What is the recommended approach to evaluating and managing a patient presenting with back pain, including red‑flag assessment, imaging, and conservative treatment?

Approach to Back Pain: A Systematic Clinical Algorithm

Immediate Red-Flag Screening

Begin by systematically screening every back pain patient for red flags that indicate serious pathology requiring urgent imaging and intervention. 1, 2

Critical Red Flags Requiring Urgent Action

• Neurological deficits (motor weakness, sensory changes, saddle anesthesia, bowel/bladder dysfunction, asymmetric reflexes) demand urgent MRI without contrast as the first-line test—do not obtain plain radiographs first. 1, 2
• Fever with back pain suggests spinal infection (discitis, osteomyelitis, epidural abscess) and requires immediate MRI with and without IV contrast after obtaining inflammatory markers. 3, 1
• History of cancer increases malignancy probability from 0.7% to 9% and warrants expedited imaging. 1, 4
• Unintentional weight loss, night pain, or pain lasting >4 weeks raise concern for malignancy or infection. 3, 1, 2
• Tachycardia or palpable lymphadenopathy indicate systemic infection or malignancy. 1, 2
• Abnormal spinal curvature, gait abnormalities, or morning stiffness suggest structural or inflammatory pathology. 3, 1, 2

Common Pitfall to Avoid

Do not rely on a single red flag in isolation—most individual red flags have high false-positive rates, but their presence mandates further evaluation. 4 However, history of cancer is the best-performing single red flag for malignancy. 1

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Imaging Algorithm Based on Clinical Presentation

For Patients WITH Neurological Deficits

Order urgent MRI of the affected spine region without contrast immediately—this is the definitive first-line test with superior soft-tissue visualization of vertebral marrow, spinal canal, nerve roots, and intervertebral discs. 2 Delayed diagnosis leads to permanent disability. 2

For Patients WITH Red Flags BUT NO Neurological Deficits

Obtain plain radiographs (AP and lateral views) first as the standard initial imaging, providing 9-22% diagnostic yield when combined with detailed history and physical examination. 2

If Radiographs Are Negative But Red Flags Persist:

• MRI without contrast is the next step, increasing diagnostic yield by 25-34% after negative plain films. 3, 2
• Add IV contrast when infection (discitis, osteomyelitis, epidural abscess) or malignancy is suspected—always obtain precontrast images first to accurately assess enhancement. 3, 2
• Bone scan with SPECT/CT is appropriate when bony pathology (spondylolysis, osseous neoplasm) is specifically suspected. 3, 2
• CT without contrast may be useful for evaluating nondisplaced fractures or spondylolysis when MRI is contraindicated. 3, 2

For Patients WITHOUT Red Flags (Nonspecific Low Back Pain)

Do not obtain imaging or laboratory tests—more than 85% of these patients have self-limiting pain that resolves within 4-6 weeks with conservative management. 1, 5

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Physical Examination: Specific Findings to Document

• Neurological screening: Test motor strength in all lower extremity muscle groups, sensory distribution in dermatomal patterns, reflexes (patellar, Achilles), and straight-leg raise for radiculopathy. 1, 2
• Palpation of spinous processes: Tenderness may indicate fracture, infection, or tumor. 1
• Spinal curvature and alignment: Scoliosis or kyphosis may indicate structural pathology. 1, 2
• Gait testing: Heel-walk, toe-walk, and tandem gait assess motor function and coordination. 1
• Range of motion: Limited flexion with morning stiffness suggests inflammatory conditions; pain with forward flexion raises concern for meningeal irritation in cervical spine cases. 1, 6
• Skin examination: Look for café-au-lait spots, hairy patches, or dimples suggesting underlying spinal dysraphism. 1

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Conservative Management (Only When Red Flags Are Absent)

Initiate outpatient management with close follow-up for nonspecific low back pain, including: 1, 5

• Avoid bed rest—activity modification is preferred over immobilization. 5
• NSAIDs or acetaminophen as first-line pharmacologic treatment. 1, 5
• Nonpharmacologic therapies (exercise therapy, spinal manipulation, physical therapy, heat) as first-line management. 5
• Reassurance and education about the self-limiting nature of most back pain. 1
• Return precautions: Instruct patients to return immediately if fever, progressive neurological deficits, or severe night pain develops. 1

Contraindications to Conservative Management

Do not initiate conservative therapy when: 1

• Progressive neurological deficits are present
• Imaging reveals structural instability
• Serious pathology is confirmed or highly suspected

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Special Considerations for Pediatric Patients

• Children with back pain have higher rates of serious pathology than adults—red flags include night pain, fever, neurological deficits, pain >4 weeks, and abnormal spinal curvature. 3
• MRI without contrast has 100% sensitivity for detecting osseous injury in children and is the preferred imaging modality when red flags are present. 6
• Plain radiographs have only 73-90% sensitivity in children and frequently miss soft-tissue pathology—do not rely on them alone. 6
• Occult neck injuries can occur from trampoline use or sports activities even without reported trauma—any neck pain after such activities warrants prompt evaluation. 6
• Intervertebral disk pathology is now more common than spondylolysis/spondylolisthesis in pediatric back pain due to increased MRI use. 3

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Critical Pitfalls to Avoid

• Do not assume negative radiographs exclude serious pathology—they guide further investigation but are inadequate as a sole diagnostic tool. 3, 2
• Do not order MRI with contrast alone for suspected infection or malignancy—precontrast images are essential to interpret enhancement. 3
• Do not delay imaging for a trial of conservative therapy when red flags are present—the presence of red flags itself demands immediate evaluation. 1, 2
• Do not obtain routine laboratory tests for nonspecific low back pain without red flags. 1
• Do not use plain radiographs alone when serious pathology is suspected—sensitivity is inadequate. 6, 2

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Post-Imaging Management Pathways

• If malignancy is identified: Proceed to image-guided biopsy for tissue diagnosis and refer to oncology. 1
• If infection is confirmed: Initiate appropriate antimicrobial therapy and consider surgical drainage for abscesses. 1
• If radiculopathy without progressive deficits: Manage conservatively with follow-up in 4-6 weeks; consider epidural corticosteroid injections for short-term symptom relief only. 1, 5
• If persistent functional disability despite conservative management: Evaluation for surgery may be considered in cases of progressive spinal stenosis, worsening spondylolisthesis, or herniated disk. 5