Diagnosis and Management of Lumbar Sprain

Initial Diagnosis

The American College of Physicians recommends that the diagnosis of lumbar sprain (nonspecific low back pain) be made through focused history and physical examination, ruling out serious pathology using "red flags" before considering imaging studies 1, 2
The initial evaluation should include a directed history to assess the pattern of pain distribution, duration, and severity of symptoms 3
The patient should be asked if the pain radiates down the leg in a radicular distribution (suggesting disc herniation, not simple sprain) 4
Psychosocial factors ("yellow flags") such as inadequate coping strategies, job dissatisfaction, or somatization should be identified 2

The American College of Physicians recommends that patients with nonspecific low back pain without red flags be started on conservative management without imaging, as most patients improve substantially within the first month 6, 7
Patient education is obligatory, informing the patient about the generally favorable prognosis with a high likelihood of substantial improvement within the first month 6, 7
The patient should be advised to remain active, as this is more effective than bed rest for acute or subacute low back pain 6, 7
Analgesics should be started with simple options, and nonsteroidal anti-inflammatory drugs (NSAIDs) should be used for a short time after considering side effects 5
Opioids should be avoided 5

The American College of Physicians recommends against routine imaging in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence) 1, 2
Imaging should be ordered immediately in cases of severe or progressive neurological deficits, suspected cauda equina syndrome, suspected cancer with impending spinal compression, or suspected vertebral infection 1, 2
MRI (preferred) or CT should be ordered after 6-8 weeks in patients with persistent pain and signs or symptoms of radiculopathy or spinal stenosis, only if the patient is a potential candidate for surgery or epidural steroid injection 6, 2, 3

The majority of patients with lumbar disc herniation with radiculopathy improve within the first 4 weeks with non-invasive management 6, 7, 4