CHAPTER 31

ACUTE LOW BACK PAIN

Susannah Lichtenstein, DO, Christopher Miles, MD, CAQSM

INTRODUCTION
Acute low back pain (ALBP) is defined as less than 6 weeks of pain between the costal angles and gluteal
folds. This may be accompanied by radicular pain, which radiates down one or both legs and may indicate
irritation of a nerve root.
Low back pain (LBP) is the fifth most common reason for medical office visits in the United States and
a leading cause of work-related disability. Only about 1% of patients with ALBP in the primary care setting
have a serious underlying cause.
1. What is the differential diagnosis of ALBP?
The differential diagnosis of ALBP is broad and may be categorized into mechanical, nonmechanical,
and visceral (Table 31.1). Most patients who present with ALBP are diagnosed with nonspecific,
mechanical-type pain. 
2. What are emergent causes of ALBP that should prompt referral to the emergency
department (ED)?
• Cauda equina syndrome (CES); occurs when there is compression on the lower spinal nerve roots
that results in urinary retention or incontinence, bilateral lower extremity weakness, and/or saddle
anesthesia
• Spinal fracture
• Infection (e.g., epidural abscess, vertebral osteomyelitis)
• Cancer (CA) 
3. What symptoms/historical details are red flags that should prompt referral to the
ED?
• Severe or progressive neurologic deficits (e.g., those seen in CES).
• Trauma. Suspect fracture when there has been a significant mechanism of injury, including motor
vehicle collision >35 mph, fall >15 feet, or automobile versus pedestrian.
• Patient has a history of or risk factors for CA or osteoporosis and presents with sudden onset of
LBP after a minor fall or heavy lifting. Suspect pathologic or compression fracture.
• Fever, constitutional symptoms, or risk factors for infection. Risk factors for infection include
immune compromise or immunosuppression (human immunodeficiency virus [HIV]/acquired im-
munodeficiency syndrome [AIDS], alcoholism, diabetes, chronic steroid use), intravenous drug use,
recent spinal surgery or injection, or recent bacterial infection.
• Known CA history or worsening LBP >4 weeks that is worse at night, not responsive to analgesics,
and associated with unintentional weight loss and/or night sweats. 

Table 31.1.  Differential Diagnosis of Acute Low Back Pain

MECHANICAL NONMECHANICAL VISCERAL
• Muscle strain • Cancer • Pelvic organ disease
• Sacroiliac joint dysfunction • Infection • Renal disease
• Degenerative disease • Inflammatory arthritis • Abdominal aortic aneurysm
• Disc herniation • Scheuermann kyphosis • Gastrointestinal disease
• Spinal stenosis • Paget disease
• Spondylolysis/spondylolisthesis
• Fracture
• Apophyseal injury
• Congenital disease

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4. What additional historical features, symptoms, or signs that may not be as

concerning in adults are unique red flags for children? (Note: The above red flags
are ALSO red flags for children.)
• Age <4 years
• Pain that interferes with daily activity
• Limp or altered gait
• Back pain despite no clear mechanism of injury
• Acute or repetitive trauma 
5. List key exam findings that are red flags and might suggest a concerning etiology.
• Fever.
• Midline tenderness: Sensitive but not specific for spinal infection, cancer, and compression fracture.
• Sensory or motor deficit: Abnormal neurologic exam of the lower extremities (strength, sensation,
reflexes, gait) or loss of anal sphincter tone.
• Straight leg raise (SLR): With the patient supine, knee extended, and ankle dorsiflexed, passive hip
flexion of the affected leg to 30–60 degrees reproduces radicular pain. Suggests nerve root irrita-
tion, most commonly at L5 or S1 and often caused by a herniated disc.
• Crossed SLR: SLR of the unaffected leg reproduces radicular pain in the affected leg and suggests
nerve root irritation.
• Slump test: While seated, the patient slumps forward, flexing the cervical, thoracic, and lumbar
spine. The patient then extends the knee and dorsiflexes the ankle on the affected side. This repro-
duces radicular pain in the affected leg. Pain should then decrease with cervical spine extension.
May better detect irritation to upper lumber nerve roots. 
6. When is imaging indicated in the evaluation of ALBP?
For both adults and children, consider imaging when patients present with red flags on history or
exam that raise suspicion for a serious underlying condition (cauda equina syndrome, fracture,
infection, or CA). 
7. Which imaging modality is appropriate? Which views? (Fig. 31.1)
• X-ray lumbar spine to assess for lytic lesions or fracture in patients with ALBP and red flags for CA
or fracture. Standing anteroposterior (AP) and lateral views are typically sufficient. Obtain additional
bilateral oblique views if there is concern for a pars interarticularis fracture (spondylolysis). Lateral
flexion and extension views may be helpful if there is concern for instability (e.g., spondylolisthesis).
• MRI in patients with ALBP and red flags for spinal infection, cauda equina syndrome, or spinal cord
compression/injury.
• CT without contrast for blunt trauma from a significant mechanism of injury (defined in question
3) with any of the following: back pain or midline tenderness, local signs of thoracolumbar injury,
abnormal neurologic exam, cervical spine fracture, altered level of consciousness, major distracting
injury, or alcohol or drug intoxication. 
8. Are labs indicated in the evaluation of ALBP?
If history or exam reveals red flags concerning for infection or malignancy, obtain a complete blood
count (CBC) and erythrocyte sedimentation rate (ESR). See Fig. 31.1. 
9. How should patients with nonspecific, mechanical ALBP pain be treated in the
outpatient setting?
• Education: Discuss expected course and establish goals of treatment. ALBP is often self-limited.
With self-care, 75% of cases resolve within 4 weeks and 90% within 6 weeks. Treatment should
focus on improving pain and function as well as reducing time away from work. Patients should
stay active and avoid bed rest.
• Pharmacologic: Nonsteroidal antiinflammatory drugs (NSAIDs) or acetaminophen are first line. After
discussing potential adverse effects, consider the addition of a muscle relaxant. For patients with
severe pain who are not responding to or are unlikely to respond to these options, the short-term
use of opioids may be appropriate, after carefully weighing the risks and benefits. Current evidence
does not support the use of systemic steroids.
• Nonpharmacologic: Superficial heat is helpful in reducing pain and improving function.
• Follow-up: Educate patient on red flags (discussed above), which should prompt return. Otherwise,
patient should follow up with primary doctor in 4–6 weeks if the pain is not improving. 
 Acute Low Back Pain   189

