Back pain made simple: An approach based on principles and evidence
ABSTRACTIn cases of low back pain, the goal is to detect serious problems and to prevent the pain from becoming chronic by promptly detecting risk factors. The authors lay out a simple, evidence-based approach to low back pain.
KEY POINTS
- Most back pain has no recognizable cause and is therefore termed “mechanical” or “musculoskeletal.” Underlying systemic disease is rare.
- Most episodes of back pain are not preventable.
- Confounding psychosocial issues are common.
- A careful, informed history and physical examination are invaluable; diagnostic studies, however sophisticated, are never a substitute. Defer them for specific indications.
- Refer patients only if they have underlying disease or progressive neurologic dysfunction or do not respond to conservative management.
- Encouragement of activity is benign and perhaps salutary for back pain and is desirable for general physical and mental health. Evidence to support bed rest is scant.
- Few if any treatments have been proven effective for low back pain.
WHAT SHOULD BE REMEMBERED ABOUT LOW BACK PAIN?
Low back pain is a common and costly medical condition with only a weak correlation between symptoms and pathologic changes, resulting in a lack of objective clinical findings on which a definitive diagnosis can be based.22 Most back pain has no recognizable cause and is usually regional and musculoskeletal. Back pain as a result of an underlying systemic disease is rare and needs to be excluded by a good history and physical examination. Diagnostic studies are best reserved for specific indications.
Referral to a specialist is warranted when the patient is not responding to conservative treatment, when a progressive neurologic deficit or cauda equina syndrome is noted or suspected, or when the patient has an underlying malignancy, infection, fracture, or spinal instability.
Bed rest is best avoided, and activity within the limits of pain is encouraged. NSAIDs and acetaminophen are usually the drugs of choice for controlling acute low back pain.
Ultimately, the goal for clinicians is to identify serious conditions and to prevent the back pain from becoming chronic pain by promptly identifying the various risk factors.
