Diagnosis & Treatment
of Low Back Pain
Diagnosis can often be based on history and physical examination alone:
Low back pain alone Lumbosacral Possible spinal
(~93% of patients) radiculopathy stenosis
Low back pain with Pain relieved by sitting;
associated radicular pain usually in older adults
(4% of patients) (3% of patients)
Certain patients exhibit red flags or risk factors requiring urgent evaluation
and management:
• Major or progressive motor or sensory deficit
• New-onset bowel or bladder incontinence or urinary retention
• Saddle anesthesia
• Bilateral radiculopathic symptoms
• Pain increased by rest
• Unexplained weight loss, fever, or night sweats
• History of osteoporosis, spine surgery, or cancer that can metastasize to bone
• Significant trauma
• Prolonged history of glucocorticoid use or immunosuppression
• Intravenous drug use
• Suspected lumbar stenosis with intolerable symptoms or neurologic deficits
⚠ Consider urgent consultation or imaging, especially if findings are
consistent with cauda equina syndrome or cord compression.
For nonurgent cases:
Simple low Unilateral Spinal stenosis
back pain radiculopathy Tolerable symptoms
without bladder involvement without neurologic deficit
Testing / imaging is not needed initially
Counsel the patient to try conservative therapy for 4 to 6 weeks:
• Stay active, avoid bed rest, and avoid twisting and bending
• Try nonpharmacologic treatment (e.g., heat, massage, acupuncture, yoga, spinal manipulation)
• Consider a short trial of an NSAID (unless contraindicated)
• If NSAIDs are ineffective, consider nonbenzodiazepine skeletal muscle relaxants
(e.g., cyclobenzaprine, metaxalone, and tizanidine)
• Consider acetaminophen (although efficacy has not been demonstrated in clinical trials)
• Consider referral for PT (although studies have not shown benefit from early PT)
Educate the patient:
• Set reasonable expectations: most patients’ pain will improve in one month
• Provide resources (e.g., medlineplus.gov/backpain.html)
If the pain does not improve in 4 to 6 weeks:
• Refer for PT
• Continue noninvasive nonpharmacologic treatments:
exercise, multidisciplinary rehabilitation, acupuncture,
cognitive behavioral therapy
• Consider switching to a different NSAID
• Consider nonbenzodiazepine skeletal muscle relaxants
if not already prescribed
When to consider diagnostic imaging
Consider diagnostic imaging if the pain is:
• Worsening or severe
• Not improving after 12 weeks of conservative therapy
RADIOGRAPH MRI CT
if you suspect if you suspect if MRI is
fracture or infection, contraindicated,
degenerative joint malignancy, such as in the
disease or nerve presence of
compression metallic implants
Imaging normal or shows only Findings other than degenerative
degenerative joint disease: joint disease identified:
Consider the following additional Treat underlying cause:
treatments:
• Disk herniation: consider glucocorticoid
• Continue a supervised or independent
injection or diskectomy
exercise program
• Spinal stenosis: consider glucocorticoid
• Focus on nonpharmacologic interventions
injection or laminectomy
such as multidisciplinary rehabilitation,
• Infection, malignancy, fracture: treat
acupuncture, mindfulness-based stress
accordingly
reduction, tai chi, yoga, cognitive
behavioral therapy, or spinal manipulation
• Continue first-line pharmacologic
treatment with NSAIDs
• Second-line pharmacologic treatments:
duloxetine and tricyclic antidepressants
• Refer for consideration of glucocorticoid
injection (MRI required)
Note: Opioids other than tramadol should be
considered only if the above-mentioned therapies
fail and the potential benefits of opioid therapy
outweigh the risks. A 2018 randomized controlled
trial compared the effect of opioid and nonopioid
medication regimens in patients with chronic back,
hip, and knee pain. Treatment with opioids was not
superior to treatment with nonopioids for pain-related
function, further supporting the avoidance of opioids
in the treatment of chronic back and musculoskeletal
pain.
References:
1. Qaseem A et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice
guideline from the American College of Physicians. Ann Intern Med 2017 Apr 4; 166:514.
2. VA/DoD clinical practice guideline: diagnosis and treatment of low back pain. 2022.
https://www.healthquality.va.gov/guidelines/pain/lbp/
Last reviewed Sep 2023. Last modified Sep 2023. The information included here is provided for educational purposes
only. It is not intended as a sole source on the subject matter or as a substitute for the professional judgment of qualified
health care professionals. Users are advised, whenever possible, to confirm the information through additional sources.
© 2023 Massachusetts Medical Society. All rights reserved.