Evaluate for red

flags

No red Red flags

flags suggest:

No diagnostic Cauda equina Fracture Infection Cancer

studies syndrome or
progressive
neurologic deficit

Conservative Fracture present Send to ED or

Send to Highly Less arrange prompt
management X-ray +/- CT (or still
ED suspicous suspicious follow-up with PCP
for 4–6 weeks suspected)
or appropriate
specialist, as
clinically indicated
Send to ED for X-ray
No Send to
surgical evaluation &
fracture ED
or treat ESR
conservatively
as indicated

Conservative
Abnormal x-ray Normal x-ray
management with
OR &
follow-up in 1–2
high ESR ESR
weeks

Send to Conservative
ED management
and follow-
up, as clinically
indicated

Fig. 31.1.  Evaluation of acute low back pain.

10. In the absence of red flags, what should you recommend regarding return to play
(RTP)? Return to work?
• The athlete may RTP when the pain has resolved at rest and with activity. Consider sports medicine
consultation for guidance on RTP.
• The patient should continue to work as pain permits, with possible job modifications. Refer to local
regulations for workers compensation cases. 
11. Colin is an otherwise healthy 14-year-old high school wrestler presenting to
urgent care with 4 weeks of low back pain. It is occasionally present at rest but
worsens with activity. He has tried over-the-counter (OTC) ibuprofen with little
benefit. He denies trauma, fevers, weight loss, nighttime pain, radiation of pain,
paresthesias, or weakness. On exam, he has mild tenderness to deep palpation
at L5, and his pain worsens with lumbar extension. Neurologic exam of his lower
extremities is normal. He sees you to determine if he can continue to wrestle.
Which of the following is the next step in management?
A. Given no systemic or neurologic red flags, he may continue to wrestle.
B. Obtain plain films of the lumbar spine, including AP, lateral, and oblique views.
C. Obtain an MRI of the lumbar spine.
D. Refer to orthopedic surgery.
The correct answer is B. Colin is presenting with symptoms and signs concerning for
spondylolysis, a stress fracture of the pars interarticularis. This is a common cause of LBP in
adolescent athletes. Oblique view x-rays should be obtained if spondylolysis is suspected, as
these views may show a defect in the pars (scotty dog lesion). When x-ray findings are normal and
spondylolysis is still suspected, additional imaging should be performed. Bone scintigraphy with single
photon emission computed tomography (SPECT) followed by CT if positive is preferred. MRI is an
alternative but is less sensitive for detecting acute stress reaction of the pars interarticularis. 
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Key Points
1 . Know the red flags that should prompt urgent/emergent evaluation.
2. Most patients do not need imaging.
3. Medical management should begin with NSAIDs or acetaminophen. Short-term muscle relaxants or
opioids may be appropriate in selected patients.
4. Encourage patients to stay active. Bed rest is NOT helpful for acute low back pain (ALBP).
5. Follow-up should occur in 4–6 weeks if symptoms are not improving.

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