Acute Low Back Pain

Low back pain is a very common problem with approximately 80% of Australians suffering from back pain during their lifetime (1). Back pain can be a significant and debilitating condition placing a considerable strain on healthcare systems, with up to 35% of sufferers still experiencing problems after 5 years (2,3). However, with an early, effective and multidisciplinary approach to management, the rate of recurrence and long-term disability can be substantially reduced (2-5).

Only about 40% of those with back pain will seek medical advice and around 10% of those patients will have significant disability, with a proportion of these attending the Emergency Department (ED) (1,5,6). Such patients pose a significant burden to the ED accounting for up to 2% of all attendances and requiring an average length of stay between 4 to 5 hours (2).

The vast majority of patients with acute low back pain will have a non-specific musculoskeletal cause with a self-limiting course that will typically improve rapidly within a month and be fully resolved by 6 weeks. However, a minority (0.1-1%) of patients will have potentially serious spinal conditions such as fractures, tumours, spinal infections and cauda equina syndrome that require urgent diagnosis and management(1,5,6,7). Others may have significant non spinal causes of back pain including pyelonephritis, renal colic or abdominal aortic aneurysm that require just as urgent attention. These serious conditions can be identified in the initial assessment and examination by searching for the presence of any red flag features. - see acute low back pain - assessment.

If any red flag features are identified then a senior emergency doctor review should be sought to determine appropriate and timely investigations and management. If no red flags are identified patients should be commenced on a suitable multimodal analgesic strategy, reassured, educated, encouraged to mobilise (as tolerated) and referred to a physiotherapist early.

This clinical tool has been produced to provide a guide for the safe and effective management of adults with acute low back pain (pain for less than 4 weeks). Patients with persistent or subacute (pain for 4-12 weeks) or chronic low back pain (longer than 12 weeks) may require a more complex approach with consultation of multidisciplinary services such as rheumatology, pain specialists and neurosurgery.

Further References and Resources

  1. Walker, B.F., Muller. R. & Grant, W.D. Low back pain in Australian adults: prevalence and associated disability, J Manipulative Physio Ther, 2004; 27(4):238-44.
  2. Lovegrove, M.T. et al. Analysis of 22,655 presentations with back pain to Perth emergency departments over five years, International Journal of Emergency Medicine, 2011; 4:59.
  3. Chou, R. et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society, Ann Intern Med, 2007;147(7):478-91.
  4. Dahm, K.T. et al. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica, Cochrane Database Syst Rev, 2010;(6):CD007612.
  5. National Collaborating Centre for Primary Care. Low back pain: early management of persistent non-specific low back pain. NICE clinical guideline 88, London: National Institute for Health and Clinical Excellence 2009.
  6. Jarvik, J.G. & Deyo, R.A. Diagnostic evaluation of low back pain with emphasis on imaging, Annals of Internal Medicine, 2002; 137(7): 586-97.
  7. Goergen, S. et al. Acute Low Back Pain. Education Modules for Appropriate Imaging Referrals, Royal Australian and New Zealand College of Radiologists; 2015.
  8. Lavy, C. et al. Cauda equina syndrome, BMJ, 2009, 338:b936
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  10. Capra, F. et al. Validity of the straight leg test for patients with sciatic pain eith or without lumbar pain using magnetic resonance imaging results as a reference standard, J Manipulative Physiol Ther, 3 May 2011, 24(4), 231-8.
  11. Murphy, D.R. et al. Pain patterns and descriptions in patients with radicular pain: Does the pain necessarily follow a specific dermatome? Chiropractic and Osteopathy, 2009; 17(9).
  12. Agency for Clinical Innovation, Management of people with Acute Low Back Pain: Model of Care, 2016.

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