Evaluating and managing acute low back pain in the primary care setting

Acute low back pain is a common reason for patient calls or visits to a best spine specialist’s primary care. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected.

For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self­limited, many patients treat themselves without contacting their primary consultant for spine care. When patients do call or schedule a visit for Spine treatment , evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x­rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations.

Acute low back pain is a very common symptom. Up to 90% of all adults suffer at least once in their life from a low back pain episode, in the majority of cases a nonspecific lumbago. They are, with or without sciatica, usually self­limited and have no serious underlying pathology and subside in 80­90% of the concerned patients within six weeks. Beside a sufficient pain medication and physiotherapy, reassurance about the overall benign character and the favourable prognosis of the medical condition should be in the centre of the therapeutic efforts. A more thorough assessment is required for selected patients with warning signs, so called “red flags” findings, because they are associated with an increased risk of cauda equina syndrome, cancer, infection, or fracture. These patients also require a closer follow­up and, in some cases, an urgent surgical intervention or spinal surgery. Among patients with acute nonspecific mechanical low back pain, imaging diagnostic can be delayed for at least four to six weeks, which usually
allows the medical condition to improve. From a therapeutic viewpoint, there is enough evidence for the effectiveness of paracetamol, nonsteroidal anti­inflammatory drugs, skeletal muscle relaxants, heat therapy, physiotherapy, and the advice to stay “active”. A complete relief and protection represent an out­dated concept, because the deconditioning is stimulated and the return to the workplace is needlessly delayed. Spinal manipulative therapy may provide short­term benefits in certain patients. In a multimodal therapeutic concept, the patient education should focus on the natural history of an acute back pain episode, the overall good prognosis, and recommendations for an effective treatment.

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