Management of Acute Back Pain

Michigan Quality Improvement Consortium. Management of acute low back pain. Southfield (MI): Michigan Quality Improvement Consortium; 2008 Mar. 1 p.

RECOMMENDATIONS
MAJOR RECOMMENDATIONS
The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.

Eligible Population
Adults with low back pain or back-related leg symptoms for < 6 weeks

Patients with Low Risk of Serious Pathology (No Red Flags)
Reassure patient that 90% of episodes resolve within six weeks regardless of treatment [C]. Advise that minor flare-ups may occur in the subsequent year.

Therapy
Stay active and continue ordinary activity within the limits permitted by pain. Avoid bedrest [A]. Early return to work is associated with less disability.
Injury prevention (e.g., use of proper body mechanics, safe back exercises)
Recommend ice for painful areas and stretching exercises [D].
McKenzie exercises [A] are helpful for pain radiating below the knee.

Referral
If no improvement at 1 to 2 weeks, refer for goal-directed manual physical therapy, not modalities such as heat, traction, ultrasound, transcutaneous electrical nerve stimulation (TENS).
Surgical referral usually not required if no "red flags."

Medication Strategies
Medication treatment depending on pain severity with acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) [A]
COX-2 inhibitors and muscle relaxants have not been shown to be more effective than NSAIDs [A].
Opiate analgesics have not been shown to be more effective than NSAIDS in acute low back pain.

Testing
Diagnostic tests or imaging usually not required.
If no improvement after 6 weeks, consider imaging.

Assessment to Identify Potential Serious Pathology
Assess for "Red Flag" Indications of Serious Disease
Cauda Equina
Severe or progressive neurologic deficit
Recent bowel or bladder dysfunction
Saddle anesthesia
Cancer
Men and women age >50
Cancer history
Insidious onset
No relief at bedtime or worsening when supine
Constitutional symptoms (e.g., fever, weight loss)
Male with diffuse osteoporosis or compression fracture
Fracture
Traumatic injury or onset, cumulative trauma
Steroid use history
Women age >50
Infection
Steroid use history
Diabetes mellitus
Immune suppression
History of urinary tract infection (UTI) or other infection
Constitutional symptoms (e.g., fever, weight loss)
No relief at bedtime or worsening when supine
Human immunodeficiency virus (HIV)
Previous surgery
Insidious onset
Intravenous (IV) drug use
Patients with High Risk of Serious Pathology (Red Flags)
Cauda Equina syndrome or severe or progressive neurologic deficit — Refer for emergency studies and definitive care [C]
Spinal fracture or compressions — Plain lumbosacral (LS) spine X-ray [B]. After 10 days, if fracture still suspected or multiple sites of pain, consider either bone scan [C] or referral [D] before considering computed tomography (CT) or magnetic resonance imaging (MRI).
Cancer or infection — complete blood count (CBC), urinalysis, erythrocyte sedimentation rate (ESR) [C]. If still suspicious consider referral or seek further evidence (e.g., bone scan [C], other labs — negative plain film X-ray does not rule out disease).
Definitions:

Levels of Evidence for the Most Significant Recommendations
Randomized controlled trials
Controlled trials, no randomization
Observational studies
Opinion of expert panel
CLINICAL ALGORITHM(S)
None provided