You are on page 1of 2

1/29/2019 about:blank

Practice Guidelines
ACP Guidelines for the Diagnosis and Treatment of Low Back Pain

Table 1
Diagnostic Work-up for Initial Evaluation of Low Back Pain

POSSIBLE KEY FEATURES ON HISTORY OR PHYSICAL ADDITIONAL


IMAGING*
CAUSE EXAMINATION STUDIES*

Ankylosing Morning stiffness; improvement with exercise; alternating Anteroposterior ESR and/or
spondylitis buttock pain; awakening because of back pain during the pelvis plain CRP, HLA-
second part of the night; younger age radiography B27

Cancer History of cancer with new onset of low back pain MRI ESR

Unexplained weight loss; failure to improve after one Lumbosacral ESR


month; age older than 50 years plain
radiography

Multiple risk factors present Plain ESR


radiography or
MRI

Cauda equina Urinary retention; motor deficits at multiple levels; fecal MRI None
syndrome incontinence; saddle anesthesia

Herniated Back pain with leg pain in an L4, L5, or S1 nerve root None None
disc distribution; positive straight-leg-raise test or crossed
straight-leg-raise test

Symptoms present longer than one month MRI Consider


EMG/NCV

Severe or Progressive motor weakness MRI Consider


progressive EMG/NCV
neurologic
deficits

Spinal Radiating leg pain; older age; pseudoclaudication is a None None


stenosis weak predictor

Symptoms present longer than one month MRI Consider


EMG/NCV

about:blank 1/2
1/29/2019 about:blank

POSSIBLE KEY FEATURES ON HISTORY OR PHYSICAL ADDITIONAL


IMAGING*
CAUSE EXAMINATION STUDIES*

Vertebral History of osteoporosis; use of corticosteroids; older age Lumbosacral None


compression plain
fracture radiography

Vertebral Fever; intravenous drug use; recent infection MRI ESR and/or
infection CRP

CRP = C-reactive protein; EMG = electromyography; ESR = erythrocyte sedimentation rate; HLA = human leukocyte
antigen; MRI = magnetic resonance imaging; NCV = nerve conduction velocity.

*— Level of evidence for diagnostic evaluation is variable.

Adapted with permission from Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice
guideline from the American College of Physicians and the American Pain Society [published correction appears in
Ann Intern Med. 2008;148(3):247–248]. Ann Intern Med. 2007;147(7):481.

Copyright © 2008 by the American Academy of Family Physicians.


This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that
printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied,
printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in
writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

about:blank 2/2