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Sunday, June 27, 2010

Acute nonspecific low back pain

A 48-year-old man is evaluated in the office for back pain of 1 month's duration. He describes the pain as an ache that has been slowly worsening and is only partially relieved with acetaminophen. He is most comfortable lying down and least comfortable sitting or moving. He has not had any recent trauma or previous back pain. He has not had weight loss, fever, chills, numbness or weakness in his legs, or problems with bowel or bladder function. His only other medical problems are hypertension and osteoarthritis of the knees, for which he takes hydrochlorothiazide and acetaminophen, with occasional ibuprofen.

On physical examination, vital signs, including temperature, are normal. He has mild lumbar paravertebral tenderness and spasm. Neurologic examination, including muscle strength, deep tendon reflexes, and sensation, is normal. The straight-leg-raising test is normal.

Complete blood count and metabolic panel performed in the office 3 months ago were normal.

Which of the following is the best initial management plan for this patient?
A Analgesics and strict bed rest
B CT scan of the lumbosacral spine
C MRI of the lumbosacral spine
D Physical therapy
E Symptomatic treatment


This patient should do well with symptomatic treatment alone. Most acute nonspecific pain resolves over time without the need for treatment, and controlling pain while symptoms diminish on their own is the goal for most persons. A patient with back pain but at low risk for serious disease by history and physical examination does not need anything other than simple analgesics and continued activity. Some patients may benefit from the addition of moist heat.

Strict bed rest is associated with prolongation of symptoms and higher morbidity. A systematic review of bed rest for low back pain and sciatica showed that advice to continue normal activities was more beneficial than bed rest. The need for obtaining plain radiographs of the spine can be determined on the basis of the history and physical examination. More sophisticated imaging is most useful when the pretest probability of underlying serious disease is high. Diagnostic imaging techniques are indicated in individuals with “red flags” for serious underlying disease, including fever, chills, weight loss, history of malignancy, injection drug use, trauma, or indolent course. Some authorities recommend radiographic imaging of patients >50 years of age with low back pain because of the increased incidence of malignancy, compression fractures, and spinal stenosis in this age group. Physical therapy is an appropriate adjuvant but is not an appropriate initial treatment. Clinical trial evidence has shown that beginning back exercises immediately actually delays recovery.

Key Points

* Most acute nonspecific low back pain resolves over time without the need for treatment.
* Diagnostic imaging is indicated for individuals with “red flag” signs or symptoms for serious disease, including fever, chills, weight loss, history of malignancy, injection drug use, trauma, or indolent course.

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