What is the recommended evaluation and stepwise management for a patient presenting with back pain?

Evaluation and Management of Back Pain

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

Initial Red Flag Assessment

The first priority is identifying serious pathology that requires urgent imaging or specialist referral. Screen for these critical red flags:

Cauda Equina Syndrome (0.04% prevalence) 1, 2

• Urinary retention (90% sensitivity) 3
• Fecal incontinence 2
• Saddle anesthesia 2
• Bilateral motor weakness or progressive neurologic deficits at multiple levels 2, 3
• If present: Urgent MRI within hours and immediate neurosurgical consultation 2, 3

Malignancy (0.7% prevalence, 9% if prior cancer history) 1, 3

• History of cancer 3
• Unexplained weight loss 3
• Age >50 years 3
• Failure to improve after 1 month 3
• Night pain or constant pain 4

Infection (0.01% prevalence) 1, 2

• Fever 5
• Recent infection or IV drug use 2
• Immunocompromised status 2

Compression Fracture (4% prevalence) 1

• History of trauma 5
• Long-term steroid use 5
• Osteoporosis risk factors 1

Inflammatory Spondyloarthritis (0.3-5% prevalence) 1, 2

• Morning stiffness >30 minutes that improves with movement 2
• Age <40 years at onset 1
• Pain that worsens with rest 2

Imaging Strategy

Do NOT routinely obtain imaging for nonspecific low back pain—it does not improve outcomes and increases costs. 1, 3

When to Image Urgently 1, 3

• Severe or progressive neurologic deficits 1
• Any red flags present on history/examination 1
• MRI is preferred over CT for spinal pathology 1

When to Image Selectively 1

• Persistent symptoms with radiculopathy or spinal stenosis ONLY if patient is a surgical or epidural steroid injection candidate 1
• For suspected cancer without cord compression, consider plain radiography or ESR (≥20 mm/h has 78% sensitivity) first 3

Risk Stratification for Nonspecific Low Back Pain

If no red flags are present, use the STarT Back tool at 2 weeks to predict risk of developing chronic disabling pain and guide treatment intensity. 1, 4

Low-Risk Patients 1, 4

• Encourage self-management with comprehensive resources (online materials, telephone helplines, evidence-based educational materials) 4
• Advise remaining active—bed rest is contraindicated 1, 4
• Provide reassurance about favorable prognosis (high likelihood of substantial improvement within first month) 3

Medium-Risk Patients 1

• Refer to physiotherapy for patient-centered management plan 4
• Personalized, supervised exercise programs with stretching and strengthening 4

High-Risk Patients 1

• Refer to physiotherapy with skills for comprehensive biopsychosocial assessment 1
• Review no later than 12 weeks 1
• If no improvement, consider referral to specialist pain center 1

Pharmacological Management

Start with NSAIDs or acetaminophen as first-line therapy, assessing cardiovascular and GI risk factors before prescribing. 1, 4

• NSAIDs (e.g., naproxen) are first-line 4
• Use lowest effective dose for shortest duration 4
• Acetaminophen is reasonable alternative if NSAIDs contraindicated (though slightly weaker analgesia) 4
• Assess severity of baseline pain and functional deficits before initiating therapy 1

Non-Pharmacological Interventions

For Acute Low Back Pain (<4 weeks) 1

• Spinal manipulation 1

For Chronic or Subacute Low Back Pain (>4 weeks) 1

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

Timing for Specialist Referral

Urgent Referral (Within 2 Weeks) 4

• Disabling pain 4
• Motor or sensory deficits present 4

Non-Urgent Referral (No Later Than 12 Weeks) 1, 4

• Symptoms persist despite conservative management 4
• Pain severity increases or functional disability worsens 4

For Radiculopathy 3

• Reserve surgical referral for persistent radicular symptoms at 12 weeks unresponsive to conservative care 3
• Consider discectomy or epidural steroids after failed conservative therapy 3

Critical Pitfalls to Avoid

• Never prescribe bed rest—staying active is superior for back pain management 1, 4
• Avoid "physical therapy for all" approach—use stratified care based on risk level 4
• Do not delay imaging in suspected cauda equina syndrome—poorer outcomes result, particularly for urinary and bowel function 3
• Do not routinely image nonspecific low back pain—it does not improve outcomes 1, 3
• Do not miss cancer in older patients—age >50 alone only increases probability to 1.2%, but history of cancer increases it to 9% 3