B-QuiCK: Acute low back pain

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Acute Low Back Pain


  • Determine
    • Site of pain
    • Pain radiation patterns
    • Mode of onset
    • Aggravating and relieving factors
    • Severity and functional impact
    • Associated “red flag” features that may indicate fracture, infection, malignancy or cauda equina syndrome (see box)
    • Any psychosocial factors that may influence recovery (“yellow flags”)
  • Perform a physical examination guided by relevant clues in the patient history
    • Observe the posture, gait and general demeanour of the patient
    • Palpate the spine to try to localise the pain and identify a vertebral level
    • Assess for pain, swelling, deformity, muscle tone and heat. If infection is suspected, check body temperature.
    • Assess spinal range of motion, as tolerated
    • Palpate abdomen for abdominal mass or abdominal aortic aneurysm, if suspected
    • Perform a neurological examination if neurological symptoms are present
  • Diagnostic laboratory investigations, e.g. FBC, CRP, or imaging, e.g. lumbar X-ray, MRI, are not routinely recommended, unless there is suspicion of a serious underlying cause or if the results are likely to change management
  • Exclude other possible causes of low back pain, e.g. referred visceral pain, pregnancy, vascular causes, axial spondyloarthritis, radicular syndromes

Red flags

  • Aged > 50 years with new onset back pain, especially aged > 65 years
  • History of malignancy with other features, e.g. unexplained weight loss
  • Severe worsening or unrelenting pain, particularly at night or when supine
  • History of trauma, or risk factors for fracture, e.g. osteoporosis, older age, prolonged systemic corticosteroid use
  • Significant neurological symptoms, e.g. bilateral radicular pain or radiculopathy, impaired bladder/urethral sensation, urinary hesitancy or urgency, poor stream, loss of perineal sensation
  • Symptoms or signs of infection, e.g. fever (> 37.8°C), night sweats or chills; or risk factors for infection, e.g. intravenous drug use, immunosuppression
  • Cardiovascular risk factors for aneurysm, e.g. smoking history, hypertension, older age, male sex

Management of acute non-specific low back pain

  • Involve the patient in their management plan and discuss what has or has not worked for them in the past, including allied health services. Ensure that patients have a realistic expectation of what a pain management strategy will achieve.
  • Give practical reassurance, i.e. using facts and logic, not emotional reassurance, of the favourable prognosis and benign nature of acute non-specific low back pain
  • Discuss coping strategies, including distraction techniques, to manage an acute flare
  • Encourage patients to remain physically active, minimise bed rest and return to normal work and daily activities as soon as possible. Explain that experiencing pain does not always mean harm and that some level of pain is to be expected with increased activity.
  • Assess for risk of progression to chronic low back pain, e.g. using STarTBack
  • Prioritise non-pharmacological interventions, e.g. superficial hot-cold applications, relaxation and distraction techniques, exercise, physiotherapy
  • Pharmacological treatments have limited evidence of effectiveness and are usually reserved for people with severe pain, although may be required initially to support patients while they return to their normal routine and daily activities, and during the introduction of non-pharmacological interventions
  • If an analgesic is required, trial a NSAID (or paracetamol) and prescribe short courses only at the lowest effective dose to avoid long-term dependence on medicines. Pharmacological treatments should always be used alongside non-pharmacological interventions.


  • Review the patient after two weeks of treatment to assess response
    • If there is not adequate improvement, consider reassessment, including repeating a focused history and physical examination to rule out the development of any red flags and address any yellow flags that may be contributing to delayed recovery
  • If the patient has developed persistent low back pain:
    • Encourage them to return to primary care at regular intervals to ensure that symptoms are not progressing and that no red flags have developed
    • Continue with treatments used for acute pain, e.g. education, reassurance, self-management strategies and simple analgesics
    • Address and manage any co-morbidities, e.g. anxiety or depression
    • More complex medicines, cognitive behavioural therapy and multidisciplinary rehabilitation programmes are generally reserved for second-line care only if other interventions are not successful
    • Consider referral if symptoms suggestive of a serious underlying cause develop or if debilitating pain persists after six months of appropriate management
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