CLINICAL PRACTICE GUIDELINES FOR ACUTE

LOW BAC K PAINAETNA

USHEALTHCARE

PATIENT GOALS

• Prevent or minimize daily symptoms/recurrent exacerbations with return to baseline function.

• Foster optimal use of specialty and ancillary services.

• Minimize the need for acute care services (ER/urgent care visits, hospitalizations.

DIAGNOSIS

• Initial assessment includes a focused history, physical, and neurological exam.

• Exclude “Red Flags” which include fracture, cancer, infection, and Cauda Equina Syndrome.

• Cauda Equina syndrome is diagnosed when there is saddle anesthesia, loss of bladder or bowel sphincter tone and/or rapidly progressive neurological deficit.

ASSESSMENT

• With a symptomatic herniated disc leg pain usually outweighs back pain.

• 90% of patients will recover within four weeks, regardless of treatment, unless there are “Red Flags”.

ASSESSMENT

• X-rays and lab tests (CBC, U/A, ESR) should be considered when there is no response to an initial four weeks of conservative therapy, to further evaluate potentially serious pathology, or when surgery is being considered.

• MRI/CT should be requested on the basis of clinical findings since 1/3 of asymptomatic adults may show a bulging disc on MRI/CT

THERAPY

• Acetaminophen is the safest drug treatment for common acute low back pain.

• Salicylates or NSAIDs can be used alone or added to acetaminophen therapy.

• Muscle relaxants and narcotics should be reserved for severe cases in the first week only.

THERAPY

• A short course of physical therapy may be beneficial.

• A short course of oral steroids may be considered after failure of initial conservative therapy.

• Surgery is primarily for unrelenting sciatica with signs of nerve root compression and a concordantly abnormal imaging study.

PATIENT INSTRUCTIONS

• Activity as tolerated: there is no relationship between activity level, rest, and recovery.

• Resume daily activities and support return to work with initial improvement.

• Patient does not have to be completely pain-free before returning to work.

PATIENT INSTRUCTIONS

• Events and activities that “trigger” acute low back pain should be identified and avoided, and “safe lifting” techniques should be taught.

• Develop a long-term daily program of flexibility and back-strengthening exercises as soon as symptoms resolve.

WARNING SIGNS

• Re-evaluate if symptoms do not improve after 4 weeks of initial therapy and consider imaging studies and/or referral to specialist.

• Depression is a barrier that may confound the symptoms and assessment of chronic back pain.

SPECIALIST INVOLVEMENT

• If symptoms do not improve after 4 weeks of conservative therapy.

• If new or progressive neurological deficits and/or if any “Red Flags” are recognized at any time.

• Recurrent symptoms (more than two episodes in a 6-month period).

• Recurrent symptoms after low back surgery.