What is the appropriate management for a patient presenting with lower back pain?

Management of Lower Back Pain

Initial Evaluation and Risk Stratification

Conduct a focused history and physical examination to classify patients into one of three categories: nonspecific low back pain (85% of cases), back pain with radiculopathy or spinal stenosis, or back pain with a specific spinal cause. 1

Red Flag Assessment (Requires Urgent Evaluation)

• Cauda equina syndrome indicators: new-onset bowel/bladder incontinence, urinary retention, saddle anesthesia, or loss of anal sphincter tone 2, 3
• Malignancy risk factors: history of cancer, unexplained weight loss, age >50 years 4, 3
• Infection indicators: fever, recent bacterial infection, immunosuppression 4
• Fracture risk: age >70 years, significant trauma, prolonged corticosteroid use, osteoporosis 4, 3
• Progressive neurologic deficits: major motor weakness, sensory loss in dermatomal distribution 2, 3

Neurological Examination Specifics

• Perform straight-leg raise test (91% sensitivity for herniated disc) 4
• Test motor strength, reflexes, and sensory distribution for radiculopathy 4
• Assess for spinal stenosis symptoms: leg pain with walking that improves with sitting or forward flexion 1

Psychosocial Risk Factor Assessment

• Screen for depression, anxiety, passive coping strategies, and job dissatisfaction—these predict chronicity more strongly than physical findings 4, 2
• Consider using the STarT Back tool to stratify patients into low, medium, or high-risk categories for chronic disability 4

Imaging Guidelines

Do not routinely obtain imaging in patients with nonspecific low back pain without red flags. 1, 4

When to Image:

• Urgent MRI: suspected cauda equina syndrome, severe/progressive neurologic deficits, history of cancer with new back pain 5, 2
• MRI or CT (if surgical candidate): persistent pain with radiculopathy or spinal stenosis after 4-6 weeks of conservative treatment 1
• Plain radiography: suspected vertebral compression fracture in patients >65 years with midline tenderness 2

Treatment Algorithm

First-Line: Patient Education and Self-Care

Advise patients to remain active and avoid bed rest—activity is more effective than bed rest for acute or subacute low back pain. 1, 3

• Provide evidence-based self-care education (e.g., The Back Book) 1
• Recommend application of heat for short-term relief of acute pain 1
• Use medium-firm mattress (not firm) for chronic pain 1
• Reassure patients that >85% of cases are nonspecific and self-limited 1

Second-Line: Pharmacologic Management

For most patients, first-line medication options are acetaminophen or NSAIDs. 1

Medication Selection:

• NSAIDs (preferred for moderate-severe pain): More effective than acetaminophen by 10 points on 100-point visual analogue scale 2

  • Ibuprofen: 400 mg every 4-6 hours (maximum 3200 mg/day), though doses >400 mg show no additional benefit for acute pain 6
  • Caution: gastrointestinal and cardiovascular risks; avoid in CKD with GFR <45 4, 6

• Acetaminophen (first-line for mild pain or NSAID contraindications): Safer profile but slightly less effective 1

  • Caution: asymptomatic aminotransferase elevations at 4 g/day 1

• Opioids or tramadol: Reserve for severe, disabling pain uncontrolled by NSAIDs/acetaminophen; use judiciously with careful risk-benefit assessment 2

Third-Line: Nonpharmacologic Therapies

For patients not improving with self-care after 2-4 weeks, add nonpharmacologic therapy based on pain duration. 1

Acute Low Back Pain:

• Spinal manipulation (moderate-quality evidence) 1

Chronic or Subacute Low Back Pain (choose based on patient preference and availability):

• Intensive interdisciplinary rehabilitation 1
• Exercise therapy 1
• Acupuncture 1
• Massage therapy 1
• Yoga 1
• Cognitive-behavioral therapy 1
• Progressive relaxation 1

Radicular Pain Specific Management:

• Consider earlier specialist referral (within 2 weeks) if pain is severe or disabling 2
• Image-guided epidural steroid injections may be considered for severe radicular pain based on patient choice 2

Reassessment Timeline

Reevaluate patients with persistent, unimproved symptoms after 1 month. 4, 2

• Earlier reassessment warranted for: severe pain, functional deficits, age >65-70 years, or signs of radiculopathy/stenosis 4, 2
• Lower threshold for imaging in elderly patients (>65-70 years) due to higher prevalence of serious pathology 4

Common Pitfalls to Avoid

• Avoid routine imaging: Increases costs without improving outcomes in nonspecific low back pain 1, 4
• Avoid bed rest: Remaining active leads to better outcomes 1, 3
• Avoid firm mattresses: Medium-firm mattresses are superior for chronic pain 1
• Avoid NSAIDs in advanced CKD: Use acetaminophen as first-line in patients with GFR <45 4
• Avoid delaying MRI when red flags present: May result in worsening outcomes, particularly with suspected malignancy or cauda equina syndrome 5, 2