From the Guidelines
For acute back pain, a thorough history and physical examination should be performed to rule out red flags, and imaging should not be routinely obtained unless red flags are present, as recommended by the most recent guidelines 1. When evaluating a patient with acute back pain, it is essential to consider the potential causes and risk factors. The patient's history should include questions about the onset, duration, and severity of pain, as well as any associated symptoms such as numbness, tingling, or weakness. A physical examination should be performed to assess for any neurological deficits or signs of infection. The American College of Radiology recommends that imaging not be routinely performed for acute low back pain unless red flags are present, such as cauda equina syndrome, infection, fracture, or malignancy 1. This is because most cases of acute back pain are self-limiting and resolve with conservative management. Some key points to consider when evaluating a patient with acute back pain include:
- The patient's medical history, including any previous episodes of back pain or underlying medical conditions
- The presence of any red flags, such as fever, chills, or recent trauma
- The severity and duration of pain, as well as any associated symptoms
- The patient's functional status and ability to perform daily activities For patients with acute back pain, first-line treatment should include non-pharmacological approaches such as reassurance and encouragement to maintain normal activities as tolerated, as well as medication such as acetaminophen or NSAIDs for pain management 1. Opioids should be avoided unless pain is severe and unresponsive to other treatments, and then only for a very short duration at the lowest effective dose. Follow-up should be arranged if symptoms persist beyond 2 weeks or worsen despite treatment, and imaging should be considered if red flags are present or if the patient has not responded to conservative management. Overall, the goal of treatment for acute back pain is to provide symptom relief, improve functional status, and prevent chronic disability.
From the Research
Evaluation of Acute Back Pain
- The evaluation of acute back pain typically involves a thorough history and physical examination to identify any underlying serious conditions, such as fractures, tumors, or spinal infections 2, 3, 4.
- Red flags, such as significant trauma, major or progressive motor or sensory deficit, and history of cancer, should prompt aggressive treatment or referral to a specialist 4.
Diagnostic Testing
- Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation of acute, nonspecific low back pain 2, 3.
- Imaging studies, such as MRI or CT scans, may be considered if there are signs of serious underlying pathology or if the patient's symptoms do not improve with conservative treatment 4.
Treatment Options
- Conservative care, including time, reassurance, and education, is the primary emphasis of treatment for acute, nonspecific low back pain 2.
- Medications, such as nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants, may be beneficial in managing pain and inflammation 2, 5, 4.
- Exercises, such as the McKenzie method and spine stabilization exercises, may decrease recurrent pain and need for healthcare services 4.
- Referral for physical treatments, such as physical therapy, chiropractic care, or massage therapy, may be considered for patients whose symptoms are not improving with conservative treatment 6.
Management of Acute and Chronic Low Back Pain
- Primary care providers typically recommend staying active and pharmacologic management for acute low back pain, while nonpharmacologic treatments are more commonly recommended for chronic low back pain 6.
- The cost of nonpharmacologic treatments may be a barrier to referral, but primary care providers working in low-income neighborhood clinics are as likely to recommend these approaches as those from high-income neighborhood clinics 6.