Low back pain is a common complaint, which ranks among the top 10 most common reasons for why people to see their health care providers.  Low back pain accounts for about 15% of all sick leave from work and is the leading cause of disability under the age of 45.   A person’s lifetime risk of developing low back pain is thought to be about 60-90%.  In about 85% of people complaining of low back pain, a clear-cut cause (i.e. a “specific diagnosis”) is not identified.  The initial assessment of low back pain is direccted toward identifying “red flag” signs, which may indicate potentially serious causes of low back pain, including cancer and spinal infection.  In the absence of “red flag” signs, imaging studies and further testing are usually not particularly helpful, particularly during the first 4 weeks after the onset of low back pain.

Over-the-counter pain medications and reasonable activity modifications are usually sufficient in treating people, who do not have “red flag signs,” particularly during the first 4 weeks of their low back pain symptoms.  If narcotic medications like Percocet or Vicodin are prescribed, these should be used for short periods of time only.  Bed-rest is no longer recommended for people who present with low back pain since it probably does more harm than good to stay in bed.  Physicians generally recommend that their patients with non-specific low back pain do not participate in high impact sports activities, such as running.  People, who have heavy physical demand at work may need to discuss modifications of work activities with their managers.  Non-steroidal anti-inflammatory drugs at low dosage, as tolerated by the patient, is frequently all the treatment that is needed for many patients with new onset low back pain – in the absence of “red flag” signs.  Occasionally, depending on the special circumstances of the person with low back pain, health care providers will also prescribe medications or physical therapy.

About 90% 0f people experience a complete disappearance or substantial improvement in their painful symptoms, even if low back pain was associated with leg pain or tingling, in the first 4-6 weeks.

Red flag signs

In evaluating people with recent onset low back pain, health care providers, those who meet the following criteria have a statistically higher chance of having a potentially serious conditions, i.e. a spine infection or cancer.  If one or several of the items listed below apply to a person, who has experienced the recent onset of low back pain, an early diagnostic workup (i.e. an evaluation by a physician, labs, X-rays, MRI, etc. may be helpful).

  1. Age > 50 or <20
  2. History of cancer (especially lung, breast, kidney, prostate and thyroid)
  3. Unintentional weight loss
  4. Suppression of the immune system from steroid medication, transplantation medication or HIV/AIDS
  5. Long term use of steroid medication (i.e. prednisone).
  6. Duration of low back pain > 1 month.
  7. Pain, which is worse at rest or when lying flat.
  8. Skin infections, particularly skin pus collection (furuncle)
  9. History of intravenous drug use
  10. Urinary tract infection or other infection
  11. Pain that radiates below the knee
  12. Ongoing numbness and weakness in the legs
  13. Significant recent trauma, i.e.  MVA, a fall or an altercation in a younger person or, in an older person, heavy lifting, heavy coughing or even a minor fall
  14. New urinary of fecal incontinence, new urinary retention or overflow incontinence, numbness in the “saddle region” (buttocks, genitalia, inner thighs), weakness or numbness in one or both legs.
  15. History of fever

Classification of low back pain

Providers will perform a physical examination and further diagnostic testing (i.e. X-rays, CTs, MRIs, myelograms etc.) and should be able to categorize patients with low back pain into one of the following three groups:

  1. Serious spinal condition (i.e. spinal tumor, spinal infection or cauda equina syndrome)
  2. Sciatica/radiculopathy (pain that radiates from the lower back to the buttock and the leg, resulting from compression of a spinal nerve root)
  3. Nonspecific low back problem (involving the lower back, without evidence for a serious underlying spine condition or sciatica/radiculopathy)

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