms persist beyond 4-6 weeks without improvement:

• Consider plain radiography as initial imaging option, but only if patient has not improved with conservative therapy 2, 8
• Intensify nonpharmacologic therapies including exercise therapy, multidisciplinary rehabilitation, or acupuncture 2, 4
• Reevaluate earlier (at 1 month) in patients over 65 years, with signs of radiculopathy/stenosis, or worsening symptoms 2

Chronic Low Back Pain (>12 Weeks)

Nonpharmacologic treatments remain first-line:

• Exercise therapy (moderate-quality evidence) 2, 4
• Multidisciplinary rehabilitation (moderate-quality evidence) 2, 4
• Cognitive behavioral therapy (low-quality evidence) 2, 4
• Mindfulness-based stress reduction, tai chi, or yoga (low to moderate-quality evidence) 2
• Acupuncture or spinal manipulation (moderate to low-quality evidence) 2, 4

Pharmacologic escalation if inadequate response to nonpharmacologic therapy:

• Continue NSAIDs as first-line 2, 4, 8
• Consider tramadol or duloxetine as second-line options 2, 4
• Opioids only as last resort with careful monitoring due to risk of dependence 2, 6, 4

Specialist Referral Indications

Consider referral to specialist pain center or spinal center when:

• No improvement after 12 weeks despite comprehensive conservative therapy 1
• Progressive neurologic deficits or severe functional disabilities 2, 4
• Persistent radicular symptoms despite conservative management 8, 9

Most patients with chronic low back pain will not benefit from surgery - surgical evaluation should be reserved for select patients with persistent functional disabilities from progressive spinal stenosis, worsening spondylolisthesis, or herniated disk unresponsive to multiple nonsurgical treatments 4, 8, 7

Common Pitfalls to Avoid

• Prescribing prolonged bed rest leads to deconditioning and increased disability 2, 5
• Routine imaging for uncomplicated acute low back pain wastes resources without improving outcomes 2, 4, 7
• Overreliance on opioid medications increases risk of dependence without superior pain control 2, 6, 4
• Failing to assess psychosocial factors (depression, catastrophizing, fear-avoidance beliefs) that predict chronicity 2, 4
• Physical therapy for all patients is not cost-effective - use stratified care based on STarT Back tool 1