Acute Low back pain

AN EVIDENCE BASED Family medicine playbook

Work Related?

Yes

Unless you are a workmans compensation provider, do not bill/treat for patients
work related injury. Have patient talk to their employer about appropriate referral

No

History & Physical

* The HISTORY should focus on duration of symptoms, mechanism of injury, location of

pain, severity of pain, radiculopathy symptoms, and any red flags signs (see below).
The PHYSICAL EXAM should focus on observation of walking, range of motion, areas
of tenderness, strength testing, and straight leg raise.

Flag on the play

Fever/Infection,
IV drug use, or
immunosuppressed

Suspect pylonephritis

UA, urine culture, and consider renal sonogram

Suspect osteomylitis
or abcess

Stat MRI, CBC, sed rate, blood cultures. To ER?

Previous cancer or
history concerning
for cancer (i.e. weight
loss or nighttime pain)

X-ray and sed rate to look for metastatic

disease. Consider MRI LS spine WITH contrast

Age > 50 or
Osteoporosis risk
(chronic steroid use)

X-ray to look for compression fractures

Trauma (age specific)

X-ray to look for acute fracture

Cauda equina or
severe/progressive
neurologic deficits

Urinary retention/incontinence, saddle

anesthesia, lower extremity weakness

STAT MRI or CT of LS spine

No

Duration
of Pain

> 4 wks
See Subacute/Chronic Low Back Pain Algorithm

< 4 wks

CONSERVATIVE THERAPY:
No further testing needed (C)
Offer encouragement (B)
Remain active, limit bedrest (A)
NSAIDs/acetaminophen (A)
Muscle relaxers (A)
Avoid opioids first line (B)

FOLLOW-UP:
In 1 week for severe pain
In 4 weeks for mild to mod pain
Discuss return to work plan

eplan h
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a
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ks wit no R
Backw back pain will resolve withhinin 62 wweeeeks with no Rx

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Most peop
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Alt
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the first 4 w
ended (A)
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Bed rest is
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eed physica
in select situ
ts do NOT n
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M
ay co
ack pain (B)
in (A). But m
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Oral steroid