Assessment and Management of Back Pain

Initial Assessment

The American College of Physicians recommends conducting a focused history and physical examination to categorize patients into one of three groups: nonspecific low back pain, back pain with radiculopathy or spinal stenosis, or back pain associated with a specific spinal cause, which guides subsequent management decisions 1, 2, 3
The assessment should include inquiring about location, frequency, duration, and intensity of pain, as well as risk factors for cancer, infection, and fracture 1, 3, 4, 5
The American College of Physicians suggests evaluating psychosocial factors, such as depression, passive coping strategies, job dissatisfaction, and somatization, as they are stronger predictors of outcomes than physical examination findings 5, 8

The American College of Physicians recommends against routine imaging for nonspecific low back pain, but considers imaging in situations such as presence of severe or progressive neurologic deficits, suspected serious underlying condition, or pain persisting >4-6 weeks despite conservative therapy 5, 8
The American College of Physicians suggests considering plain radiography for suspected vertebral compression fracture in high-risk patients, and MRI or CT for suspected radiculopathy or spinal stenosis that may require intervention 8

The American College of Physicians recommends providing education and reassurance about favorable prognosis, recommending remaining active and avoiding bed rest, and considering heat application for short-term relief for nonspecific low back pain 9
The American College of Physicians suggests considering physical therapy and exercise programs, as well as cognitive behavioral therapy, especially for chronic pain 6, 7
The American Society of Anesthesiologists recommends considering epidural steroid injections for short-term symptom relief for back pain with radiculopathy or spinal stenosis 6, 7

The American College of Physicians recommends reevaluating patients with persistent, unimproved symptoms after 1 month, and considering earlier or more frequent reevaluation for patients with severe pain, functional deficits, older age, or signs of radiculopathy or spinal stenosis 5

The American College of Physicians warns against ordering routine imaging for nonspecific back pain, which exposes patients to unnecessary radiation and may lead to unnecessary interventions 5, 8
The American College of Physicians advises against overreliance on opioids for chronic pain management without considering risks, and recommends assessing psychosocial factors to avoid missing red flags that may indicate serious underlying conditions requiring urgent attention 5, 8, 9