Lower Back Pain Evaluation and Management

Introduction to Lower Back Pain

• The American College of Physicians recommends seeking immediate medical attention for lower back pain if you experience severe or progressive neurologic deficits, new-onset bowel or bladder dysfunction, or if your pain follows significant trauma, especially if you have risk factors for osteoporosis 1

Red Flags Requiring Immediate Medical Attention

• Patients with cauda equina syndrome, characterized by urinary retention, incontinence, saddle anesthesia, bilateral leg weakness, or loss of anal sphincter tone, require immediate medical care 5
• Progressive neurological deficits, such as worsening weakness, numbness, or tingling, necessitate prompt medical evaluation 1
• A history of cancer, especially cancer known to metastasize to bone, is a red flag for lower back pain 1, 6
• Suspected spinal infection, characterized by fever, recent infection, or immunocompromised state, requires immediate medical attention 1
• Severe, unrelenting pain that doesn't improve with rest or worsens at night is a red flag for lower back pain 6

Yellow Flags That May Indicate Risk of Chronic Pain

• Psychological factors, such as depression, passive coping strategies, or somatization, may indicate a risk of chronic pain 6
• Social factors, including job dissatisfaction or disputed compensation claims, can contribute to the development of chronic pain 6
• Higher disability levels, characterized by significant functional limitations, are associated with a worse prognosis 6

Differentiating Types of Lower Back Pain

• Acute low back pain is defined as pain lasting less than 4 weeks 2
• Subacute low back pain is characterized by pain lasting 4-12 weeks 3
• Chronic low back pain is defined as pain lasting more than 12 weeks 4

When to See a Doctor Based on Duration

• For acute pain (< 4 weeks), most cases resolve with self-care, but medical evaluation is recommended if red flags are present or pain is severe and disabling 2, 3
• For subacute pain (4-12 weeks), medical evaluation is recommended if pain persists beyond 4 weeks 1, 7
• For chronic pain (> 12 weeks), medical evaluation is recommended for all cases, and may require a more comprehensive assessment and treatment approach 3

When to Consider Imaging

• Immediate imaging (MRI preferred) is recommended for severe or progressive neurological deficits, suspected serious underlying conditions (cancer, infection, cauda equina), or history of significant trauma with suspected fracture 1
• Delayed imaging may be appropriate if pain persists for more than 1-2 months despite standard therapies, or if symptoms of radiculopathy or spinal stenosis persist 1
• Routine imaging is not recommended for nonspecific low back pain without red flags 1

When to Consider Specialist Referral

• Consider referral to a back specialist when pain does not respond to standard noninvasive therapies, or if nonspecific back pain persists after 3 months of failed nonsurgical interventions 4